Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to comply with the requirement to post the most recent Federal or State survey results in a location that is readily accessible to residents, family members, and legal representatives. During an observation on April 1, 2025, it was noted that the survey binder located in the main entrance lobby contained survey results dated August 2023, despite a more recent survey having been conducted on March 19, 2025. In an interview conducted on April 2, 2025, the Nursing Home Administrator acknowledged the expectation that the survey books should be up to date and confirmed that they had been updated. However, the failure to post the most recent survey results was identified as a deficiency, indicating non-compliance with the regulatory requirements outlined in 42 CFR Part 483 Subpart B and the 28 PA Code.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. 1. At time of discovery, the survey binder was updated to include the most recent surveys. 2. Education was provided by the Director of Operations to the Nursing Home administrator on updating the binder after a survey is cleared and the results are posted. 3. An audit will be conducted weekly x 4 by the NHA or designee to verify that any surveys within the prior week have been included in the public binder. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.