Incomplete Facility Assessment Omits Cultural, Staffing, and Contracted Service Considerations
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment as required. The assessment did not include any cultural considerations to address the specific needs of the resident population. Additionally, the staffing plan only listed the desired number of full-time equivalent (FTE) nurses and CNAs, without specifying staffing needs for each shift, including nights and weekends, or adjusting for changes in the resident population. The facility assessment also did not evaluate or document the contracted services used to provide necessary care, such as goods, medical services, facility management, emergency services, transportation, and dialysis. During an interview, the Administrator acknowledged missing the cultural consideration section and was unaware of the requirement to detail shift-specific staffing and contracted services in the assessment. These omissions had the potential to affect all 88 residents in the facility.