F0838

F

Inaccurate Facility Assessment of Staffing Needs

Shadyside, Ohio Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to accurately complete its facility-wide assessment regarding the number of staff needed to provide competent care to all residents during routine operations and emergencies. The written Facility Assessment Tool, updated 02/13/26, documented an average daily census of 83 residents, including a locked memory care unit with a 32-bed capacity and an average daily census of 28. The assessment identified a wide range of care needs for the memory care unit, including ADLs, mobility and fall risk, bowel and bladder care, skin integrity, mental health and behavioral needs, medications, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and person-centered psycho/social/spiritual support. The facility’s assessment stated it estimated needing 12–14 licensed nursing staff to provide direct care, 20–25 nurse aides, and three nursing personnel with administrative duties to care for the resident population.

During an interview, the Regional Administrator confirmed that the staffing estimates documented on the Facility Assessment were incorrect. She explained that, when determining the number of licensed nurses providing direct care, she had inappropriately included administrative nurses such as the DON, ADON, and MDS nurse. Similarly, when calculating the number of nurse aides, she had included individuals in administrative roles, such as admissions and medical records staff. As a result, the facility assessment did not accurately reflect the overall number of facility staff actually needed to ensure a sufficient number of qualified staff were available to meet each resident’s needs as identified through resident assessments and care plans. This deficiency was identified as an incidental finding during the investigation of Master Complaint Number 2746972.