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.
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.
Residents were not given easy access to view survey results or to communicate with advocate agencies, as required. This deficiency was identified through observations that the necessary information was not made available to residents.
Ten residents reported not knowing where to find the facility's latest survey results or how deficiencies had been corrected. Interviews with the DON and Administrator revealed that the responsibility for posting survey results was with the Administrator, who was unaware of the residents' lack of knowledge. Facility policy states residents have the right to access survey results and plans of correction, but this information was not effectively communicated.
The facility did not ensure that the most recent survey results were posted in a location easily accessible to residents, family members, or legal representatives. Instead, the results were kept in a binder inside the Administration office, which was locked after business hours, preventing access as required by federal regulations.
Nine residents attending a council meeting were unaware of the location or availability of the facility's latest survey results and corrective actions. Staff interviews and observations confirmed that the survey result binder was either missing or incomplete, and facility policy requiring survey results to be readily accessible was not followed.
The facility did not post its most recent recertification survey results, leaving residents and visitors unable to access this information. A binder intended to contain survey results for multiple years was missing the latest report, and the Administrator confirmed the results were not available elsewhere in the facility, contrary to facility policy requiring survey reports to be readily accessible.
Two residents were not aware of the location or availability of the facility's latest survey results, as the survey binder was stored in an inaccessible location with an unreadable label. Staff confirmed that residents were only told to ask for the binder, rather than having direct access, which did not align with facility policy requiring survey results to be easily accessible.
Several residents who were alert and cognitively intact reported not knowing the results of previous state surveys or the location of the survey binder. Key staff, including the Activity Director, were also unaware of the binder's location. Facility policy required survey results to be accessible and communicated to residents, but this was not done, as confirmed by interviews and record review.
The facility did not ensure that residents could easily access or were informed about the location of the latest State survey results. Multiple residents reported not knowing where to find the survey results, and staff interviews and observations confirmed that the required binder was not available in the designated area, contrary to facility policy.
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