Failure to Inform Residents of Survey Results Location: The facility did not notify residents of the existence or location of the most recent survey results and CMS-2567. Ten cognitively intact residents with diagnoses including HTN, OA, muscle weakness, hypotension, and anemia stated they were not aware of the survey results or where to find them. Resident council minutes did not show that survey results were shared, and staff interviews confirmed residents had not been told about the survey binder posted near the dining area and nursing station.
The facility failed to inform cognitively intact residents about the existence and location of the most recent survey results, despite having survey binders posted near dining areas and a nursing station. Multiple residents with conditions such as HTN, osteoarthritis, hypotension, anemia, and muscle weakness, all assessed as capable of daily decision-making, reported during a resident council interview that they were unaware survey results were available or where they were kept. Review of resident council minutes showed no evidence that survey results were discussed, and the AD acknowledged not telling residents about the survey results or their location, while the DON confirmed residents should have been made aware of this information.
A facility failed to make the survey binder with the most recent survey results and CMS-2567 readily accessible to residents and visitors. During a Resident Council meeting, all residents present said they did not know where the binder was located, and an observation showed it placed on a shelf about 5.6 feet above the floor across from the nurses' station. The DON confirmed the binder was not in a readily accessible location, despite the facility policy requiring survey results or a notice of location to be posted in a readily accessible place.
Survey Results Not Accessible to Residents: Survey results binders were observed in dining room corners and reflected only the last survey date, despite the Administrator stating additional surveys had occurred. Five residents said they were not aware of the most recent survey results or where to find them. The facility policy required the most recent survey, complaint investigations, and any plan of correction to be available in prominent, accessible public areas.
A facility failed to notify residents where to find the most recent survey results and failed to post the CMS-2567 in the survey binder. During a resident council meeting, several residents said they did not know the survey results existed or where they were located. The AD said residents were only told to ask the business office, and the DON confirmed the binder was incomplete. The residents involved were cognitively intact or mildly/moderately impaired and required setup assistance with ADLs.
Failure to make survey results readily accessible: the facility did not post the most recent CMS-2567 in a location residents, visitors, or others could easily view without asking staff. Resident council members said they did not know where the survey binder was or whether it was available for review, while the AD, Admin, and Maint. D gave conflicting information about its location and accessibility. The facility’s Resident Rights policy stated residents have the right to examine survey results.
Survey results were not readily accessible to residents, family, or visitors. During a Resident Council meeting, residents said they had not seen the state survey results and did not know where they were located. The ADM retrieved the survey binder from a locked room that required staff assistance to access and confirmed there were no signs showing its location, despite the facility policy stating residents have the right to examine survey results.
Survey Results Binder Not Readily Identified: Three of four residents polled at a resident council meeting did not know where the survey results binder was located. The ADM verified the binder locations and confirmed there was no sign at one site indicating where to find it. The ADM also stated the facility had no policy and procedure for posting or making survey results accessible.
A facility failed to ensure that eight of 11 sampled residents knew where to find the survey results binder. During a resident council meeting, most residents polled did not know its location, and the DON and ADM later confirmed the binder was located without any signs posted at that site or elsewhere in the facility.
The facility did not ensure that the most recent federal survey results were accessible to residents, family members, or legal representatives. Residents were unaware of where to find the survey results, and staff, including the IP and ADM, could not locate the survey results binder, which was supposed to be by the front door but was missing during inspection. The DON confirmed that without the binder, residents could not review the survey findings or know what the facility was addressing.
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