Facility Assessment Lacked Required Stakeholder 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, residents, residents' representatives, and family members. The assessment dated 5/14/25 did not show evidence that these groups were actively involved in its development, as required by federal regulations and recent CMS guidance. This omission was confirmed during an interview and document review with the Administrator, who acknowledged the lack of participation from these key stakeholders. Additionally, the Facility Assessment did not include a plan to maximize recruitment and retention of direct care staff. The assessment also failed to address contingency planning for staffing needs in situations that do not require activation of the facility's emergency plan. These elements are specifically required by CMS regulations to ensure that the facility is prepared to meet resident care needs under various circumstances, including weekends and non-emergency events. The deficiency was identified through a review of the facility's documentation and interviews with facility leadership. The Administrator verified that the Facility Assessment had not been updated to reflect the latest CMS guidance and did not contain the required components related to staffing plans and stakeholder involvement. All residents were considered to be affected by this deficient practice, as the assessment is intended to address the needs of the entire resident population.
Plan Of Correction
5. Corrective action completion date: 8/23/2025 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee this process. Administrator will make sure any changes to facility assessment regulation, facility assessment will be updated. Annually, IDT team will update facility assessment with inputs from required representative. Administrator will present facility assessment for approval annually and when changes were made during monthly QA meeting. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025 for approval. Corrective action completion date: 8/23/2025