Deficiency in Posting Survey Results
Summary
The facility failed to ensure that the last three years of survey results were posted in a location readily accessible to residents, family members, and legal representatives, as required by their policy. During the recertification survey, it was observed that the survey results were posted at the resident courtesy phone, which was not in plain view, and not in a location where individuals could examine them without having to ask. This deficiency was evident for five out of eleven residents attending the Resident Council meeting, who stated they did not know where to find the survey results without asking. The facility's policy on posting and availability of survey results and complaint investigations, effective January 2025, mandates transparency and regulatory compliance by posting the most recent survey results in accessible locations and making past reports available upon request. However, observations on multiple units revealed that the survey results from 2022 were not posted, and there was no documented evidence in the Resident Council Meeting Minutes that the location or postings of the survey results were discussed. Interviews with the Administrative Coordinator and the Director of Nursing confirmed that the survey results should have been posted since 2022, and the Administrator stated that the survey results are discussed in resident council meetings and on admission.
Plan Of Correction
Plan of Correction: Approved February 4, 2025 F577 483.10 Rights to Survey Results / Advocate Agency Information SS=C TAG I. The following actions were accomplished for the resident(s) identified in the sample: The social worker met with each resident identified and informed of the facility survey results posting location which is located on the first-floor lobby near the security desk. The facility ensured all 3 years of facility survey results were in the binder readily accessible to residents: #15, #49, #96, #29, #42. All residents indicated were informed by the social worker on 1/28/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility identified all residents, families, and legal representatives as having the potential to be affected. The residents will receive information of the location of the facility’s survey posting during resident council, care plan meeting and upon admission which is located on the first-floor lobby near the security desk. The facility has posted the location of the facility’s survey posting on the units, vestibule entrance and lobby. The Staff Educator will provide education of staff re: location of the survey posting. III. The following system changes will be implemented to ensure continuing compliance with regulations: The facility reviewed the Policy and Procedure titled Posting and Availability of Survey Results and Complaint Investigation to ensure compliance with regulations. The policy was revised on 1/8/2025. The Administrator provided in-service to the Director of Recreation, Director of Social Service on the facility’s policies and procedures entitled “Posting and Availability of Survey Results and Complaint Investigation” to ensure compliance. The facility will post the location of the facility’s survey findings on all units, the vestibule entrance of the lobby and by security desk. The residents will be offered to review the facility survey results during Resident Council. The facility’s survey binder will be reviewed quarterly by the Director of Therapeutic Recreation, Director of Social Services or Designee to ensure three years of facility’s survey results are posted and the residents are aware of survey results location. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The corrective actions will be monitored through quality assurance to ensure the same practice will not recur. The Director of Therapeutic Recreation and Social Services or Designee will develop an audit tool to monitor compliance with facility's survey posting results and ensure accessibility to all residents, families/designated representative. The audits will be conducted monthly for six months or until two quarters are at 100% compliance. The Directors of Therapeutic Recreation and Social Services or Designee will monitor monthly for six months ensuring three years of facility survey results are posted and accessible to all residents, families/designated representative is aware of survey result location on the first-floor lobby near the security desk. The Director of Therapeutic and Social Services/Designee will utilize an audit tool to assess compliance monthly and report findings to the Quality Assurance Committee for six months. Responsible: Executive Director/Administrator will be responsible for ensuring compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Survey results were not accessible to residents. During a resident council meeting, residents said the results were kept in someone's office but did not know whose, and surveyors could not find the binder or any sign showing where it was available. The Administrator stated the binder was locked in the Administrator's office when not present, and staff had no way to provide it without asking the Administrator.
Missing Survey Results Notice: The facility failed to post a notice making annual and complaint survey reports from the past 3 years, along with any POC in effect, available for review upon request in a prominent and accessible area. Observations found no such notice in the common areas, and a cognitively intact resident, a resident’s RP, the Activities Director, the Social Services Manager, and the Administrator all confirmed the required posting was not present.
Survey results were not readily accessible to residents or visitors because the survey book was removed from the lobby and kept in the Administrator's office during renovations. Observations found the book missing from its designated location, and residents at the Resident Council said they did not know where the State inspection results were located and wanted to review them. The Resident Council minutes also showed the location had not been discussed.
Survey Binder Not Kept Current: The facility did not keep the survey binder updated with the most recent complaint survey results for resident, family, or public review. Observation showed the binder had not been updated since 10/01/2025, and the DON acknowledged additional complaint surveys had been completed but were not added to the binder.
