Survey Results Not Accessible on Secured Unit
Penalty
Summary
The facility failed to ensure that state survey results were available and accessible to residents residing on the secured unit. During a resident council interview, five residents on the secured unit reported they were unaware of where to find the state survey results. Observations confirmed that while the most recent survey results from 2023 were available in the facility lobby, they were not present on the locked unit. An orange binder labeled 'State Survey' behind the nurse's desk on the secured unit was found to be dusty and only contained outdated results from 2019, missing the 2021 and 2023 re-certification surveys. Multiple staff interviews, including with the Administrator, Recreation Director, DON, and Scheduler, revealed uncertainty and lack of knowledge regarding the location and requirement for survey results on each floor, with none able to confirm their presence on the secured unit.