Facility Assessment Lacks Staffing Level Information
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included information regarding the level of staff needed to meet the needs of each resident during both day-to-day operations and emergencies. Record review of the facility assessment dated 4/30/25 revealed that it did not contain details about staffing levels required to provide competent care for residents. The facility's policy states that the assessment should inform staffing decisions and consider staffing needs for each shift, but this was not reflected in the actual assessment document. During an interview, the Administrator acknowledged uncertainty about whether the facility assessment included staffing level information and confirmed that the assessment was not used when creating the nursing staff schedule. Instead, staffing decisions were based on the facility's PPD (per patient day) and census, with a CNA-to-resident ratio of 1:15. The Administrator also referenced the facility's star rating and national staffing averages but did not indicate that individual resident needs or the facility assessment were used to determine staffing levels.