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 The admission handbook was also found to be deficient, as it contained incorrect and outdated contact information for the state ombudsman program and the SD DOH complaint coordinator.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:
Missing Required State Agency and Complaint Postings: Surveyors observed that required postings listing state agencies, advocacy groups, and the complaint process were absent from resident common areas. A cognitively intact resident, the resident's RP, the Activities Director, the Social Services Manager, and the Administrator all confirmed the information was not posted or accessible, and the Administrator stated she was unaware the posting requirement existed.
Failure to Post Required State Agency and Advocacy Contact Information: The facility did not display required contact information for the State Survey Agency, DSS, the LTC Ombudsman, the Resident Advocacy Network, home and community based service programs, or the Medicaid Fraud Control Unit in resident common areas. Two residents said they did not know how to contact the State Agency to file a complaint, and an Activities Director was unaware of the posting location. The Administrator stated the signs had been removed for wall painting and were stored in her office, with replacement in common areas overlooked.
State agency complaint information was not posted in an accessible location for residents and resident representatives. During facility observation, the LDH Nursing Home complaint phone number was not displayed, and both the DON and Administrator confirmed it was not posted.
Required postings for State agencies and advocacy groups were not fully displayed in an accessible location. Surveyors found that the Ombudsman, State Survey Agency, and APS postings lacked email addresses, several required agencies and programs were missing, and the statement advising residents that they may file a complaint with the State Survey Agency was not posted. During a resident group interview, residents were unaware of where the required information was located, and the NHA stated they were responsible for the postings.
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.
Missing Required State Agency and Complaint Postings
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, as well as a statement explaining how a resident may file a complaint with the State Survey Agency regarding suspected violations of state or federal nursing facility regulations. During observations of all resident common areas on 06/22/2026 and again on 06/24/2026, surveyors found no such postings and no information describing the complaint process in any prominent or accessible location. Interviews supported the observation. A cognitively intact resident, based on a quarterly MDS with a BIMS score of 15 and ARD of 05/20/2026, stated the facility did not have the required postings in a prominent location for residents and families to view. The resident's responsible party also stated the information was not posted in a location or format that made it accessible. The Activities Director, Social Services Manager, and Administrator each confirmed the postings were not present, and the Administrator stated she was unaware the information was required to be posted.
Failure to Post Required State Agency and Advocacy Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers for required state agencies and advocacy groups, including the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program, the Resident Advocacy Network, home and community based service programs, and the Medicaid Fraud Control Unit. This deficiency was observed in the facility, including all hallways, on multiple days during the onsite recertification and complaint survey, and no such postings were seen in the resident common areas. During the Resident Council meeting, two residents stated they did not know how to contact the State Agency to file a complaint or where that information would be found in the facility. During a walking tour and interview with the Activities Director, the required postings were still not present, and the Activities Director stated she was not aware of the postings location and would need to consult the Administrator. The Administrator later stated the postings had been removed for wall painting completed one week earlier and were being stored in her office, and that she had overlooked replacing the signage in resident common areas.
State Agency Complaint Information Not Posted
Penalty
Summary
The facility failed to ensure that the name, address, and telephone numbers of all pertinent State agencies were posted in a manner accessible to residents and resident representatives. During observation throughout the facility, the LDH Nursing Home complaint phone number was not posted in a place accessible to residents and resident representatives. In interviews, the DON confirmed that the LDH Nursing Home complaint phone number was not posted, and the Administrator later confirmed the same finding.
Required State Agency and Advocacy Postings Not Accessible or Complete
Penalty
Summary
The facility did not ensure that required contact information for pertinent State agencies and advocacy groups was posted in an area accessible to residents and staff. Surveyors observed that the facility’s postings were located behind a glass cabinet on the left wall when entering the facility and were not located in any other area. The posted information for the State Survey Agency, Ombudsman, and Adult Protective Services did not include email addresses, and required information for the Protection and Advocacy Network, Home and Community Based Service Programs, Family and Medical Leave Act, Medicaid Fraud Control Act Unit, and Applying for Medicare and Medicaid was not posted. Surveyors also found that the required statement informing residents that they may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations was not posted, including information related to resident abuse or neglect, non-compliance with advanced directives requirements, and requests for information regarding returning to the community. During a group interview, all six residents in attendance stated they were not aware of where facility-required resident information was posted, and five residents did not know what an Ombudsman was or where Ombudsman information was located. The Nursing Home Administrator stated they were responsible for the postings but had no further explanation for why the required information was not posted in an easily accessible location.
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.
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