Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors across all nursing floors and the lobby. The facility's policy, dated April 27, 2017, mandates that survey reports and plans of correction be accessible in a binder located in the resident's day room. However, during a resident council meeting, it was revealed that the residents were unaware of the recent survey results, indicating a lack of compliance with the policy. A facility tour conducted with the Director of Social Services confirmed that the survey results binder in the lobby was outdated, with the last recorded results from November 2024. Additionally, no survey result binders were available on the second, third, and fourth-floor nursing units. The Administrator confirmed that the facility had more recent survey results, but these were not included in the binder in the front lobby, further contributing to the deficiency.
Plan Of Correction
1. Updated survey results book Added survey books to 2nd, 3rd and 4th floor nurses station. All residents have been updated on status of where survey books are located. 2. Survey book location will be added - Flyer in elevator - Admissions Welcome Packet - Reviewed at Residents Council 3. Education provided to medical records who will keep survey books up to date adding the most recent surveys upon receipt of letter/2567. Education provided to staff as to where survey book is so that when residents ask they know where to find. 4. Random audits by the Administrator/designee once a week for one month, twice a week for one month, and then once a month for one month to ensure residents are aware where to find survey results and that the survey books are located in lobby, and nurses station on 2, 3 and 4. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months.