Deficient Facility Assessment and Inaccurate Staffing Plan
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment as required. The assessment did not involve all necessary parties in its development, specifically lacking input from direct care staff, residents, resident representatives, and family members. Additionally, the assessment listed outdated administrative personnel, including a former Administrator, Medical Director, and Social Worker, rather than the current staff. The staffing plan included in the assessment only provided the desired number of full-time equivalent (FTE) nurses and CNAs, but did not address specific staffing needs for each shift, weekends, or account for changes in the resident population. The staff type and position list was also inaccurate, listing a Staff Development Coordinator (SDC) position that did not exist at the facility. Further, the facility assessment did not specify the required skills and competencies for licensed nursing staff and CNAs. During an interview, the current Administrator confirmed she had not reviewed or updated the facility assessment since her employment began and acknowledged the inaccuracies in the staff position list. No additional documentation regarding the facility assessment was provided at the time of the survey exit. These deficiencies had the potential to affect all 54 residents in the facility.