Failure to Make All Survey Results Available for Review
Penalty
Summary
The facility failed to ensure that all recertification survey results and additional complaint investigation findings were available for review by residents, families, staff, and visitors. During an observation, only some of the required survey results were found in the designated folder outside the Social Services office. Specifically, the folder contained results from the most recent recertification and a limited number of complaint investigations, while several other complaint investigation results with cited deficiencies were missing. The administrator confirmed responsibility for managing the posting of survey results and acknowledged awareness of the requirement to make all 2567 forms available for review, but admitted that not all necessary documents had been printed or placed in the folder. Further review of the facility's records against the Aspen Central Office (ACO) documentation revealed that multiple complaint investigations with deficiencies were not present in the facility's survey results folder. The licensed social worker reported having temporarily removed some documents due to disarray but returned them to the administrator. Despite this, a comparison with ACO records showed that several required survey results remained unavailable for public review. The facility's policy, referencing Minnesota Statute § 144A.10, Subdivision 3, mandates the posting of all correction orders and notices of noncompliance in a conspicuous and accessible location, a requirement that was not fully met.