Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Based on document review and interview, the facility failed to maintain a complete and accurate Facility Assessment to reflect resident needs and staffing patterns and required competencies.
Findings include:
Review of facility document titled 'Facility Assessment Portfolio' dated August 2021 indicated the following:
* Staffing plan- See attached
Further review of the Facility Assessment failed to include any attachments or a staffing plan.
* Staff Competency- Part 3 of the Facility Assessment indicated Facility resources needed to provide competent support and care for the resident population everyday and during emergencies and included facility staff members health care professionals and medical practitioners. …
Based on review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for it's residents. Specifically, the facility failed to ensure licensed nursing staff were competent in wound care.
Findings include:
Review of the Facility Assessment, dated as reviewed with the QAPI committee, in [DATE], indicated the following:
-Facility Profile indicated the average daily census range: 103 - 108
Part 1 Facility Profile
- Wound Care Manual Annual Review Date [DATE]
- Review of the diagnosis potentially treated at the facility include, Aphasia, Behavioral Health Disorders (Anxiety /Personality/ Dissociative), Bipolar Disorder, Blood Disorders-DVT, PE, Bleeding, Anemia, Sickle Cell,… …
F · No harm, potential for more than minimal, widespreadMay 28, 2026
Based on observation, interview, and document review, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day-to-day care of the population the facility currently serves. Specifically, the facility failed to include information related to safe smoking practices and a safe smoking environment for ten residents identified as active smokers, out of a total census of 109. Findings include:Review of the Facility Assessment, last updated 10/1/25 and reviewed with the QAPI Committee on 10/15/25, failed to include an evaluation of the smoking population and services necessary to meet the needs of the residents, including how the facility needs to be equipped and maintained to protect and… …
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