Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for all residents to review, as required by their policy. The policy, revised in April 2017, stated that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' dayroom. However, during observations on March 5, 2025, the survey results could not be found in the facility. Interviews with various staff members revealed a lack of awareness and communication regarding the location of the survey results binder. The Activities Director was unaware of the requirement for the survey results to be available without asking, and the Social Services Director last saw the binder three weeks prior when the state surveyors were present. Further interviews indicated that the Administrator and the Director of Nursing (DON) were also unaware of the binder's current location. The DON admitted to taking the binder on March 3, 2025, to update it with the most recent survey and forgot to return it to its designated location. This oversight resulted in the survey results binder not being available in its usual location for that week. The Administrator and DON both confirmed that the survey results binder should be accessible to all residents, highlighting a breakdown in the facility's process for maintaining compliance with their policy on survey result accessibility.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Within 5 minutes the survey binder was located and put in the correct position. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Once we were notified that the survey binder was missing, it was located within two minutes and returned to the front desk of the facility. The survey binder had only been away from the front for less than 24 hours. It was temporarily taken to the copier for updates following a deficiency received through RSS on February 28th. During the rush of the survey, the facility inadvertently forgot to place it back at the front. To prevent recurrence of this issue, we have placed a laminated sign that reads "DO NOT REMOVE SURVEY BINDER FROM TABLE FOR ANY REASON." In instances where the survey binder needs updating, staff will ensure it is promptly returned to the front desk. In addition, the facility educated all staff in-service on 3/28/25, emphasizing where the survey binder is located and the importance of residents and residents' families having access to these results. How the facility plans to monitor its performance to make sure that solutions are sustained: For the next three months, the Activities Director will conduct a weekly audit to ensure that the survey binder is consistently located on the front table by the entrance of the building. Additionally, these audit findings will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: All corrective actions will be completed by March 28, 2025.