Incomplete Facility Assessment for Staffing and Acuity
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of the facility assessment dated 3/24/25 revealed it was not comprehensive and did not accurately include information on how the assessment was used to address staffing needs or resident acuity, nor did it reflect the high usage of agency staff. During an interview, the Administrator acknowledged that the assessment lacked accurate and comprehensive information related to staffing. No additional information was provided to address these deficiencies.