Failure to Complete and Accurately Document Required Facility Assessment
Penalty
Summary
Facility leadership failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. On 1/16/26 at 10:55 AM, the Nursing Home Administrator (NHA) was informed that an extended survey was being conducted and was asked to provide the Facility Assessment. During an interview later that day at 12:21 PM with the NHA and the Nurse Educator/Infection Preventionist, the NHA stated she was unable to locate the assessment and needed to request it from the corporate office. When asked if she had reviewed or developed a facility assessment since assuming the position in 8/2025, she reported that she had not. At 1:30 PM on the same day, the NHA provided a document titled “Facility Assessment Tool,” dated 1/5/26, which indicated it had been completed by the NHA, Medical Director, Governing Body representative, and others; however, review showed it was incomplete. In a subsequent interview at 1:46 PM, the NHA confirmed she had not reviewed or completed a facility assessment until the surveyor requested it on 1/16/26, initially explaining this by stating she started in the position in 8/2025, although it was later reported she had previously served as the facility’s NHA from 2020–2024. In a later interview on 1/20/26 at 3:17 PM, the NHA reported she had not been in contact with the governing body since returning in 8/2025, meaning she could not have obtained input from a governing body member as documented on the assessment provided to the survey team. Cross references were made to F835 and F940.
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