Failure to Post Recent Survey and Investigation Results for Resident and Family Access
Penalty
Summary
The facility failed to post the results of the most recent surveys and investigations, including plans of correction, in a location readily accessible to residents, family members, and legal representatives. During an observation, surveyors found that the only available information was a survey binder in a bin labeled "survey binder" near the first hall to the right of the nurses' station, with a sign indicating its location. Review of this binder showed it contained only the last standard recertification survey dated 10/29/2024 and did not include any subsequent investigation findings. In an interview, the Administrator stated he was responsible for updating the survey binder but was unaware that investigation findings, along with their plans of correction, also needed to be included. He confirmed that the last survey results placed in the binder were from the 10/29/2024 standard survey and acknowledged that investigation findings from 1/26/2025, 3/07/2025, 5/25/2025, 8/01/2025, 10/16/2025, 11/07/2025, and 1/15/2026 were not posted. He reported that no one had requested these investigation findings and that mock surveys conducted by administrators from sister facilities had not identified the omission. The Administrator also stated he did not know if the facility had a policy regarding survey result posting, and no such policy was provided at exit conference.
