Failure to Post Ombudsman and SD DOH Contact Information
Summary
The provider failed to ensure that the contact information for the ombudsman and the South Dakota Department of Health (SD DOH) was posted in a location accessible to all 35 current residents, visitors, and families. During an interview with the resident council, it was revealed that the residents were unaware of where to find the ombudsman's contact information and did not know they could contact the SD DOH directly or file a complaint. Observations confirmed that the ombudsman's contact information was posted in the entryway vestibule, which required a door code to access, and in the social worker's office, which was not always accessible to residents. Additionally, there was no SD DOH contact information or a statement that residents could file a complaint with the SD DOH posted anywhere in the facility. The administrator confirmed that the ombudsman's contact information was only posted in the social worker's office and that the SD DOH contact information was not posted. The admission handbook was also found to be deficient, as it contained incorrect and outdated contact information for the state ombudsman program and the SD DOH complaint coordinator. The table of contents listed State and Federal Contacts on page 19, but there was no page 19, and the contact information started on page 18, followed by a mislabeled page 2. This lack of accessible and accurate information prevented residents from knowing how to file complaints or seek assistance from the ombudsman or SD DOH.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Post State Survey Agency Contact Information: The facility did not post the State Survey Agency’s name, address, and telephone number on Station 2 and Station 3. Survey observations found no such posting on either unit, and residents reported they were unaware of any posting. The NHA confirmed the contact information was not posted on the nursing units.
The facility failed to maintain required postings of Ombudsman contact information in accessible areas for residents and their representatives. Surveyor observations found that Ombudsman information was not posted in the facility and that, when present, it was placed on the side of a refrigerator in the Activities Room rather than in a clearly visible location. The Administrator reported that Ombudsman posters had been removed to allow painting and were not re-posted afterward. This deficiency had the potential to affect all residents in the facility, as they and their representatives would not be aware of how to contact the Ombudsman about concerns.
Incomplete contact information for the State LTC Ombudsman program and Adult Protective Services was posted in three locations, including the First Floor and the 2nd and 4th floor nursing units. Surveyors observed that the Ombudsman posting lacked the name and email address, and the APS posting lacked the name, mailing address, phone number, and email address. The NHA confirmed the missing information.
Surveyors found that the facility did not post complete and current Adult Protective Services (APS) contact information, including email, phone number, and mailing address, on the South, North, and West nursing units. Observations showed the required APS details were missing from the resident rights postings, and the Nursing Home Administrator confirmed that the postings on all three units lacked the full APS contact information as required by regulation.
Surveyors found that required State Agency and Ombudsman contact information was not posted in an accessible manner for residents, including those using wheelchairs. During a Resident Council interview, several residents reported they did not know where to find Ombudsman or State Agency contact details. These residents lived on a floor where they could not independently access the area where the State Agency posting was located, as they were not given the elevator code and had to be accompanied by staff. Observations showed no required postings on their floor, and the only State Agency posting on another floor lacked Ombudsman information and was mounted at a height the AD acknowledged would be difficult for a wheelchair user to see. This conflicted with the facility’s Resident Rights policy and state requirements to post names, addresses, and phone numbers of pertinent State advocacy groups in a form and manner residents can access and understand.
Ombudsman Contact Information Not Posted: The facility failed to keep the State LTC Ombudsman program’s contact information posted in a visible area for residents. An alert resident with COPD, HTN, and dysphagia stated he did not know where to find the information, and the IPN and DON confirmed it was not posted after being removed during repainting. The facility policy stated the Ombudsman and CDPH contact details were to be posted on the consumer board.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to post the name, address, and telephone number of the State Survey Agency on two of two units, Station 2 and Station 3. Observations on all days of the survey on both units found no posting of the contact information for the State Survey Agency. During a group interview with residents on April 21, 2026, at 1:00 p.m., residents stated they were not aware of any posting containing the State Survey Agency contact information. The Nursing Home Administrator confirmed on April 23, 2026, at 12:50 p.m. that the State Survey Agency contact information was not posted on the nursing units.
