Failure to Maintain and Post Current Survey Results in Public Notebook
Penalty
Summary
The facility failed to make the most recent survey results readily available to residents and visitors by not updating the survey results notebook in the front lobby with multiple completed surveys. On two separate days of the survey, the notebook on a low table in the lobby was observed to contain only the results from a recertification survey completed on 8/16/23, despite the iQIES database showing that the most recent survey was a complaint investigation completed on 11/7/25. Review of records identified that several intervening surveys were missing from the notebook, including a complaint investigation survey dated 1/30/24, a focused infection control survey dated 4/8/24, complaint investigation surveys dated 8/22/24, 12/30/24, 1/15/25, 7/15/25, and 11/7/25, and a recertification survey dated 11/21/24. In an interview, the Administrator reported he began employment at the facility at the end of July 2025 and acknowledged awareness of the regulation requiring that the most recent survey results from any survey be placed in the notebook. He stated that technical issues initially prevented him from printing the survey results when he started, and that while he had the survey results in his office, he had not placed them in the public binder. The Administrator acknowledged that he should have placed the survey results in the notebook once he was able to print them but could not explain why this had not been done.
