Facility Assessment Lacks Required Components and Updates
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was updated to include all necessary components as required by current standards of practice. The assessment provided did not identify the current Administrator or Director of Nursing (DON), nor did it specify resources required to provide necessary care and services to residents during both routine operations and emergencies, including nights and weekends. Additionally, the assessment lacked an evaluation of the overall number of staff needed to ensure sufficient qualified personnel are available to meet each resident's needs as identified through assessments and care plans. The assessment also omitted pertinent information about the resident population, such as race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy, or other factors affecting access to care and health outcomes related to health equity. Further deficiencies included the absence of information regarding the physical environment, assistive technology, individual communication devices, or other material resources needed to provide required care and services. The facility assessment did not evaluate the training program to ensure training needs are met for all staff, including managers, nursing and direct care staff, contracted service providers, and volunteers. There was also no evaluation of applicable policies and procedures, nor a facility-based and community-based risk assessment using an all-hazards approach to maintain continuity of operations and secure required supplies and resources during emergencies or natural disasters. When asked, the Administrator confirmed that the provided assessment was all the information available and stated there was no policy for the facility assessment. At the time of the survey, there were 60 residents residing in the facility.