Failure to Provide Access to Survey Results and Plans of Correction
Penalty
Summary
The facility failed to make the previous three years of surveys, complaint investigations, and any plans of correction readily accessible to residents, families, or visitors. During a facility tour, it was observed that the survey book located at the entrance to the activity room did not contain any surveys, certifications, complaint investigations, or plans of correction from 2022 to the present. Review of the Certification and Survey Provider Enhanced Reporting (CASPER) report confirmed that multiple surveys and complaint investigations, some of which were substantiated and resulted in plans of correction, had occurred during this period. In an interview, the Administrator and DON acknowledged that the survey book had not been updated with the required information for the past three years.