Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors in three key locations: the first-floor lobby, and the nursing units on the fourth and sixth floors. During an interview, four residents expressed that they were unaware of where the survey results were located. Observations revealed that signage in the lobby, fourth floor, and sixth floor indicated that survey results could be found on the 1st, 4th, and 6th floors, but the survey result book was not found in the lobby or the sixth floor. On the fourth floor, the survey result book was found behind empty folders and contained outdated survey results from 2023, despite the most recent survey being conducted on 2/12/24. The Director of Nursing confirmed the facility's failure to make the Department of Health's most recent survey results readily accessible to residents and visitors. This deficiency was identified through observations and interviews, highlighting a lack of compliance with the requirement to post survey results in a place that is easily accessible to residents, family members, and legal representatives. The facility did not meet the regulatory requirement to ensure transparency and accessibility of survey results, as evidenced by the inability of residents and visitors to locate the necessary information in the designated areas.
Plan Of Correction
No residents were affected by not having access to the survey results. Previous years surveys have been printed and placed in the survey binders. The Director of nursing was educated on Access to survey results. The Director of nursing will audit the binders monthly for up-to-date 2567 information. Findings will be reported in quality assurance and process improvement meetings.