Inaccessible Survey Results for Residents
Summary
The facility failed to ensure that the results of the most recent Federal/State survey were posted in a location that was readily accessible to residents, family members, and legal representatives. During a Resident Council meeting, eight anonymous residents expressed that they were unaware of their ability to view the previous survey results and did not know where these results were located. An observation revealed that the State Survey binder was placed on a high shelf behind the reception desk, making it inaccessible to residents and visitors without assistance. Interviews with staff members, including a receptionist and a social worker, confirmed that residents or family members would need to request access to the survey results, as they were not easily reachable, especially for those in wheelchairs. The Administrator, who was new to the role, acknowledged the oversight and stated that they were unaware of the inaccessibility issue. The survey results had previously been located in a living room, but were moved when the room was no longer in use, contributing to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff did not ensure that State survey results and the plan of correction were readily accessible for review. An observation of the lobby showed no posted State inspection results and no sign indicating where the survey book could be found. The MDS coordinator reported that the survey book was in the Administrator’s locked office, awaiting maintenance to open it. Later, the DON produced the survey book and acknowledged that it had not been placed in an easily accessible area and that no sign had been posted to inform residents, families, or visitors of its location.
Survey results were not clearly posted or easily identifiable in the lobby, and residents reported not knowing where to find them. During a Resident Council meeting, multiple residents stated they were unaware of the survey results’ location, and one recalled that only a sign about passing the survey had been posted in the past. Observations of the reception area showed no visible survey results or signage directing residents or visitors, and the survey binder was kept on a high countertop, partially hidden by decorations and without clear labeling on the visible side. The receptionist and administrator indicated that residents and visitors had to ask for the binder and that information about survey results was printed on the binder cover and discussed during Resident Council meetings.
The facility failed to inform cognitively intact residents about the existence and location of the most recent survey results, despite having survey binders posted near dining areas and a nursing station. Multiple residents with conditions such as HTN, osteoarthritis, hypotension, anemia, and muscle weakness, all assessed as capable of daily decision-making, reported during a resident council interview that they were unaware survey results were available or where they were kept. Review of resident council minutes showed no evidence that survey results were discussed, and the AD acknowledged not telling residents about the survey results or their location, while the DON confirmed residents should have been made aware of this information.
Surveyors found that the facility failed to post its most recent survey results in an area readily accessible to residents, families, and representatives, and did not maintain survey reports from the prior three years for review upon request. A binder labeled as containing entrance survey results near the front desk held only older survey documents, and the receptionist could not identify where current State Agency survey results were kept. During a Resident Council meeting, residents reported they were unaware that State inspection results were available or where to locate them without asking, and there was no evidence that current survey reports, complaint investigations, or plans of correction were accessible to the public.
The facility failed to ensure resident rights were honored when past survey results and plans of correction were not readily accessible. A binder labeled “State Survey Results” was placed in a corridor pocket folder but was blocked by a stuffed chair with stacked equipment, two vital signs towers, and an extra-large padded specialized wheelchair, preventing easy access. During a Resident Council discussion, residents reported they were unaware of the facility’s responsibility to make the past three years of survey results available, did not know they had the right to review them, and did not know where the survey results were posted. The Administrator confirmed that the survey results were inaccessible due to being blocked by stored equipment.
The facility did not maintain current survey results in the publicly accessible survey notebook, leaving only an older recertification survey available for review while multiple subsequent complaint, infection control, and recertification surveys were missing. During tours, surveyors observed that the lobby notebook contained outdated information despite more recent surveys being documented in the iQIES system. The Administrator, who started in mid-2025, reported initial technical issues with printing survey results and admitted that although he had the survey reports in his office and knew they were required to be placed in the notebook, he did not update the binder and could not explain the failure to do so.
Failure to Provide Accessible State Survey Results and Posting Location Information
Penalty
Summary
Facility staff failed to make the results of the annual recertification survey and plan of correction readily accessible to residents, family members, and legal representatives. During an observation of the lobby at 8:05 AM on 3/24/26, there was no evidence of State inspection results displayed in an open and easily accessible area for residents, staff, and visitors to review, and no sign was posted indicating where the State survey results were located. At 8:11 AM, the MDS coordinator stated that they were waiting for maintenance to open the Administrator’s office to obtain the survey book, indicating that the survey results were kept in a locked office rather than in an accessible location. At 8:52 AM, the DON presented the survey book to the surveyor and confirmed that the survey inspection results were not placed in an area easily accessible for review and that a sign directing individuals to the location of the State survey results had not been posted. No specific residents or their medical conditions were mentioned in the report, and the deficiency centered on the facility’s failure to properly display and provide access to the State survey results and related information for review by residents, families, and legal representatives.
