F0577

E

Failure to Inform Cognitively Intact Residents of Survey Results and Their Location

Reseda, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were notified of the existence and location of the most recent standard survey results, as required by 42 CFR 483.10(g)(10)-(11). Ten cognitively intact residents, each with various medical diagnoses such as hypertension, osteoarthritis, hypotension, anemia, and generalized muscle weakness, were identified as not being informed about the survey results. These residents had documented decision-making capacity on their MDS assessments, indicating they were capable of understanding and using such information.

Review of resident council meeting minutes for multiple dates showed no documentation that residents were informed about the survey results or where they could be found. During a resident council interview, ten of eleven participating residents stated they were not aware that survey results were available for them to review and did not know where the survey results were located. They also reported that no one had told them about the survey results.

Surveyors observed that survey result binders containing the most recent recertification survey were posted in holders near dining room entrances and a nursing station on various floors, indicating that the physical posting requirement had been met. However, during interviews, the Activities Director acknowledged that she had not informed residents during resident council meetings about the existence or location of these survey results, despite recognizing the importance of residents knowing about them. The DON similarly stated that residents should be made aware of the previous year’s survey results and their location, confirming that residents’ rights to examine survey results and receive related information had not been fully implemented in practice.

Plan Of Correction

F-577 Corrective Action for Affected Residents: The Administrator or designee met with Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 2, during resident council or individually to inform them of the existence of the most recent survey results, the location of the survey results binder on each floor near the dining room entrance and next to the consumer board in JEK, and their right to review these results at any time. The Administrator or designee provided each resident with written information documenting the location of the survey results on their respective floors.

Identifying other Residents having the Potential to be Affected: The Administrator or designee met with residents during resident council meeting on 3/19/26 and informed them of the existence and location of the most recent survey results. The Director of Activities made announcements in all main dining rooms to inform them of the existence of the survey results dated, the location of the survey results binder on their floor, and their right to review the results.

Measures put into place or Systemic Changes: The Administrator or designee will notify residents of the existence and location of survey results during the resident council meetings at least quarterly. The Activities Director (AD) or designee added a standing agenda item to resident council meetings to inform residents of the existence and location of survey results, ensuring this information is communicated at least quarterly. The AD or designee will document this notification in the resident council meeting minutes.

Plan to Monitor Performance: Beginning 4/6/26, Director of Activities or designee will ask residents during resident council and during randomly to verify they are aware of location and existence of survey findings. The Director of Activities or designee will report audit results, including any identified deficiencies and corrective actions taken, to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.