Deficiency in Posting Survey Results
Summary
The facility failed to ensure that the last three years of survey results were posted in a location readily accessible to residents, family members, and legal representatives, as required by their policy. During the recertification survey, it was observed that the survey results were posted at the resident courtesy phone, which was not in plain view, and not in a location where individuals could examine them without having to ask. This deficiency was evident for five out of eleven residents attending the Resident Council meeting, who stated they did not know where to find the survey results without asking. The facility's policy on posting and availability of survey results and complaint investigations, effective January 2025, mandates transparency and regulatory compliance by posting the most recent survey results in accessible locations and making past reports available upon request. However, observations on multiple units revealed that the survey results from 2022 were not posted, and there was no documented evidence in the Resident Council Meeting Minutes that the location or postings of the survey results were discussed. Interviews with the Administrative Coordinator and the Director of Nursing confirmed that the survey results should have been posted since 2022, and the Administrator stated that the survey results are discussed in resident council meetings and on admission.
Plan Of Correction
Plan of Correction: Approved February 4, 2025 F577 483.10 Rights to Survey Results / Advocate Agency Information SS=C TAG I. The following actions were accomplished for the resident(s) identified in the sample: The social worker met with each resident identified and informed of the facility survey results posting location which is located on the first-floor lobby near the security desk. The facility ensured all 3 years of facility survey results were in the binder readily accessible to residents: #15, #49, #96, #29, #42. All residents indicated were informed by the social worker on 1/28/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility identified all residents, families, and legal representatives as having the potential to be affected. The residents will receive information of the location of the facility’s survey posting during resident council, care plan meeting and upon admission which is located on the first-floor lobby near the security desk. The facility has posted the location of the facility’s survey posting on the units, vestibule entrance and lobby. The Staff Educator will provide education of staff re: location of the survey posting. III. The following system changes will be implemented to ensure continuing compliance with regulations: The facility reviewed the Policy and Procedure titled Posting and Availability of Survey Results and Complaint Investigation to ensure compliance with regulations. The policy was revised on 1/8/2025. The Administrator provided in-service to the Director of Recreation, Director of Social Service on the facility’s policies and procedures entitled “Posting and Availability of Survey Results and Complaint Investigation” to ensure compliance. The facility will post the location of the facility’s survey findings on all units, the vestibule entrance of the lobby and by security desk. The residents will be offered to review the facility survey results during Resident Council. The facility’s survey binder will be reviewed quarterly by the Director of Therapeutic Recreation, Director of Social Services or Designee to ensure three years of facility’s survey results are posted and the residents are aware of survey results location. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The corrective actions will be monitored through quality assurance to ensure the same practice will not recur. The Director of Therapeutic Recreation and Social Services or Designee will develop an audit tool to monitor compliance with facility's survey posting results and ensure accessibility to all residents, families/designated representative. The audits will be conducted monthly for six months or until two quarters are at 100% compliance. The Directors of Therapeutic Recreation and Social Services or Designee will monitor monthly for six months ensuring three years of facility survey results are posted and accessible to all residents, families/designated representative is aware of survey result location on the first-floor lobby near the security desk. The Director of Therapeutic and Social Services/Designee will utilize an audit tool to assess compliance monthly and report findings to the Quality Assurance Committee for six months. Responsible: Executive Director/Administrator will be responsible for ensuring compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Survey Findings Binder Not Updated: A resident council meeting revealed that residents were not aware of where to find the state survey inspection results. Observation of the Survey Findings Binder at the front entrance showed it did not include all 2025 survey findings and had no 2026 survey findings. The ED acknowledged the binder was not updated with the most recent survey results.
Survey results binder near the elevators did not include the facility's POC for the most recent survey or the prior 3 years, and there was no indication that the POCs could be requested from facility staff. The administrator confirmed the missing POCs after reviewing the binder, and the facility did not provide the policy on posting survey results.
The facility failed to keep the DOH survey binder in the main lobby updated with the most recent survey results and any active POC. During observation, the binder was available but only contained a 2024 document, despite more recent surveys having been completed. The NHA stated they were responsible for updating the binder and were unaware it had not been updated since 2024.
Survey results were not readily available or accessible to residents and visitors. A binder at one location contained only an older recertification survey, while the current 2024 and 2025 recertification and complaint survey results were missing from the display area. Residents stated they did not know the survey results were available for review, and staff gave conflicting accounts about where the binders were kept and whether the current results were on the hallway or had been removed for use.
Survey Results Binder Not Readily Accessible: The facility failed to keep the survey results binder in a readily accessible location for residents, families, and visitors. The AD and ADM could not initially locate the binder, staff at the central nurses station did not know where it was, and residents stated they did not know where to find it. When the binder was found, it was missing multiple recent 2567s from survey and complaint/incident investigation visits, despite staff stating the binder was meant to provide access to survey results and complaints.
