Other·December 23, 2021

§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 the 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 the CMS. The number shall be in a clear and easily readable font of at least two inches print. On 11/6/2021 an unannounced visit was made to conduct the facility’s annual recertification survey. The facility failed to post its most recent Five-Star Quality Rating system (helps consumers compare nursing homes) in accordance with CMS (Centers of Medicare and Medicaid Services), in at least the following three locations in the facility: (A) An area accessible and visible to members of the public; and (B) An area used for employee breaks; and (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities area. As a result, residents and consumers did not have the information readily available. During an observation, on 11/06/2021 at 8:55 a.m., during the facility's recertification survey, the Five-Star Quality Rating System was observed in the lobby above the closed double doors. The Five-Star Quality Rating System posted indicated, "4". During an observation of the resident's dining room, on 11/07/2021 at 10:32 a.m., the Five-Star Quality Rating System was not posted. During an observation of the employee's breakroom, on 11/07/2021, at 10:35 a.m., the Five-Star Quality Rating System was not posted. On 11/07/2021 at 9:30 PM, during an interview and record review, the Director of Nurses (DON) stated the facility’s current star rating was "2". During an interview and record review, on 11/07/2021 at 9:34 p.m., the Social Services Director (SSD) stated that the Five-Star Quality Rating System posting was only located in the lobby of the facility and was not posted anywhere else in the facility. SSD confirmed Five-Star Quality Rating System rating post in the lobby above double doors was a "4". During an interview, on 11/10/2021 at 2:04 p.m., the Director of Nursing (DON) stated that according to the CMS website the facility's star rating was "1". The DON stated it was important to post an accurate Five-Star Quality Rating System posting because the facility should not deceive residents and their families. A review of the facility's policy titled, "California star rating posting policy and procedure," dated 11/2019, indicated it is the policy of the facility that the star rating is posted per state regulations. The facility will post their overall star rating information in at least the following locations: An area accessible and visible to the public; An area used for employee breaks; and an area used by residents for communal functions and activities. The facility failed to post its most recent Five-Star Quality Rating system (helps consumers compare nursing homes) in accordance with CMS (Centers of Medicare and Medicaid Services), in at least the following three locations in the facility: (A) An area accessible and visible to members of the public; and (B) An area used for employee breaks; and (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities area. As a result, residents and consumers did not have the information readily available. The above violation had a direct relationship to the health, safety, or security of the residents.