Incomplete Facility Assessment of Required Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive facility-wide assessment that accurately documented the number of RNs, LPNs, and CNAs needed to meet resident needs during routine and emergency operations. The CMS Form 671, dated 1/12/26 and signed by the Administrator, documented that 44 residents resided in the facility. The facility’s written Facility Assessment, revised 5/29/25 by the Administrator in Training, stated that it was intended to be a complete review of internal human and physical resources required to care for residents competently during day-to-day and emergency operations, and that it would identify the facility’s capabilities as a skilled nursing service provider and serve as the basis for surveyors to determine preparedness. Despite this stated purpose, the Facility Assessment listed a daily average census of 49 but did not specify the number of RNs or LPNs required to meet the needs of the residents and documented that 0 CNAs were needed. During an interview on 1/14/26 at 2:55 PM, the Administrator in Training verified that the staffing numbers needed for RNs, LPNs, and CNAs were not documented in the Facility Assessment and acknowledged that they should have been. This omission affected the accuracy and completeness of the facility’s assessment of necessary staffing resources for its resident population.
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