Failure to Properly Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post the required Ombudsman contact information in areas accessible to residents and their representatives, as required by regulations mandating that names, addresses, and telephone numbers of pertinent State agencies and advocacy groups be posted along with a statement that residents may file a complaint with the State Survey Agency. On 04/29/26 at 9:35 AM, an observation of the facility revealed that staff did not have the Ombudsman information posted. Later that morning at 10:00 AM, an observation of the Activities Room showed that staff had placed an 8.5 x 11-inch paper with Ombudsman information roughly at eye level on the side of a refrigerator, rather than in a more generally visible or designated posting area. On 04/30/26 at 12:47 PM, the Administrator stated in an interview that the facility had taken down the Ombudsman posters in order to paint and confirmed that staff failed to put the Ombudsman posters back up after the painting was completed. This deficiency had the potential to affect all 89 residents identified on the census list provided by the Administrator on 04/29/26, as residents and their representatives would not be aware of how to contact the Ombudsman about concerns they have.
Incomplete Posting of Ombudsman and APS Contact Information
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program and Adult Protective Services at three locations: the First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor. During observations on 4/7/26 from 12:51 p.m. through 1:10 p.m., surveyors found that the posted Ombudsman information did not include the Ombudsman’s name or email address. The same observations showed that the Adult Protective Services posting did not include APS’s name, mailing address, phone number, or email address. During an interview on 4/7/26 at 2:13 p.m., the Nursing Home Administrator confirmed that the facility failed to post complete contact information for both programs as required.
Incomplete Posting of Adult Protective Services Contact Information on All Nursing Units
Penalty
Summary
The facility failed to meet federal and state requirements for posting complete and current contact information for Adult Protective Services (APS) on all three nursing units (South, North, and West). During an observation on 4/9/26 at approximately 1:00 p.m., surveyors noted that the required postings on each of these units did not include APS email address, phone number, and mailing address, as required under 42 CFR 483.10(g)(5). In a subsequent interview on 4/10/26 at approximately 3:00 p.m., the Nursing Home Administrator confirmed that the facility had not posted complete and current APS contact information on the three nursing units, resulting in noncompliance with federal resident rights posting requirements and related Pennsylvania regulations. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency pertains to facility-wide posting of resident rights and contact information for state agencies and advocacy groups, specifically APS.
Plan Of Correction
Complete and current contact information for Adult Protective Services has been posted in a form and manner, accessible and understandable to residents and representatives on three of the three nursing units (South, North, West). The Social Worker has been educated by the Administrator on the regulation to maintain these required posting. The Administrator/Designee will complete random audits to ensure the placement of the required posting is maintained. Results of this audit will be presented to the QAPI committee for review and further recommendations.
Failure to Provide Accessible Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required State Agency and Ombudsman contact information was prominently displayed in a location and manner accessible to residents, including those using wheelchairs. During a Resident Council group interview, three residents reported they did not know where to find information for the local Ombudsman or how to contact the State Agency with concerns. One resident stated he could ask the Activities Director for the information. These residents lived on the third floor, where residents were not allowed to access the first floor without staff supervision due to the presence of residents on the third floor who were considered elopement risks. An observation of the third floor revealed no visible postings of State Agency or Ombudsman information. Further observation on the first floor showed that the required State Agency information was posted on the wall next to the elevators, but the posting did not include the Ombudsman’s contact information. During an interview and observation with the Activities Director, the State Agency informational poster was measured at 58 inches from the ground, and the Activities Director acknowledged it would be difficult for a person in a wheelchair to see the information at that height. The Director of Nursing confirmed that residents on the third floor were not given the elevator code and had to be accompanied by staff to go downstairs. The facility’s Resident Rights policy stated that information must be provided to each resident in a form and manner the resident can access and understand, and that the facility must post the names, addresses, and telephone numbers of all pertinent State client advocacy groups, including the State survey and certification agency and the State ombudsman program, among others, as required by 410 IAC 16.23.1-4(j)(3).
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman program contact information was posted in a visible area for residents. During observation of the front lobby and the walls throughout the facility, no Ombudsman contact information was posted. The Infection Prevention Nurse stated the information was usually posted in the front lobby but was not posted at the time because it had been taken down when the walls were recently repainted. The nurse also stated the information should be posted in a visible place for residents so they could report concerns or make complaints to the Ombudsman. Resident 52, who was admitted and later readmitted to the facility, had diagnoses including COPD, HTN, and dysphagia. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS described him as cognitively intact and needing staff supervision for eating and toileting, with partial assistance for bathing and personal hygiene. During interview, Resident 52 stated he did not know where to find the Ombudsman’s contact information in the facility. The DON stated the Ombudsman information was usually posted in the front lobby but had been removed during repainting, and the facility policy stated that addresses and telephone numbers for the local Long Term Care Ombudsman’s office and the California Department of Public Health were posted on the facility consumer board.
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