Failure to Provide Accessible Survey Results to Residents
Penalty
Summary
The facility failed to ensure that residents were aware of the availability and location of the most recent survey results, as well as the corrections made for identified deficiencies. During a Resident Council Meeting attended by nine residents, it was revealed through interviews and observations that none of the residents knew where to find the survey results or how to access information about the facility's corrective actions. Activity staff confirmed that all present residents were unsure of the survey results' location, and this was further corroborated by direct questioning and translation for non-English speakers. Subsequent observations showed that the survey result binder was either missing from its designated location or did not contain the latest survey results and plan of correction. The Administrator acknowledged that the binder was being updated in his office and that staff had not followed instructions regarding its maintenance. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the survey results and corrective actions should be accessible to residents, families, and staff without the need to request them from facility personnel. A review of facility policy also indicated that survey results should be posted in a readily accessible location.