Incomplete Facility Assessment and Missing Resource Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all required components necessary to determine the resources needed to competently care for residents during both routine operations and emergencies. Specifically, the assessment did not contain a completed facility-based and community-based risk assessment, nor did it include a comprehensive list of medical and non-medical equipment descriptions. Additionally, documentation of contracts, memorandums of understanding, and other agreements with third parties to provide services or equipment during normal and emergency situations was missing. During interviews, facility administrators acknowledged that the assessment was incomplete and that referenced appendices containing critical information could not be located. The assessment also contained outdated information regarding the facility's admission policy for active COVID-19 residents, which did not reflect current practices. These omissions were identified through record review and staff interviews, indicating a lack of thorough documentation and assessment as required by facility policy.