Failure to Display [NAME] Consent Decree Posters
Summary
The facility failed to display posters informing residents of their rights to explore or decline community transition under the [NAME] Consent Decree, as well as their right to be free from retaliation regardless of their decision. This deficiency was observed during a survey conducted on 03/04/2025, where no signs or posters related to the [NAME] Consent Decree were found in public and accessible locations throughout the facility, including the main entrance, dining rooms, and various floors. Staff members, including nurses and the Psychiatric Rehabilitation Services Coordinator, were unaware of the facility's partnered agencies for community transition and could not locate any relevant signage. The Social Service Director acknowledged that the facility should have flyers pertaining to the [NAME] Consent Decree and transition agency on every floor, but staff were unable to locate them when asked. The facility's Pre-Admission Screening and Resident Review (PASRR) policy, last revised in December 2023, documents the facility's role in submitting census data to the IDPH appointed company to comply with the [NAME] Consent Decree but does not include how the facility educates [NAME] Class Members about their rights. The facility did not provide any other policy related to the [NAME] Consent Decree, indicating a lack of compliance with the Illinois Administrative Code and the State Operations Manual Appendix PP requirements.
Penalty
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Required postings with contact information for State agencies and advocacy groups, as well as complaint filing instructions, were placed in an area inaccessible to residents. Two residents confirmed they had never seen this information and would like access to it. The Activities Recreation Director verified that the postings were not in resident living areas and that residents did not have routine access to the posted information.
Required postings with contact information for state agencies and advocacy groups, as well as a statement about filing complaints with the State Survey Agency, were not displayed in any common areas or hallways of one house, affecting all residents living there. The Administrator confirmed the absence of these postings.
The facility did not display required contact information for state agencies and advocacy groups in accessible areas, affecting all residents. An observation confirmed the absence of postings, and the Administrator verified this deficiency.
The facility did not display required contact information for the State Survey Agency and other pertinent agencies, affecting all 65 residents. The Administrator confirmed the absence of these postings during an interview.
The facility failed to ensure that required information was posted and updated, affecting all 86 residents. An observation revealed outdated ombudsman contact details and missing information on the Medicaid fraud unit, Adult Protective Services, and complaint filing with the Ohio Department of Health. Interviews with the Ombudsman Program Director and the Administrator confirmed these findings.
Required Resident Rights Postings Not Accessible
Penalty
Summary
The facility failed to ensure that required postings, including the list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, as well as the statement that residents may file a complaint with the State Survey Agency, were readily accessible to all residents. Observations during the annual survey revealed that these postings were located in a hallway outside of the building's interior locked doors, an area inaccessible to residents. Further observations confirmed that the postings were not present within the three locked hallways where residents were confined. Interviews with two residents during a resident council meeting confirmed they had never seen the postings or documents with information on how to contact the ombudsman or state department of health and expressed a desire to have this information. The Activities Recreation Director also confirmed that the postings were not in resident living areas and that residents did not have routine access to the area where the postings were located.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to display a list of names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, as well as a statement informing residents of their right to file a complaint with the State Survey Agency. This deficiency was identified through observation and staff interview, which revealed that the required postings were not present in any common areas or hallways of the Cornerstone Cottage, affecting all ten residents residing there. The Administrator confirmed that the necessary information was not posted, and the facility census at the time was seventeen residents. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to ensure that all required postings, including contact information for pertinent state agencies and advocacy groups, were displayed in a manner accessible at all times. This deficiency affected all 44 residents residing in the facility. During an observation conducted on January 2, 2025, at 1:22 P.M., it was noted that there was no posted contact information for essential entities such as the State Survey agency, the State licensure office, adult protective services, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit in any of the facility's common areas and hallways. An interview with the Administrator confirmed the absence of this information, verifying that the facility did not have a list of pertinent state agencies and advocacy groups posted.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to ensure that all required postings, including contact information for the State Survey Agency and other pertinent agencies and advocacy groups, were displayed in a manner that was accessible and understandable to residents and their representatives. This deficiency was observed during a facility inspection conducted on June 26, 2024, between 2:45 P.M. and 3:00 P.M. The absence of these postings had the potential to affect all 65 residents residing in the facility. During an interview at 3:10 P.M. on the same day, the Administrator confirmed that the required information was not posted.
Failure to Update Resident Advocate Contact Information
Penalty
Summary
The facility failed to ensure that required information was posted and updated as mandated, affecting all 86 residents. An observation on 05/01/24 at 3:30 P.M. in the common area adjacent to the 100 hall revealed a document titled 'Resident Advocate Contact Information' with outdated long-term ombudsman contact details. The document lacked information regarding the Medicaid fraud unit, Adult Protective Services, and instructions on how to file a complaint with the Ohio Department of Health (ODH). An interview on 05/02/24 at 9:47 A.M. with the Ombudsman Program Director confirmed that the posted ombudsman information was several years old. The Administrator confirmed these findings during an interview on 05/02/24 at 3:30 P.M.
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