Incomplete Facility-Wide Assessment of Staffing Needs
Penalty
Summary
Facility staff failed to complete a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility's assessment, dated 10/09/25, included general staffing numbers for RNs, LPNs, CNAs, and CMTs across shifts, but lacked specific direction or guidance regarding shift times and did not address staffing needs for each resident unit. Observations confirmed the facility was organized into multiple halls, but the assessment did not specify staffing requirements for these individual units. During interviews, both the DON and the administrator acknowledged their involvement in the assessment process but were unaware that the assessment needed to include specific staffing needs for each resident unit.