Facility Assessment Lacks Required Stakeholder Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, their representatives, residents, residents' representatives, and residents' family members. Review of the assessment and interviews with the Administrator confirmed that these groups were not actively involved in the development process. Additionally, the assessment did not include a plan to maximize recruitment and retention of direct care staff, nor did it contain a contingency plan for staffing needs. These omissions were identified during a review of the facility's assessment and an interview with the Administrator, who verified the lack of involvement from key stakeholders and the absence of required plans. The Administrator also acknowledged that the Facility Assessment had not been updated to reflect the latest CMS guidance, as outlined in QSO-24-13-NH, which requires these elements to be addressed.