Survey Results Not Accessible to Residents
Summary
The facility failed to ensure that the most recent survey results were readily accessible for all residents to review, as required by their policy. The policy, revised in April 2017, stated that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' dayroom. However, during observations on March 5, 2025, the survey results could not be found in the facility. Interviews with various staff members revealed a lack of awareness and communication regarding the location of the survey results binder. The Activities Director was unaware of the requirement for the survey results to be available without asking, and the Social Services Director last saw the binder three weeks prior when the state surveyors were present. Further interviews indicated that the Administrator and the Director of Nursing (DON) were also unaware of the binder's current location. The DON admitted to taking the binder on March 3, 2025, to update it with the most recent survey and forgot to return it to its designated location. This oversight resulted in the survey results binder not being available in its usual location for that week. The Administrator and DON both confirmed that the survey results binder should be accessible to all residents, highlighting a breakdown in the facility's process for maintaining compliance with their policy on survey result accessibility.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Within 5 minutes the survey binder was located and put in the correct position. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Once we were notified that the survey binder was missing, it was located within two minutes and returned to the front desk of the facility. The survey binder had only been away from the front for less than 24 hours. It was temporarily taken to the copier for updates following a deficiency received through RSS on February 28th. During the rush of the survey, the facility inadvertently forgot to place it back at the front. To prevent recurrence of this issue, we have placed a laminated sign that reads "DO NOT REMOVE SURVEY BINDER FROM TABLE FOR ANY REASON." In instances where the survey binder needs updating, staff will ensure it is promptly returned to the front desk. In addition, the facility educated all staff in-service on 3/28/25, emphasizing where the survey binder is located and the importance of residents and residents' families having access to these results. How the facility plans to monitor its performance to make sure that solutions are sustained: For the next three months, the Activities Director will conduct a weekly audit to ensure that the survey binder is consistently located on the front table by the entrance of the building. Additionally, these audit findings will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: All corrective actions will be completed by March 28, 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Survey results were not readily visible for residents and visitors to access without asking. The admin stated the survey book was kept behind the front desk in a holder, but a chest-high partition blocked it from view even though a posted sign said the annual state survey results were available and readily accessible 24 hours daily. During a resident council interview, a resident said the survey results were there, but they had to ask for them.
Survey results were posted only in the lobby, and residents on two units were not aware of where to find them. Residents reported they could not access the lobby because the elevator required a code, and the NHA confirmed the results were not posted in a location readily accessible to residents.
Facility staff did not ensure that residents knew they could review the survey results binder or where it was located. In a resident group meeting with the council president and several residents, all attendees reported they were unaware of their ability to access the survey book and could not identify its location, with one suggesting it might be behind the nurse’s station. The Activities Director stated that residents were educated at each resident council meeting about the binder’s location and that this was documented in council minutes, but no approach was described for updating residents going forward. When these findings were presented to the Interim Administrator, DON, ADON, and a corporate nurse consultant, they offered no comments or concerns.
Surveyors found that the facility’s lobby survey-results binder was not updated with the most recent survey findings or the related plan of correction, containing only older survey results and no complaint citations from the latest cycle. Record review confirmed the absence of the most recent survey, and the administrator acknowledged that the required documents were missing from the survey book.
Survey results were not posted in a location readily accessible to residents, family members, or legal representatives for all residents. During a resident council meeting, residents said they did not know where the most recent survey results were located. An observation showed the survey binder and posted notice were placed above wheelchair level near the entrance, and a resident in a wheelchair could not reach the binder or read the sign without assistance.
Missing Most Recent Survey Results in Accessible Binder: The facility failed to keep the most recent standard survey in the survey binder located by the front entrance and accessible to residents, family members, and legal representatives. The ADM stated he was responsible for keeping the binder current, believed the survey was included, then confirmed it was missing after review. Eight residents reported they did not have access to the most recent survey results and wanted to review them, and the facility policy titled Required Postings did not address posting the most recent survey results.
Survey Results Not Readily Visible
Penalty
Summary
The facility failed to ensure that survey results were available for residents and others to view without first needing to ask for them. During observation and interview, the administrator stated that the survey book was kept at the front desk behind the desk in a holder, with a notification indicating where it was located. However, the book was not visible from the front of the desk because a chest-high partition blocked it, even though a posted sign stated that annual state survey results were located at the front desk reception and were available and readily accessible for residents to view 24 hours daily. During an interview with the resident council, an anonymous resident stated that the survey results were there, but they had to ask for them.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent Department of Health survey in a place readily accessible to residents for two of two units, Stations 2 and 3. Observations during all days of the survey showed only a posting in the lobby stating that the state survey results were available there. During a resident group meeting, residents stated they were not aware of the location of the state survey results and reported that they do not have access to the lobby because the elevator to the lobby requires a code. The Nursing Home Administrator confirmed that the survey results were only located in the lobby, which was not readily accessible to residents.
Residents Unaware of Access to Survey Results Binder
Penalty
Summary
Facility staff failed to ensure that residents knew where the survey results binder was located or that they had access to it. During a resident group meeting held with the Resident Council President and four other residents who regularly attend, all five residents reported they were unaware they could review the survey book or had access to it, and none could identify its location; the council president speculated it might be behind the nurse’s station. A subsequent interview with the Director of Activities revealed that the facility’s position was that residents were educated at every resident council meeting on where to locate the survey results binder, and this education was documented in the resident council minutes, but no suggestions were offered on how residents would be updated going forward. In a final interview with the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns.
Failure to Provide Access to Most Recent Survey Results and Plan of Correction
Penalty
Summary
The facility failed to provide residents, family members, legal representatives, visitors, and the public with access to the most recent survey results and plan of correction as required. During an observation in the lobby, surveyors noted a 3-ring binder labeled “Hemingford Care Center Survey Results,” which, upon review, contained survey results only up to a survey ending in December 2024. The binder did not include the results of the most recent survey that ended on 2/2/26, nor did it contain the corresponding plan of correction for that survey. Record review further showed that there were no citations related to complaints following the previous survey included in the book. In an interview, the administrator confirmed that the required documents were not included in the survey results book. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the issue centered on the facility’s failure to maintain and make available up-to-date survey documentation for review by stakeholders.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives for 46 of 46 residents. During a resident council meeting, residents stated they were unaware of the location of the most recent survey results. An observation of the survey binder showed it was placed in a bin attached to the wall by the facility entrance, with a sign above it indicating survey results availability, but neither the binder nor the sign were at wheelchair level. When the binder and posting were observed with Resident 18, the co-president of resident council, and the Executive Director, Resident 18 required assistance in her wheelchair to reach the binder and stated she could not read the posting above it.
Missing Most Recent Survey Results in Accessible Binder
Penalty
Summary
The facility failed to post its most recent standard survey in the survey binder located next to the front entrance, an area accessible to residents, family members, and legal representatives. On 04/13/2026 at 3:25 PM, observation of the binder showed that it did not include the results from the most recent standard survey completed on 02/12/2025. During an interview on 04/13/2026 at 3:35 PM, the ADM stated he was responsible for keeping the survey binder up to date and believed the most recent standard survey was in the binder. After reviewing it, he recognized that the survey was missing and stated that if a resident requested to review the survey results while he was not present, they would not be readily available. During a confidential group interview, 8 residents stated they did not have access to the most recent standard survey results and wanted to review them. Record review of the facility policy titled Required Postings, revised 05/2025, did not address posting the most recent standard survey results in an area accessible to residents, family members, and legal representatives.
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