Failure to Provide Access to Required Survey Results and Plans of Correction
Penalty
Summary
The facility failed to ensure that the survey result binder included the most recent three years of recertification survey results and their associated plans of correction, as required by policy. Upon review, it was found that the binder only contained the 2024 annual recertification survey results and plan of correction, while the 2022 and 2023 survey results and their associated plans of correction were missing. This omission was confirmed during multiple reviews of the binder and through interviews with the Director of Nursing and the Administrator, both of whom acknowledged the absence of the required documents. The facility's policy mandates that copies of the most recent and three preceding years of standard surveys, including any follow-up reports and state-approved plans of correction, be accessible in an area frequented by residents, their representatives, and visitors. The lack of the 2022 and 2023 survey results and plans of correction in the binder prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's responses to deficiencies.