Facility Assessment Not Updated for Lack of RT Contract: The facility failed to update its Facility Assessment after it no longer had an active RT contract. The assessment still listed RT as a needed resource, while the Admin confirmed there was no contracted RT company in place and acknowledged the assessment should be updated annually and as needed.
The facility failed to include IV medication administration and the IV bulb infusion system in its facility assessment of nurse competencies. Although the assessment noted that the facility provides IV meds and that 3-4 residents receive them, it only listed injectable, oral, subcutaneous, and topical medication competencies. The ADM acknowledged that IV medication administration and the IV bulb infusion system should have been included.
The facility failed to ensure its Facility Assessment included a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs. During interview and document review, the Administrator verified the Facility Assessment did not reflect the current CMS guidance and stated he was not aware of it. The assessment also did not show the required staffing resources for resident care, including weekends, or the active involvement of direct care staff in developing the assessment.
Incomplete Facility Assessment Lacked Staffing and Competency Details: The facility assessment was missing a staffing plan and did not document the training, education, or competencies needed to care for the resident population. The assessment did not address how the facility's Program Flex and Workforce Shortage Waiver would meet resident needs, determine staffing levels, or define staff qualifications. The facility cared for residents receiving dialysis, residents with tracheostomies, and residents on ventilators, and the Admin confirmed these services were provided. The DON stated she was unaware the assessment was incomplete.
Incomplete Facility Assessment: The facility’s Facility Assessment was reviewed and found to be missing key components, including a data-driven staffing plan based on resident acuity and care needs, documentation of participation by leadership, direct care staff, and resident/family representatives, staffing contingency planning for emergencies or shortages, and ongoing evaluation of competencies and resources needed for behavioral health services. The AED and SCD confirmed the missing elements, and the AED stated the assessment needed to be updated.
Incomplete and Inaccurate Facility Assessment: The Facility Assessment did not show input from residents or resident representatives. It also inaccurately listed a Social Services Director and only one LVN treatment nurse, even though the Social Services Assistant stated the facility had not had a Social Services Director for months and the May staff assignment showed two treatment nurses.
The facility failed to complete an accurate, building-specific facility assessment to determine needed resources and staffing for its resident population, including many residents with dementia or cognitive impairment. The written assessment left the behavioral and cognitive acuity fields blank, did not describe how supervision needs for cognitively impaired residents would be met, and contained generic staffing ratios that did not account for 12‑hour shifts or explain how staffing levels were determined for each unit. Leadership interviews revealed that about half of the residents had dementia or cognitive impairment, there was no formal acuity measure in use, and nursing staff levels were insufficient to meet supervision needs, with reports that residents were getting hurt. The DSD, interim DON, and administrator all acknowledged that the assessment did not clearly address dementia care, supervision requirements, or a method to determine acuity for staffing.
Facility Assessment Missing Staffing Contingency Plan: The facility failed to include a staffing contingency plan for emergencies in its Facility Assessment. The DON stated the assessment covered day-to-day operations but did not address emergency staffing, and the facility's Scope of Care policy also did not mention a contingency plan in the Facility Assessment. CMS guidance reviewed by surveyors stated the assessment must address resources needed for care during routine operations, nights and weekends, and emergencies.
Facility Assessment Not Updated to Reflect Actual Census: The facility failed to maintain an updated average daily census on the Facility Assessment Tool. The ADM stated she was responsible for updating the tool and that it should be updated yearly or as needed when the census changes or when special treatments or services are provided. The assessment listed an average daily census of 80 residents, while the facility census showed 83 residents, and the ADM stated three residents were not accounted for on the tool.
Incomplete Annual Facility Assessment: The facility failed to complete the annual facility assessment for all residents. The DON stated the assessment was incomplete, and the Admin acknowledged it had been attempted but not finished. The DON also described assisting with day-to-day operations, including staffing, equipment, services, and department oversight, while the Admin stated she was acting as facility administrator and was unable to say when the assessment was last completed.
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