Incomplete Facility Assessment and Lack of Required Participant Involvement
Penalty
Summary
The facility failed to conduct and document a complete facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The facility assessment on file was undated in the report, not signed, and lacked evidence of review and active involvement by all required participants, with no signature page or other documentation identifying who participated in its development. Surveyors’ review of the assessment showed several sections were blank or incomplete and many sections lacked supporting documentation. During an interview, the Administrator and Regional Director of Operations confirmed that this incomplete and unsigned assessment was the only facility assessment available for review, and this inaction in administering the facility had the potential to affect all residents living in the facility. No specific residents, medical histories, or clinical conditions were described in the report.
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