Inaccurate and Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to accurately complete its Facility Assessment as required by regulation. Review of the Facility Assessment Tool dated 4/15/25 showed that the section titled "Disease and Conditions" contained tables intended to document categories of care and the average number of residents receiving special treatments, but these tables were left blank. In the same section, a table to document residents’ levels of assistance with Activities of Daily Living (ADLs) was also left blank. The "Disease and Conditions" section further stated that the facility denies admissions for residents requiring ventilator care, while elsewhere in the assessment conflicting information was documented. In the section titled "Physical Environment and Building/Plant Needs," the facility listed ventilators as a type of physical equipment available for resident care, which conflicted with the statement that residents needing ventilator care are not admitted. This section also listed a gift shop and a café/snack bar/bistro as available for resident use. In the "Staffing Plan" section, the facility documented that it follows all state and federal guidelines for staffing education; however, review of in-service education records showed that no nurse aide met the 12-hour annual in-service requirement. During an interview, the Nursing Home Administrator confirmed that the Facility Assessment had not been accurately completed.
Plan Of Correction
The facility will accurately complete the Facility Assessment to include Review of the Disease and Conditions, Activities of Daily Living that residents require. Physical Environment and Building/Plant. Staffing Plan and in-service education for facility staff. This assessment will be reviewed quarterly and as necessary. Results of this assessment will be presented to the Governing Board of the Greenery Center for Rehab and Nursing quarterly and when changes are made. The Administrator will be educated by the Regional Nurse Consult on completing the required sections of the facility assessment. The Governing Board of the Greenery Center for Rehab and Nursing will monitor this assessment for further compliance with this regulation. Results will be presented at the QAPI committee meeting for review and further recommendations.
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