§483.71 Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.
§483.71(a) The facility assessment must address or include the following:
§483.71(a)(1) The facility's resident population, including, but not limited to:
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population, using evidence-based, data-driven "methods" that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under § 483.20;
(iii) The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;
(iv)The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.
§483.71(a)(2) The facility's resources, including but not limited to the following:
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies;
(iv) All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
§483.71(a)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in §483.73(a)(1).
§ 483.71(b) In conducting the facility assessment, the facility must ensure:
§ 483.71(b)(1) Active involvement of the following participants in the process:
(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and
(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.
(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.
§483.71(c) The facility must use this facility assessment to:
§483.71(c)(1) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in § 483.35(a)(3).
§483.71(c)(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.
§483.71(c)(3) Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.
§483.71(c)(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.
§483.71(c)(5) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.
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Observations:
Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.
Findings include:
Review of the facility's facility assessment, dated July 28, 2025, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members.
Interview with Employee E2, Director of Nursing, on March 12, 2026, at 10:20 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment.
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 211.12(c)(d)(1) Nursing services
| | Plan of Correction - To be completed: 05/05/2026
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.
The facility assessment was revised to include input from direct care staff and/or residents. Documentation of participation was completed.
All staff and residents have the potential to be affected by this.
The Administrator was educated by the Regional Administrator regarding requirements for facility assessment, including documentation of staff and resident input.
The Administrator/designee will audit facility assessment compliance monthly x3 to ensure required input is documented. Findings will be reported to QAPI for 3 months. LNHA will monitor results of audit.
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