Failure to Provide Accessible Survey Results and Advocate Agency Information
Penalty
Summary
The facility failed to ensure that residents could easily view the results of the most recent survey and access information about advocate agencies, as required by facility policy and regulatory standards. Although the policy stated that survey results would be posted in a place readily accessible to residents, family members, and legal representatives, observations and interviews revealed that this was not consistently implemented. During a Resident Council Meeting, all residents present reported not knowing where to find the survey results. A walkthrough showed that the binder containing survey results was placed on a second shelf in the lobby, partially obstructed by a sign listing visiting hours, and there were no signs indicating the availability of survey results in the lobby or on any of the facility's units or hallways. Further interviews with facility staff, including the administrator, receptionist, and DON, confirmed that the survey results were sometimes kept in the administrator's office and not always available in the lobby as intended. Staff were unaware of any signage indicating the location of the survey results, and at one point, the binder was missing from its usual location in the lobby. These actions and inactions resulted in residents and visitors not having clear or consistent access to the survey results or information about advocate agencies, contrary to facility policy and regulatory requirements.