Facility Assessment Failed to Reflect Actual Staffing Requirements
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately reflected the actual staffing requirements and current staffing practices. During a complaint survey, the DON confirmed participation in the assessment process and believed the assessment was up to date, but the document reviewed was dated August 2024. The staffing levels outlined in the assessment did not match the actual staffing practices reported by the DON, who described lower staffing levels than those documented. Staffing sheets from July 2025 also confirmed that the facility was operating below the levels indicated in the assessment. When the Administrator was interviewed, he also believed the assessment was current, but upon review, the staffing information was found to be incorrect or missing. The Administrator provided a second copy of the assessment, also dated August 2024, with the staffing section left blank. Both the DON and Administrator acknowledged that the assessment did not accurately reflect the facility's current staffing requirements or practices, and no updated assessment for 2025 was available.