Failure to Maintain Current Facility Assessment and Address Emergency Medical Equipment Needs
Penalty
Summary
The deficiency involves the facility’s failure to conduct and maintain an accurate, comprehensive facility-wide assessment that reflects necessary resources, including emergency medical equipment, and current administrative leadership. The facility assessment reviewed on 2/3/2025 listed various medical and non-medical equipment such as Hoyer lifts, sliding boards, transfer devices, grab bars, wheelchair-accessible transportation, feeding tube equipment and bolus services, wheelchairs, specialty cushions, air mattresses, nebulizer and oxygen services, and noted that the facility did not have access to rental CPAP and BiPAP machines, requiring new admissions after 1/1/2024 to provide their own devices and supplies. However, the assessment did not address emergency medical equipment required to meet residents’ emergent medical needs. In addition, the assessment did not show evidence of participation or sign-off by the current Medical Director, Director of Nursing, Administrator, Social Worker, or a representative from the Governing Body. During an interview, the Administrator stated he had been in the position for only a month and had not yet reviewed the facility assessment, despite acknowledging that the assessment must be reviewed at least annually and when there are changes in administrative staff. The Director of Nursing had been in the role since July 2025, yet the assessment had not been updated to reflect the current administrative team. Facility policy on the Governing Body indicated that the Skilled Nursing Administrator is responsible for annual review and ongoing updates of the facility assessment as needed, with data reported to the Governing Body and reviewed through QAPI programs. Despite this policy, the assessment remained outdated and incomplete regarding both administrative staff changes and emergency medical equipment needs at the time of the survey.
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