Failure to Maintain Accurate and Timely Facility Assessment
Penalty
Summary
The facility failed to review and update its Facility Assessment accurately and in a timely manner, as required by regulations. During the annual recertification survey, the Administrator provided a copy of the Facility Assessment that was outdated, listing former staff members—including the Administrator, DON, Medical Director, Medical Records staff, Social Services Director, and MDS Coordinator—who were no longer employed at the facility. The assessment also contained outdated information regarding the COVID-19 pandemic, referencing the federal Public Health Emergency that had already ended. When the surveyor pointed out these inaccuracies, the Administrator attempted to provide updated versions of the Facility Assessment. However, subsequent versions continued to include outdated information, such as references to the pandemic and incorrect documentation of the governing body and staff involved in the assessment. The Administrator acknowledged missing several areas that required updating and recognized the need for further revisions during the survey process. Throughout the survey, the facility was unable to present a current and accurate Facility Assessment that reflected the present staff, governing body, and relevant operational information. The repeated provision of outdated and inaccurate documents demonstrated a failure to conduct and document a comprehensive, up-to-date facility-wide assessment as required for both day-to-day operations and emergency preparedness.