Failure to Inform Cognitively Intact Residents of Survey Results and Their Location
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.
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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