Survey Results Binder Not Readily Accessible: The facility failed to keep the survey results binder in a readily accessible location for residents, families, and visitors. The AD and ADM could not initially locate the binder, staff at the central nurses station did not know where it was, and residents stated they did not know where to find it. When the binder was found, it was missing multiple recent 2567s from survey and complaint/incident investigation visits, despite staff stating the binder was meant to provide access to survey results and complaints.
A facility failed to keep the survey results binder readily accessible and complete for resident and family review. The binder was not posted in a visible common area, there was no sign directing people to it, and it was located behind the receptionist desk where it was not easily seen or reached. The binder contained only the May 2025 annual survey results and was missing prior state visit results; most residents interviewed did not know how to access it, and the DON, Social Worker, Receptionist, and Administrator all described gaps in training and oversight of the binder.
Survey Results Not Readily Available to Residents and Public: The facility failed to keep the most recent survey results posted where residents, family members, and legal reps could easily view them. Surveyors found no hallway signage or binder showing the prior annual survey results, residents in council were unaware of their location, and the ADM later retrieved the 2025 survey results from his desk after stating they were usually kept in the hallway and that the facility had no policy on posting survey results.
A facility failed to make its most recent survey results readily available for residents, family members, and the ombudsman. A survey binder was kept behind the reception desk, and staff including the receptionist and a CNA stated they did not know where it was located without asking the DON or Administrator. The ADM acknowledged the binder should be available for review, but it had remained behind the desk and there was no policy on where it should be placed.
Survey Results Not Posted or Available in Public Binder: The facility failed to keep the most recent standard survey results in the public survey binder and failed to post them in an area readily accessible to residents, family members, and legal representatives. The binder was located behind the receptionist desk, did not include the latest survey findings, and two residents reported they could not access the survey results without asking the receptionist. The ADM acknowledged the binder was not up to date and that residents have a right to review the most recent survey results without requesting them.
Survey Binder Missing Required Survey Results: A white binder labeled "Survey Binder" was available near the entrance, but it contained only one recent health visit's Forms 3614, 3630, and 2567 and did not include the prior recertification survey or other complaint/incident investigation results from the preceding 3 years, or any applicable POC. Residents stated they did not know where recent survey results were located, and the AD and ADM both acknowledged the binder was meant to inform residents and families of survey outcomes and corrections.
Survey Results Binder Not Kept Up to Date: A white three-ring binder labeled "Survey Results" was observed at the entrance, but it did not contain the most recent recertification survey results or several 2567 reports. In a group interview, 13 of 13 residents said they did not know where recent inspection results were located and did not believe they were available to them. The ADM stated it was her responsibility to ensure survey and investigation results were available for residents and the public to view.
Survey Results Not Readily Accessible: The facility failed to ensure a notice of survey results availability was posted in a prominent, accessible location for residents, family members, and legal representatives. Residents interviewed said they were unaware of their right to review survey results and did not know where to find them. The Activity Director stated the resident council had not been informed, and observation showed the survey results binder was behind pamphlets at the front entrance with no visible signage.
Survey Results Not Posted for Resident Review: A facility failed to keep the most recent survey results available in the survey inspection binder for resident and family review. Surveyor observations found the binder behind the reception desk contained older survey results, but not the latest recertification survey. Residents stated they did not know how to view prior survey results, and the ADM said she was responsible for posting the results and believed they may have been removed.
Survey Results Not Available for Resident Review: The facility failed to keep the most recent survey results in the lobby survey binder for resident and family review. Observation showed the binder contained older survey results, and the ADM confirmed the December survey results were not included. The facility policy reviewed did not include language about residents’ right to access the most recent survey results.
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