Survey Results Not Clearly Posted or Identifiable in Lobby
Penalty
Summary
The deficiency involves the facility’s failure to make survey results easily accessible and visible to residents and visitors in the main lobby. During a Resident Council meeting attended by eight residents, participants reported they did not know where the survey results were located. One resident stated that in the past the facility had posted a sign indicating they had passed the survey. Subsequent observation of the receptionist desk and adjacent sitting area in the main lobby showed that no survey results were accessible and no signage was visible to direct residents or visitors to the survey results. On a later observation and interview at the receptionist desk, there was still no visible signage indicating the location of the survey results. The receptionist stated that residents and visitors needed to ask for the survey book and pointed to a white binder on the reception desk countertop, which was approximately four feet from the floor and partially obscured by foliage and decorations, with no visible identification on the cover. When turned over, the binder cover indicated it contained information including results of compliance surveys and that similar notebooks were in each neighborhood. The administrator stated that survey results were kept at the receptionist desk and in each neighborhood, that the signage was printed on the front of the binder, and that residents were told survey results during Resident Council meetings.
Failure to Inform Cognitively Intact Residents of Survey Results and Their Location
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were notified of the existence and location of the most recent standard survey results, as required by 42 CFR 483.10(g)(10)-(11). Ten cognitively intact residents, each with various medical diagnoses such as hypertension, osteoarthritis, hypotension, anemia, and generalized muscle weakness, were identified as not being informed about the survey results. These residents had documented decision-making capacity on their MDS assessments, indicating they were capable of understanding and using such information. Review of resident council meeting minutes for multiple dates showed no documentation that residents were informed about the survey results or where they could be found. During a resident council interview, ten of eleven participating residents stated they were not aware that survey results were available for them to review and did not know where the survey results were located. They also reported that no one had told them about the survey results. Surveyors observed that survey result binders containing the most recent recertification survey were posted in holders near dining room entrances and a nursing station on various floors, indicating that the physical posting requirement had been met. However, during interviews, the Activities Director acknowledged that she had not informed residents during resident council meetings about the existence or location of these survey results, despite recognizing the importance of residents knowing about them. The DON similarly stated that residents should be made aware of the previous year’s survey results and their location, confirming that residents’ rights to examine survey results and receive related information had not been fully implemented in practice.
Plan Of Correction
F-577 Corrective Action for Affected Residents: The Administrator or designee met with Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 2, during resident council or individually to inform them of the existence of the most recent survey results, the location of the survey results binder on each floor near the dining room entrance and next to the consumer board in JEK, and their right to review these results at any time. The Administrator or designee provided each resident with written information documenting the location of the survey results on their respective floors. Identifying other Residents having the Potential to be Affected: The Administrator or designee met with residents during resident council meeting on 3/19/26 and informed them of the existence and location of the most recent survey results. The Director of Activities made announcements in all main dining rooms to inform them of the existence of the survey results dated, the location of the survey results binder on their floor, and their right to review the results. Measures put into place or Systemic Changes: The Administrator or designee will notify residents of the existence and location of survey results during the resident council meetings at least quarterly. The Activities Director (AD) or designee added a standing agenda item to resident council meetings to inform residents of the existence and location of survey results, ensuring this information is communicated at least quarterly. The AD or designee will document this notification in the resident council meeting minutes. Plan to Monitor Performance: Beginning 4/6/26, Director of Activities or designee will ask residents during resident council and during randomly to verify they are aware of location and existence of survey findings. The Director of Activities or designee will report audit results, including any identified deficiencies and corrective actions taken, to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Maintain and Post Accessible Survey Results for Residents and Public
Penalty
Summary
Facility staff failed to post the results of the most recent survey in a place readily accessible to residents, family members, and resident representatives, and failed to maintain survey reports from the three preceding years for review upon request. During an observation and interview with the front desk receptionist, the employee was unable to identify where the most recent State Agency survey results were kept and had to contact the Administrator for clarification. A binder labeled "Entrance Survey Results Book" was observed near the front entrance, but it only contained survey results from 2022, including a recertification and annual licensure survey, a licensure survey, an emergency preparedness and life safety code survey, and a federal comparative life safety code survey. No recent state or federal surveys were present in the binder at that time. During a Resident Council meeting, residents reported that they did not know that State inspection results were available to read or where to find them without having to ask. At the time of the observations and interviews, there was no evidence that the facility had posted the results of its most recent survey in an area readily accessible to residents, families, and resident representatives. Additionally, the facility did not have available, upon request, its survey reports for the prior three years, including certification surveys, complaint investigations, and any plan of correction in effect, and these reports were not maintained in areas easily accessible to the public.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to honor resident rights by not making the past three years of state survey results and plans of correction readily accessible to residents and their representatives. On multiple days of observation, a binder labeled “State Survey Results” was located in a pocket folder on the wall of a corridor leading to the courtyard, but access to the binder was blocked by a stuffed chair with large equipment stacked on it, two vital signs towers, and an extra-large padded specialized wheelchair. During a Resident Council group discussion with surveyors, residents reported they were not aware that the facility was responsible for making the past three years of survey results readily accessible, nor were they aware of their right to review these results and plans of correction, and they stated they did not know where the survey results were posted. The Administrator later confirmed that the survey results were not accessible because they were blocked by stored equipment. No specific resident medical histories or clinical conditions were described in relation to this deficiency.
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.
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