Failure to Post Required Survey and Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that both recertification survey results and documentation of complaint investigations were readily available for review by residents, families, visitors, and staff. During the recertification survey, it was observed that the survey binder near the main entrance contained only the recertification surveys from the past three years, but lacked the required CMS 2567 forms for complaint investigations and revisits conducted during those years. Specific complaint investigations and revisits were missing from the binder, including those completed on several dates, and there was no documentation of certain desk audits or revisits. Interviews with the interim administrator and corporate nurse confirmed that the facility was aware of the requirement to post the last three years of all annual survey and complaint investigation results, including the CMS 2567 forms. However, upon review, it was verified that this information was not present in the binder as required. Additionally, the facility did not have a policy in place for the posting of survey results.