Survey findings were not readily accessible to residents and visitors. The 2024 Survey Findings Binder in the Fireplace Room did not include any 2025 or 2026 findings, and observations of the front entry, main dining room, hallway nook, and nursing station found no recent survey postings. The Receptionist was unaware of a survey binder and did not know where the recent findings were located, and the DNS acknowledged the findings were not readily accessible.
Survey results were not readily available for resident and family review. The admission packet and Resident Council minutes did not reference the right to see survey results, the posted resident rights did not include that right, and cognitively intact residents said they did not know where the results were kept or had not seen them. A surveyor could not find the results in common areas, and the DON ultimately produced the only survey results book, which was stored in a drawer at the security officer's desk near the side entrance.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure the Illinois Department of Public Health survey results were accessible to residents. During a resident council meeting, three residents stated that the survey results were in someone's office, but they were unsure whose office it was. After the meeting, surveyors toured the facility and were unable to find the survey results or any sign indicating where the survey results were available. The Administrator stated that the survey results binder was kept in the Administrator's office and was locked when the Administrator was not present, that there was no sign telling residents or visitors where it was located, and that residents would have to ask for it. The facility was unable to provide a policy regarding where survey results should be located.
Missing Survey Results Notice
Penalty
Summary
The facility failed to ensure that a notice stating the availability of all reports related to annual and complaint surveys from the past 3 years, along with any plans of correction in effect, was posted in a prominent and accessible area for resident and family review upon request. Observation of the common areas on 06/22/2026 and again on 06/24/2026 revealed no such notices posted anywhere in the facility. Resident #1’s quarterly MDS with an ARD of 05/20/2026 showed a BIMS score of 15, indicating the resident was cognitively intact. During interviews, Resident #1 stated the facility did not have the required notice posted in a prominent location for residents and families to view. Resident #2’s responsible party also stated the information was not posted in a location that made it readily accessible. S3 Activities Director and S4 Social Services Manager both indicated the notice was not posted as required, and S1 Administrator confirmed there were no notices posted and stated she was unaware the information was required to be posted.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post notice of the availability of the State survey results so that residents and visitors could easily view them. The facility policy titled, Resident Rights, stated that a resident has the right to examine the results of the most recent survey and any plan of correction in effect. However, during observations on 06/16/2026, 06/17/2026, and 06/18/2026, the survey book was not found in the front entrance lobby where it was designated to be kept. During the Resident Council Meeting, four residents who were alert and oriented stated they did not know where the State inspection results were located and said they would be interested in reviewing them. Review of the Resident Council minutes showed the location of the survey results had not been discussed with residents. The Receptionist stated the survey book had been moved from the lobby area to a drawer and later to the Administrator's office during renovations, and the Administrator confirmed the book remained in his office, meaning residents and visitors could not readily access it without asking for it or entering his office.
Survey Binder Not Kept Current
Penalty
Summary
The facility failed to ensure the most recent survey results were readily accessible to residents, family members, or anyone who wished to review them. On observation, the survey binder was last updated on 10/01/2025, and further review showed that additional completed complaint surveys had not been added. During interview, the Administrator acknowledged the facility had received additional complaint surveys since 10/01/2025 and confirmed the completed complaint survey results were not updated in the survey binder as they should have been.
Survey Findings Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to residents and visitors. On 6/17/26 at 7:15 AM, the 2024 Survey Findings Binder in the Fireplace Room was observed and it did not contain any 2025 or 2026 survey findings. Later that morning, observations of the front entry, main dining room, hallway nook, and nursing station found no recent survey findings posted or otherwise available. At 8:15 AM, the Receptionist stated she was unaware of the presence of a survey binder and did not know where the recent survey findings were located. At 9:20 AM, the DNS stated she did not know where the recent survey findings were and acknowledged they were not readily accessible to residents and visitors.
Survey Results Not Readily Available for Resident Review
Penalty
Summary
The facility failed to ensure that survey results were readily available for residents and families to easily view. Review of the admission packet provided at admission did not reference the resident's right to ready access to survey results, and the Resident Council meeting minutes did not contain any record that residents were informed of that right. During an observation, the posted resident rights on the wall did not include the right to see the results of previous surveys. During a Resident Council meeting, cognitively intact residents including Resident #71, Resident #61, Resident #86, Resident #88, Resident #92, Resident #106, and Resident #123 stated they did not know where the survey results were kept and had not seen them. A surveyor searched common areas accessible to residents and visitors and could not locate the survey results. The DON was initially unsure of the location of the results, then returned with a survey results book, which was later placed in a drawer at the security officer's desk near the coded side entrance. The DON stated this was the only copy maintained for resident and visitor review, and there was no survey results book near the front entrance.
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