Facility Assessment Lacks Required Input 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, direct care representatives, residents, residents' representatives, and family members. The assessment did not document participation from these groups, as verified by the Administrator during an interview and document review. Additionally, the assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. The deficiency was identified through a review of the Facility Assessment and confirmed by the Administrator, who acknowledged that the assessment was not updated to reflect the latest CMS guidance. The lack of comprehensive input and planning in the assessment process had the potential to result in unmet care needs for residents, particularly if the facility's population needs and available resources were not fully identified and addressed.