Incomplete Facility-Wide Assessment of Resident and Staffing Needs
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 01/30/26, completed by the administrator, showed it did not address the resident population, including the number of residents, the facility’s capacity, or the care required based on behavioral health needs, cognitive disabilities, and overall acuity. Further review showed the assessment did not address direct care staff such as RNs, LPNs, and CNAs, and did not document the overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident’s needs as identified through assessments and care plans. During an interview, the regional director of clinical operations and the administrator confirmed that the facility assessment was not completed with all required elements. This deficiency was identified as an incidental finding during the course of a complaint investigation, and the facility census at the time was 65 residents.
