Failure to Complete Comprehensive Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, last updated on 3/10/2025, included input from the Administrator, Director of Nursing Services, Director of Environmental Services, and Medical Director, but lacked involvement from direct care staff such as Registered Nurses, LPNs, Nursing Assistants, or their representatives. Additionally, there was no evidence that input from residents, their representatives, or family members was solicited or considered in the assessment process. Further review revealed that the facility assessment did not include a plan to maximize recruitment and retention of direct care staff. During an interview, the Administrator confirmed that neither direct care staff nor residents, family, or their representatives were involved in the assessment, and acknowledged the absence of a recruitment and retention plan as required by regulation.