Facility Assessment Lacks Required Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure that its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. Review of the Facility Assessment did not show evidence of participation from these groups in the assessment process. Additionally, the assessment did not address the resources necessary to care for residents during weekends or include a plan to maximize recruitment and retention of direct care staff. Furthermore, the Facility Assessment lacked a contingency plan for staffing needs, which is required to ensure adequate staffing during both routine operations and emergencies without activating the facility's emergency plan. During an interview and document review, the Administrator confirmed that the Facility Assessment was not updated to reflect the latest CMS guidance and acknowledged the absence of required involvement and planning elements.