A facility, with the participation of the resident and the resident’s guardian or resident’s representative, as applicable, must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident’s medical, nursing, mental health, psychosocial, and habilitation needs that are identified in the resident’s comprehensive assessment that allows the resident to attain or maintain the highest practicable level of independent functioning and provide for discharge planning to the least restrictive setting based on the resident’s care needs. The assessment shall be developed with the active participation of the resident and the resident’s guardian or resident’s representative, as applicable.