Survey Results and Plan of Correction Not Readily Accessible to Residents
Summary
The facility failed to ensure that the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents. During a confidential group meeting, all six residents present reported that they were unaware they could read the survey reports and did not know who to ask or where to find them. An observation revealed that the binder containing survey reports was placed on a shelf approximately 4-5 feet up on the wall in a sitting area next to the main lobby, making it difficult for residents to access. Interviews with staff further confirmed the deficiency. An LPN stated she did not know where the survey reports were located or how residents could access them. The Nursing Home Administrator acknowledged that the reports were kept in an area not frequently visited by residents and were not easily accessible. Additionally, an Activity Associate who conducts monthly resident council meetings was not aware of how residents could obtain access to the survey reports. These findings demonstrate that the facility did not make survey results and plans of correction readily accessible to residents as required.
Plan Of Correction
The facility moved the binders containing survey results to a prominent location in the lobby on a table that residents, family members, and legal representatives can reach either standing or sitting in a wheelchair. The public binders include survey results for the current year and the previous 3 years along with plans of correction. The facility also placed a prominent notice at the table stating that survey and advocacy information is available here. All residents who want this information have the potential to be affected. The facility created the policy: Facility Required Postings. The facility created the flier "Where to Find Survey Reports" and will distribute it to all patients and residents. The flier will also be added to the facility admission packet. Education will be provided to all employees about where survey information can be found. The resident council will also be given this information at the July meeting. During daily routine leadership rounds, each leader will interview at least one resident for awareness where to locate survey results, for at least the next 12 weeks. The executive director is responsible for compliance.
Penalty
Resources
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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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