Failure to Include Staffing and Resource Contingency Plan in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its facility-wide assessment included a written contingency plan, informed by that assessment, to address the availability of nursing staff and other resources during events that did not require activation of the formal emergency plan but had the potential to affect resident care. Record review of the 2025 facility assessment showed that it did not identify or contain such a contingency plan for staffing and resources for non-emergency events. This omission had the potential to affect all 38 residents in the facility. During interviews, the Assistant Administrator stated she was unaware that a contingency plan for staffing and resources for non-emergency events needed to be addressed in the facility assessment and was uncertain why it had not been completed. The DON confirmed there was no written plan specifying what to do when the facility experienced an event that could affect resident care and did not know why such a plan was not in place. The Administrator reported that the facility assessment was reviewed and revised annually but acknowledged that the written contingency plan informed by the assessment was not included, noting that management turnover beginning in 2025 had been complex, while recognizing the facility still had the responsibility to meet the facility assessment requirements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.