Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to ensure that the most recent recertification survey and subsequent complaint investigation results were readily available and accessible within the care center. According to the CMS Aspen Central Office database, the most recent standard recertification survey and an abbreviated complaint survey, which included immediate jeopardy findings, had been completed, but their results were not present in the public binder intended for such documents. During an interview, a resident who regularly attended the monthly resident council meeting stated they were unsure where the most recent state agency survey results were kept. A tour of the care center revealed that the only binder labeled for annual survey results did not contain the most recent survey or complaint investigation results. The administrator confirmed that this binder was the sole location for posting survey results and acknowledged that the most recent documents were missing due to an oversight. Facility policy required that the most recent standard survey and state-approved plan of correction be kept in a 3-ring binder in an area frequented by most residents, such as the main lobby or activity room, but this was not followed.