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. The assessment also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. This was identified through interviews and a review of facility documents, which showed that the Facility Assessment dated 7/1/24 did not reflect the updated CMS guidance issued in June 2024. During an interview and document review, the Administrator confirmed that he was unaware of the new CMS requirements and acknowledged that the Facility Assessment had not been updated accordingly. The Administrator verified that there was no evidence of active involvement from the required parties in developing the assessment, nor were there plans addressing recruitment, retention, or contingency staffing needs included in the document.