F0838

F

Incomplete Facility Assessment for Staffing Recruitment, Retention, and Contingency Planning

Robbinsdale, Minnesota Survey Completed on 03-17-2026

Penalty

Fine: $89,050

Summary

The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that included all required components related to staffing resources. The facility assessment dated 12/17/25 did not contain a plan to maximize recruitment and retention of direct care staff, despite this being a required element. The assessment also lacked a contingency plan for situations that did not trigger the formal emergency plan but could still affect resident care, such as issues with the availability of direct care nurse staffing or other care resources. During an interview on 3/13/26 at 3:32 p.m., the administrator acknowledged that while a recruitment plan existed, it was not incorporated into the written facility assessment, and further stated that the assessment did not include a staff retention plan or a plan to address direct care staffing needs outside of the emergency plan. A policy governing how the facility assessment should be conducted and documented was requested by surveyors but was not provided.

This failure had the potential to affect all 71 residents in the facility, as the incomplete assessment did not fully address how necessary staffing resources would be ensured during routine operations, nights, weekends, or non-emergency events that could impact resident care.