Survey Results Not Accessible to Residents
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Survey results were not fully posted in the lobby binder for residents, staff, and visitors to review. A review found that several recent complaint investigation survey findings were missing from the binder, and the administrator acknowledged the binder was intended to display survey results from the past 3 years and remain updated at all times per facility policy.
Survey Results Not Posted for Resident Review: A facility failed to keep the most recent survey results available in the survey inspection binder for resident and family review. Surveyor observations found the binder behind the reception desk contained older survey results, but not the latest recertification survey. Residents stated they did not know how to view prior survey results, and the ADM said she was responsible for posting the results and believed they may have been removed.
A facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. Observation showed there was no sign identifying where the survey binder was located, and an LPN found the survey in a black binder on the front reception desk without any notice directing people to it. The facility policy stated the survey results should be kept in a binder in a common area frequented by residents.
Failure to make survey results available. Observation showed the state agency results book was not available for residents and visitors to view. An Administrative Staff D stated a survey book existed but did not know where it was, and the facility could not provide a policy on past survey results availability.
Survey Results Binder Not Readily Available: The facility failed to post the location of survey results and did not place the survey binder in an identifiable location. Residents stated they were unaware they could review prior survey results and did not know where the binder was located. The receptionist was not familiar with the binder or its location, and the ADM stated the binder should have contained the past 3 years of surveys and complaint investigations, but the signage directing residents and visitors to review it was not readily available.
A facility failed to make the most recent survey results and any plan of correction readily accessible to residents and visitors in the Lobby and Activity Dept. The lobby binder did not contain the last full health survey results or the 2025 POC, and there was no binder in the Activity Dept. The NHA confirmed the survey results were not readily accessible.
Survey Results Not Fully Posted
Penalty
Summary
The facility failed to ensure that all recent survey results were posted in an accessible location for residents, staff, and visitors. During review of the survey binder located on a table on the side wall of the lobby, the binder was found to be missing information from complaint investigation surveys completed on 12/31/25, 4/2/26, 4/8/26, and 5/15/26. The review was completed to verify that surveys from the last recertification completed on 2/14/25 and subsequent follow-up surveys, including complaint investigations and findings, were available for review. On 6/2/26 at 2:16 p.m., the administrator reviewed the binder and acknowledged that the listed survey results were lacking. The administrator stated the binder was intended to reflect survey results from the past three years so the information would be available for residents, visitors, and family members to review if they wished. The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, stated that residents had the right to be aware of certain location information concerning facility operations, as well as their right of appeal and advocacy, and that the required information was to be kept posted in a visible place, accessible to all residents, and updated at all times.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. Surveyor observation on 06/02/2026 at 10:45 AM found a white binder labeled "Survey Inspection Results" on a shelf behind the reception desk that was reachable to passersby, including those in wheelchairs. The binder contained survey results dating back to 2022, but the most recent survey included was dated 07/31/2025, and the results from the most recent recertification survey dated 12/31/2025 were not present. A follow-up observation on 06/03/2026 at 1:13 PM showed the binder still lacked the 12/31/2025 survey results. During a confidential group interview, five anonymous residents stated they did not know how to view prior survey results, and three said they would like to view the most recent survey. The ADM stated during an interview on 06/04/2026 at 4:00 PM that she had checked a survey readiness checklist on 05/11/2026 and the results were not there, so she printed them and put them in the book, but she could not explain what happened and believed someone must have removed them. She stated she was responsible for ensuring the most recent survey results were posted for the public and that her habit was to place the results right after survey.
Survey Results Not Readily Posted
Penalty
Summary
The facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives of residents. On 06/01/26 and 06/02/26, observation showed there was no readily accessible posting identifying where the most recent survey results could be found. On 06/02/26 at 12:20 PM, when asked where the most recent survey was located, Nurse Consultant CC found it in a black binder on the front reception desk, but there was no sign notifying residents, family members, or representatives where the results were located. Nurse Consultant CC stated the facility should have a sign indicating where the survey results were located so residents, family members, or residents' representatives could view them. The facility policy stated that copies of the most recent survey and related reports would be maintained in a three-ring binder in an area frequented by most residents, such as the main lobby or resident activity room.
Failure to Make Survey Results Available
Penalty
Summary
The facility failed to post the previous state inspection information in a location accessible to residents and visitors. On 06/01/2026 at 07:37 AM, observation showed that the state agency results book was not available. During an interview on 06/03/2026 at 01:40 PM, Administrative Staff D stated that there is a survey book for the facility, but she did not know where it was. The facility was unable to provide a policy related to the availability of past survey results.
Survey Results Binder Not Readily Available
Penalty
Summary
The facility failed to post the location of the survey results and failed to place the survey binder in an identifiable location. During an interview with Resident Council on 05/21/2026 at 1:32 PM, residents stated they were unaware they could review previous survey results and did not know where the survey binder was located. Observations on 05/18/2026 at 9:00 AM, 05/19/2026 at 2:00 PM, 05/22/2026 at 10:30 AM, and 05/26/2026 at 9:00 AM showed a sign at the reception desk stating that reports of surveys, certifications, and complaint investigations for the preceding three years were available for any individual to review upon request. During interviews on 05/26/2026, the receptionist stated they were not familiar with the survey binder and did not know where it was located, and the Administrator stated the survey binder should have included the past three years' surveys and complaint investigations and that the signage referring residents and visitors to the Administrator to review the binder did not meet expectations because it was not readily available.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent survey results and any plan of correction were readily accessible to residents and visitors in two of two areas, the Lobby and the Activity Department. During observations, the Nursing Home Administrator and surveyor reviewed the facility posting that stated prior Department of Health survey results were available in a binder in the lobby and in the activity department. Upon inspection, the binder in the lobby did not contain the last full health survey results or the plan of correction for 2025, and there was no binder in the activity department to review. During interview, the Nursing Home Administrator confirmed the facility failed to make the Department of Health's most recent survey results readily accessible to residents and visitors.
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