F0838

F

Incomplete Facility Assessment and Staffing Plan

Charlevoix, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a comprehensive facility-wide assessment that identified the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 1/19/26 showed an incomplete staffing plan that only specified the number of staff needed for a census at or under 50 residents in a 24-hour period and for a census of 63–68 residents in a 24-hour period, with no data for census levels between 51–62 residents and no breakdown of specific staffing needs by shift. Further review showed the assessment did not include a plan to maximize recruitment and retention of direct care staff and did not establish a contingency staffing plan for events that do not trigger the facility’s emergency plan but could affect resident care. In an interview, the NHA acknowledged the lack of specific staffing needs by shift and census and confirmed there was no specific contingent staff policy, stating instead that personnel may come early or stay late and that lead nurses or management may help fill in on the floor.