Inaccurate Facility Assessment Due to Outdated Leadership Information
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment that reflected the current administrative and clinical leadership, including the Administrator, DON, Infection Preventionist, Rehabilitation Manager, Staff Development Coordinator, and Maintenance Director. The last recorded update of the facility assessment was on 10/31/24, and since that time, there had been multiple changes in leadership positions. During an interview, the interim Administrator confirmed that the assessment still listed former staff members and had not been updated to reflect the current personnel since he began his role on 9/9/25. This deficiency was identified through staff interviews and record review, and it had the potential to affect all 109 residents in the facility.