Survey Results Not Posted in Accessible Public Area: The facility failed to post the recent CDPH annual survey results for 2024 and 2025 in a prominent, accessible location for residents, family members, and visitors. A hallway survey binder contained only Complaint/FRI information and the last standard survey from 2022, and the ADM stated the binder was incomplete and not updated despite annual recertification surveys having occurred.
Survey Findings Binder Not Updated
Penalty
Summary
The facility failed to ensure the state survey inspection results contained the most recent survey results for 1 of 1 facility reviewed for resident council. During the resident council meeting on 7/22/26 at 2 PM, residents in attendance stated they were not aware of where to find the state survey inspection results in the facility. Later that day, at 4:14 PM, observation of the Survey Findings Binder at the front entrance across from the receptionist desk showed that it did not contain all of the 2025 survey findings and had no 2026 survey findings included. At 4:48 PM, Staff 1, the Executive Director, stated the administrator oversaw updating the state survey inspection result binder and acknowledged that the binder was not updated with the most recent survey results.
Survey Results Binder Missing Required POCs
Penalty
Summary
The facility failed to ensure that the plan of correction (POC) for the most recent survey was readily accessible and that the POC for the three preceding years was available upon request. During observation and record review, the survey results binder located near the elevators on the first floor contained survey results from the past three years, but the 2024 and 2025 survey results did not include the facility's POC or indicate that these could be requested from facility staff. The administrator stated that she was responsible for maintaining the binder and confirmed that the POCs for all surveys occurring from 2024 to current were missing from the binder. A request for the facility policy regarding posting survey results was made, but it was not provided.
Survey Binder Not Updated With Most Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in the main lobby. A tour of the facility on July 14, 2026, found the Department of Health Survey binder on the wall in the lobby, but the binder contained a last printed document from 2024. Review of the facility survey history showed a full health survey was conducted on August 7, 2025, and additional abbreviated complaint surveys were conducted in 2025 and 2026. During interview, the Nursing Home Administrator stated they were responsible for updating the survey binder and were unaware it had not been updated since 2024, and confirmed the binder should contain the results of the most recent federal or state survey and any plan of correction in effect.
Survey Results Not Readily Available to Residents
Penalty
Summary
The facility failed to ensure the past 3 years of survey results were readily available and accessible to residents and visitors. During observation, a survey results binder was found in a wall-mounted holder between the oxygen storage room and storage room A, but it contained only the recertification survey results dated 10/17/23 and no recertification or complaint survey results for 2024 or 2025. The administrator reviewed the binder and stated the 2024 and 2025 survey results should have been inside, but staff might have removed them for use. During a Resident Council meeting, residents stated they did not know past survey results were available for review and no one recalled staff informing them where the results were located. Later, the administrator retrieved three survey binders from the opposite side of the building, and the Scheduler stated the facility kept survey results at both building entrances, showed an empty holder outside their office, and stated they had given the 2023 and 2024 binders to the Administrator earlier that day while never having the 2025 results on their hallway.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. During observation and interview, the AD stated she did not know where the survey binder was located, and the AD and surveyors searched the facility without finding the binder containing prior 2567s. The ADM also attempted to locate it and asked nursing staff at the central nurse’s station, but no one knew where it was. Later, a black binder titled survey results was found sitting at the central nurse’s station, but it did not contain the most recent 2567s from multiple survey and complaint/incident investigation visits, including visits dated 07/02/25, 07/17/25, 08/06/25, 03/12/26, 05/07/26, and 07/02/26. During confidential interviews, 13 of 13 residents stated they did not know where the survey binder was located or that the information was available to them. An LVN stated the binder was meant to let residents, families, and visitors know what was going on in the facility and that it should be located somewhere in the front and available to everyone. The DON stated the binder was intended to keep complaints and past surveys accessible and should have been placed in a central location, such as the central nurses station. The ADM later stated he found the binder in an office near the front lobby and acknowledged it should have been easily accessible. The facility policy on Resident Rights stated residents have the right to examine survey results.
Survey Results Not Posted in Accessible Public Area
Penalty
Summary
The facility failed to post the recent California Department of Public Health annual survey results for 2024 and 2025 in areas that were prominent and accessible to residents, resident representatives, family members, and visitors. During an observation in the facility hallway, there was one survey binder hanging on the wall, but it contained only the Complaint and Facility Reported Incidents and the result of the last standard survey dated 2/11/2022. During a concurrent interview and record review, the Administrator stated the survey binder was incomplete and not updated. The Administrator stated the facility had annual recertification surveys in 2024 and 2025 and that he was responsible for placing the survey results for the past 3 preceding years in the binder. The Administrator also stated the updated survey results should be available and accessible to the public for transparency. Review of the facility's Resident Rights policy stated residents have the right to examine survey results, and the admission agreement stated the resident has the right to examine the results of the most recent survey and any plan of correction in effect, and that these should be posted in a place readily accessible to residents, family members, and legal representatives.
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