Facility assessment was not updated after a change in the contracted medical provider group. The assessment still listed the prior vendor as the primary medical practitioners and did not reflect the new attending MD, on-call coverage, or the qualifications, availability, scope of services, and clinical responsibilities of the newly contracted medical group. The Administrator confirmed the change had occurred and that the assessment language had not been revised.
Facility Assessment Did Not Include Nicotine Dependence: The FA failed to list nicotine abuse or addiction among the facility’s common diagnoses and conditions and did not document the number of residents with active or current substance use disorders. The DON confirmed the FA was incomplete, even though three residents were current cigarette smokers/vapers and the facility had a designated smoking area accessed through the main entrance.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Incomplete Facility Assessment and Staffing Documentation. The facility failed to keep its facility-wide assessment complete and current. The assessment listed an average of nine nurses and twenty-one nurse aides, but the CEO stated it was not reviewed after a change in administration and did not include required staffing levels. The CEO confirmed the staffing numbers were not accurate and were not updated to reflect current operational needs or admin changes, including the CEO and CNO.
Facility Assessment missing staffing requirements based on average census. The Facility Assessment lacked documented evidence for adequate staffing levels tied to the facility’s average census, and staffing plans did not include average census or staffing levels per shift. An Administrator confirmed the staffing plans did not show how the facility would meet resident care needs, despite the facility policy stating staffing decisions were based on resident assessments and plans of care.
The facility failed to provide nursing services in accordance with its FA for resident needs and resources. The FA called for 5 CNAs on day and evening shifts and 3 CNAs on night shift, but staffing schedules showed multiple shifts with fewer CNAs than required across several months. The Administrator and DON confirmed the staffing variances, stated the FA was followed for staffing needs, and acknowledged contracted CNA staff was available but was not used during the staffing shortages.
Facility Assessment Missing Staffing Plan: The facility assessment tool did not include a staffing plan. Instead, it contained a sample staffing schedule with staff names for each unit and shift, and the Administrator confirmed it lacked the required plan identifying the number of LPNs and CNAs needed on every shift. The staff scheduler said staffing was based on the sample schedule and training from the former HR director rather than a formal staffing plan.
Facility assessment policy was not updated to reflect current CMS guidance requiring active involvement of direct care staff and input from residents, resident representatives, and family members. The assessment tool did not document input from CNAs or floor nurses, and the Administrator could not provide evidence showing how direct care staff were involved in determining the staffing plan. The Administrator and DON confirmed the policy had remained unchanged since 2017 despite awareness of updated CMS guidance.
Surveyors found that the Facility Assessment did not include nicotine dependence or addiction among the common diagnoses, despite five residents being current smokers and a designated smoking area in use. The Interim DON confirmed that the FA lacked documentation of residents with substance use disorders, contrary to facility policy and CDC guidance.
The facility did not document the frequency of required staff trainings in its Facility Assessment and failed to identify all staff required for QAPI training, as confirmed by the Administrator and review of facility policy.
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