Failure to Make Survey Results and Reports Readily Accessible
Penalty
Summary
Facility staff failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and resident representatives. Observations revealed that only a sign indicating the survey book was available upon request was posted at the front security desk, rather than the actual survey results. When a resident's representative requested the most recent survey results, she was provided with an outdated report from 2022. Additionally, during a surveyor's visit, the front desk staff were unable to immediately locate the survey book and had to refer the surveyor to the Administrator. The Administrator confirmed that only the 2024 survey report was available at the front desk at that time. Further investigation showed that the facility did not have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect, available upon request for review by any individual. The Administrator acknowledged the absence of these reports during the surveyor's inquiry. The deficiency was identified through direct observation, staff interviews, and review of the available documentation, which confirmed that the facility did not meet the requirements for making survey results and related reports accessible to residents and the public.