Incomplete Facility-Wide Assessment and Related Care Resource Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The written Facility Assessment, last updated on 12/18/25, included basic operational data such as licensed bed count, average daily census, and average admissions and discharges by shift, but left all sections for monthly average assistance with activities of daily living (ADLs) blank. Specifically, no data were recorded for residents’ needs in bed mobility (sit to lying), mobility (sit to stand), bathing, transfers, eating, toileting, or other care, and there were no entries for levels of assistance such as set up, supervision/partial/moderate assistance, or dependent/max assistance. The assessment also contained only general narrative descriptions of how staff assignments are determined and how the infection prevention and control program is evaluated, without tying these to quantified resident care needs. During the survey, additional problems were identified that related to staffing, training, and infection control, which were not reflected in or supported by the incomplete facility assessment. These included the absence of required 12-hour CNA competencies in abuse/neglect and/or dementia care for all sampled CNAs employed more than one year, insufficient nursing staff to meet resident needs as evidenced by staff interviews and reports of missed treatments and missed ADL care, and the lack of a restorative program or speech therapy. Infection control issues were also found, including missing tuberculosis testing for all sampled residents, residents on enhanced barrier precautions without appropriate signage or PPE supplies, and housekeeping staff not using an EPA-registered hospital disinfectant for floor cleaning. In an interview, the Administrator stated an expectation that the facility assessment be fully completed with total numbers of residents requiring assistance and acknowledged responsibility for ensuring the assessment’s completion.
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