Failure to Provide Complete and Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results, including recertification surveys, complaint investigations, and facility plans of correction, were readily available for review by residents, family, visitors, and staff. During interviews and document review, it was found that a resident with moderately impaired cognition expressed a desire to view the results of state agency surveys but was unable to locate them. Upon inspection, the binder labeled as containing facility survey results was found behind other documents and was missing several required survey reports and plans of correction. Specifically, recertification surveys from certain dates and multiple complaint investigations, as well as associated plans of correction, were not present in the binder. Further interviews with facility staff confirmed that the survey results are considered public knowledge and should be accessible, but the binder did not contain all required documents. The administrator acknowledged difficulty in maintaining the availability of these documents, stating that they often go missing. No facility policy regarding the posting of survey results was provided when requested. This deficiency had the potential to affect all residents, family members, visitors, and staff by limiting access to important regulatory information.