Other·December 20, 2022

HSC § 1418.21 (a)A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1)The information shall be posted in at least the following locations in the facility: (A)An area accessible and visible to members of the public. (B)An area used for employee breaks. (C)An area used by residents for communal functions, such as dining, resident council meetings, or activities. (2)The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (A)The full name of the facility, in a clear and easily readable font of at least 28 point. (B)The full address of the facility in a clear and easily readable font of at least 20 point. (C)The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by CMS. The number shall be in a clear and easily readable font of at least two inches print. The facility failed to post their most recent Five-Star Quality Rating System (rating system to help residents and consumers more easily compare nursing homes) in accordance with Centers for Medicare & Medicaid Services (CMS) in three out of three required areas (an area accessible and visible to members of the public, the employee break room and the resident's communal function room such as dining rooms/activity rooms). This violation had the potential for residents and families, not to compare nursing homes more easily, based on the facility's combined health inspections rating. During an observation of the facility on 11/18/2021 at 8:55 p.m., during the facility's recertification survey, a "five-star" plaque was hanging on the wall of the reception area was observed. There was no current Five Star Quality Rating system posted anywhere in the facility. During an observation of the resident's dining room on 11/19/2022, at 9:32 a.m., there was no Five-Star Quality Rating System posted. During an observation of the employee's breakroom on 11/18/2022, at 10:35 p.m., there was no Five-Star Quality Rating System posted. During concurrent review of the Nursing Home Compare web site and an interview with Administrator on 11/23/2022 at 6:02 p.m., the facility overall rating was three stars posted in the CMS web site. The Administrator stated their Star rating has changed but he has not posted the signages for the new Star rating. Administrator further stated, he is assuming that the five-star plaque needs to be changed and will post the most current Star Rating accordingly. A review of the facility provided policy and procedure (P&P) titled, "Administrative Manual," revised 8/20/2019 indicated, Consumer information, including staffing requirements, shall be posted in a form and manner understandable to residents and resident representatives, in a prominent place which is visible to the public. The following consumer informal shall be posted: the most recent overall star rating given to the facility by CMS. This information shall be posted in an area: accessible and visible to members of the public, used for employee breaks, used by residents for communal functions, such as dining, resident council meetings, or activities. The facility failed to post their most recent Five-Star Quality Rating System (rating system to help residents and consumers more easily compare nursing homes) in accordance with Centers for Medicare & Medicaid Services (CMS) in three out of three required areas (an area accessible and visible to members of the public, the employee break room and the resident's communal function room such as dining rooms/activity rooms). This violation had the potential for residents and families, not to compare nursing homes more easily, based on the facility's combined health inspections rating. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.