Survey Results and Plan of Correction Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that its survey binder included the recertification and complaint survey results, along with the associated plans of correction, for two of the three preceding years reviewed. During reviews of the survey binder on two separate occasions, it was found that the binder did not contain the required recertification survey results and plans of correction dated 07/22/2024, nor the complaint survey results and plans of correction dated 08/16/2024 and 03/19/2025. The administrator, who was responsible for maintaining the survey binder, confirmed during an interview and joint record review that these documents were missing and acknowledged they should have been included. This omission prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plans of correction, as required by regulation.