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 readily visible for residents and visitors to access without asking. The admin stated the survey book was kept behind the front desk in a holder, but a chest-high partition blocked it from view even though a posted sign said the annual state survey results were available and readily accessible 24 hours daily. During a resident council interview, a resident said the survey results were there, but they had to ask for them.
Survey results were posted only in the lobby, and residents on two units were not aware of where to find them. Residents reported they could not access the lobby because the elevator required a code, and the NHA confirmed the results were not posted in a location readily accessible to residents.
Facility staff did not ensure that residents knew they could review the survey results binder or where it was located. In a resident group meeting with the council president and several residents, all attendees reported they were unaware of their ability to access the survey book and could not identify its location, with one suggesting it might be behind the nurse’s station. The Activities Director stated that residents were educated at each resident council meeting about the binder’s location and that this was documented in council minutes, but no approach was described for updating residents going forward. When these findings were presented to the Interim Administrator, DON, ADON, and a corporate nurse consultant, they offered no comments or concerns.
Surveyors found that the facility’s lobby survey-results binder was not updated with the most recent survey findings or the related plan of correction, containing only older survey results and no complaint citations from the latest cycle. Record review confirmed the absence of the most recent survey, and the administrator acknowledged that the required documents were missing from the survey book.
Survey results were not posted in a location readily accessible to residents, family members, or legal representatives for all residents. During a resident council meeting, residents said they did not know where the most recent survey results were located. An observation showed the survey binder and posted notice were placed above wheelchair level near the entrance, and a resident in a wheelchair could not reach the binder or read the sign without assistance.
Missing Most Recent Survey Results in Accessible Binder: The facility failed to keep the most recent standard survey in the survey binder located by the front entrance and accessible to residents, family members, and legal representatives. The ADM stated he was responsible for keeping the binder current, believed the survey was included, then confirmed it was missing after review. Eight residents reported they did not have access to the most recent survey results and wanted to review them, and the facility policy titled Required Postings did not address posting the most recent survey results.
Survey Results Not Readily Visible
Penalty
Summary
The facility failed to ensure that survey results were available for residents and others to view without first needing to ask for them. During observation and interview, the administrator stated that the survey book was kept at the front desk behind the desk in a holder, with a notification indicating where it was located. However, the book was not visible from the front of the desk because a chest-high partition blocked it, even though a posted sign stated that annual state survey results were located at the front desk reception and were available and readily accessible for residents to view 24 hours daily. During an interview with the resident council, an anonymous resident stated that the survey results were there, but they had to ask for them.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent Department of Health survey in a place readily accessible to residents for two of two units, Stations 2 and 3. Observations during all days of the survey showed only a posting in the lobby stating that the state survey results were available there. During a resident group meeting, residents stated they were not aware of the location of the state survey results and reported that they do not have access to the lobby because the elevator to the lobby requires a code. The Nursing Home Administrator confirmed that the survey results were only located in the lobby, which was not readily accessible to residents.
Residents Unaware of Access to Survey Results Binder
Penalty
Summary
Facility staff failed to ensure that residents knew where the survey results binder was located or that they had access to it. During a resident group meeting held with the Resident Council President and four other residents who regularly attend, all five residents reported they were unaware they could review the survey book or had access to it, and none could identify its location; the council president speculated it might be behind the nurse’s station. A subsequent interview with the Director of Activities revealed that the facility’s position was that residents were educated at every resident council meeting on where to locate the survey results binder, and this education was documented in the resident council minutes, but no suggestions were offered on how residents would be updated going forward. In a final interview with the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns.
Failure to Provide Access to Most Recent Survey Results and Plan of Correction
Penalty
Summary
The facility failed to provide residents, family members, legal representatives, visitors, and the public with access to the most recent survey results and plan of correction as required. During an observation in the lobby, surveyors noted a 3-ring binder labeled “Hemingford Care Center Survey Results,” which, upon review, contained survey results only up to a survey ending in December 2024. The binder did not include the results of the most recent survey that ended on 2/2/26, nor did it contain the corresponding plan of correction for that survey. Record review further showed that there were no citations related to complaints following the previous survey included in the book. In an interview, the administrator confirmed that the required documents were not included in the survey results book. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the issue centered on the facility’s failure to maintain and make available up-to-date survey documentation for review by stakeholders.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives for 46 of 46 residents. During a resident council meeting, residents stated they were unaware of the location of the most recent survey results. An observation of the survey binder showed it was placed in a bin attached to the wall by the facility entrance, with a sign above it indicating survey results availability, but neither the binder nor the sign were at wheelchair level. When the binder and posting were observed with Resident 18, the co-president of resident council, and the Executive Director, Resident 18 required assistance in her wheelchair to reach the binder and stated she could not read the posting above it.
Missing Most Recent Survey Results in Accessible Binder
Penalty
Summary
The facility failed to post its most recent standard survey in the survey binder located next to the front entrance, an area accessible to residents, family members, and legal representatives. On 04/13/2026 at 3:25 PM, observation of the binder showed that it did not include the results from the most recent standard survey completed on 02/12/2025. During an interview on 04/13/2026 at 3:35 PM, the ADM stated he was responsible for keeping the survey binder up to date and believed the most recent standard survey was in the binder. After reviewing it, he recognized that the survey was missing and stated that if a resident requested to review the survey results while he was not present, they would not be readily available. During a confidential group interview, 8 residents stated they did not have access to the most recent standard survey results and wanted to review them. Record review of the facility policy titled Required Postings, revised 05/2025, did not address posting the most recent standard survey results in an area accessible to residents, family members, and legal representatives.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.