Nursing Home Guide Not Posted as Required
Penalty
Summary
The facility failed to ensure that the most recent version of the Nursing Home Guide, specifically the 'Nursing Home Inspections Ratings' page, was available and accessible to residents and visitors in the survey binder located in the front lobby. During the survey, it was observed that this required page was not printed or placed in the binder for review. An interview with the Administrator revealed that she was responsible for updating the survey binder but was unaware that the inspection ratings page needed to be included quarterly and did not know how to access the necessary information from the appropriate website. This deficiency was identified through both record review and staff interview, and it was determined that the facility did not meet the statutory requirement to post all pages listing the facility in the most recent version of the Nursing Home Guide in prominent positions accessible to residents and the public.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated by the Consultant Administrator on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. The most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. C) What measures will be put in place or what system change will be made to ensure this will not recur: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. The Administrator, or designee, will audit the Nursing Home Inspection Ratings binder and website weekly to ensure that the most recent Nursing Home Guide is in the binder. Any identified concerns will be immediately addressed. D) How the corrective action will be monitored to ensure the potential will not occur: The Administrator, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.