Failure to Include Resident Representative and Family Input in Facility Assessment
Penalty
Summary
The facility failed to complete and document a compliant facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Record review showed a document titled “Facility Assessment” last updated on 9/30/2025, which listed the Administrator, Director of Nursing Services, Social Worker, Medical Director, and a resident as participants in its completion. However, further review of this assessment did not show any evidence that the facility solicited or considered input from a resident representative or family members, as required by regulation. In an interview with surveyors, the Administrator was unable to provide evidence that such input had been included and stated that he was unaware that obtaining input from a resident representative or family member was a requirement. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
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