Failure to Post Required Contact Information
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.
Penalty
Resources
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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.
Staff failed to ensure that required contact information for the State Survey Agency, State licensure office, and the State LTC Ombudsman was posted in an accessible location. The information was placed behind a concierge desk in an area where residents are not allowed, and no other signage was posted on the affected floor. During a Resident Council meeting, all residents present were unable to identify where this information was located and were unaware of their right to file complaints with these agencies. When two residents in wheelchairs were later shown the sign, they could not see it from their position in front of the desk while staff pointed to the posting behind the desk.
Surveyors found that the facility failed to maintain accurate postings of state agency and advocacy group contact information, including the State Survey Agency. Multiple wall postings still referenced the dissolved Texas Department of Aging and Disability Services (DADS), listed a nonfunctional DADS website, and did not identify HHSC as the current pertinent agency, although the phone number connected to HHSC complaint and incident intake. The Administrator reported she had not reviewed the postings since starting several months earlier, was unsure how to identify outdated materials, believed the outdated agency name did not matter as long as the phone number was correct, and confirmed there was no facility policy governing postings.
Surveyors found that the facility did not post the Missouri DHSS Elder Abuse and Neglect Hotline number or State Long-Term Care Ombudsman contact information in visible locations throughout multiple units, including elevators, Terrace 2 and 3, 3 Short, 3 Long, and the Loop. Instead, only corporate compliance and administrator contact information were prominently displayed, while the Ombudsman number appeared only on a very small label on a Resident Rights poster outside the Social Worker’s office, and no DHSS hotline number was observed there. During a resident council meeting, eight residents reported they were not aware of the Ombudsman program and confirmed that information about it was not posted. The Administrator stated he believed hotline signs should be present in a few specific areas and expected the Ombudsman print to be large enough for residents to see, but survey observations did not confirm adequate, visible posting facility-wide.
Surveyors found that the facility did not post complete contact information, including email addresses, for the State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit on all floors, and also failed to display a required statement about residents' rights to file complaints with the State Survey Agency.
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).
Required Ombudsman and State Agency Contact Information Not Accessible to Residents
Penalty
Summary
Facility staff failed to post the required list of names, mailing and email addresses, and telephone numbers for the State Survey Agency, State licensure office, and the Office of the State Long-Term Care Ombudsman in a location accessible to all residents. During an observation of the third floor, this information was found posted behind the concierge’s desk on the wall, an area where residents are not allowed. No other signage with the required information was posted on the third floor. Concierge #2 stated that residents are not permitted behind the desk, that the door to the dining room behind the desk is kept locked so residents cannot go behind the desk, and that residents must ask for the information and phone numbers if they need them. Concierge #2 also reported that in five years of employment, no resident had requested this information. During a Resident Council meeting, all 10 residents present were unable to identify where the required information was located and were unaware that they had the right to file a complaint with the State licensure office or the State Long-Term Care Ombudsman. After the meeting, the Activities Director took two residents in wheelchairs to view the Ombudsman information; they were positioned in front of the concierge’s desk while the Activities Director pointed to the sign behind the desk and explained its contents. From their position, the two residents were unable to see the information on the signage. The Activities Director stated there was another copy of the information outside her office on the second floor for assisted living residents. The Administrator later stated that the Activities Director hands out cards with Ombudsman information from time to time and that the Ombudsman conducts rounds in the facility.
Outdated State Agency Complaint and Posting Information
Penalty
Summary
The facility failed to post an accurate and updated list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency and State licensure office, as required. Surveyors observed multiple postings in public areas that still referenced the Texas Department of Aging and Disability Services (DADS), an agency that dissolved in 2017, instead of the current Health and Human Services Commission (HHSC). One posting titled "How to File a Complaint" stated that DADS hoped individuals were satisfied with care and directed complaints to DADS at a listed phone number and website, and was dated July 2007. Another posting titled "Notice" stated that inspection and survey information by representatives of DADS must be posted for public inspection, listed the DADS website, and was dated June 2006. A third posting regarding "Reporting Reasonable Suspicion of a Crime" listed a contact number for the local police department and a DADS phone number, with no date indicated. A review of the DADS website by surveyors showed that the site was not in service and confirmed that DADS had dissolved in 2017. The phone number listed on the outdated postings was found to be the current complaint and incident intake number for HHSC, but the postings themselves had not been updated to identify HHSC as the pertinent state agency. During interviews, the Administrator stated she had been in the role for four months and had not reviewed the postings since starting. She indicated she was unsure how she would know the postings were outdated and later stated she did not think having outdated postings would affect residents because the phone number was the same and the difference between agencies did not matter. When asked via email, the Administrator confirmed the facility did not have a policy regarding postings.
Failure to Post DHSS Abuse Hotline and Ombudsman Contact Information in Visible Locations
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to post required contact information for the Missouri Department of Health and Senior Services (DHSS) Elder Abuse and Neglect Hotline and the State Long-Term Care Ombudsman program in visible locations. During observations conducted over multiple days, surveyors noted that no DHSS Abuse and Neglect hotline numbers or Ombudsman contact information were posted in the elevators, on Terrace 2, on the middle hall double doors of Terrace 3, on 3 Short, on 3 Long, or on the Loop. Instead, only corporate compliance contact information was posted in several of these areas. In the front lobby, a bulletin board sign instructed individuals who suspected abuse or neglect to contact the Administrator and listed the Administrator’s phone number, but did not include the DHSS hotline. Outside the Social Worker’s office, a Resident Rights poster included the Ombudsman’s contact number only on a small label approximately 1 inch by 2 5/8 inches, and there was no DHSS hotline number observed there. During a resident council meeting interview, all eight residents present stated they were not aware of the Ombudsman program and confirmed that information about the program was not posted. One resident asked for the correct spelling of the advocacy agency, further indicating unfamiliarity. In a subsequent interview, the Administrator reported that there should be signs for the hotline number by the business office, by the stairwell near Terrace 2, and near the bird cages, but he was only aware of those locations and could not confirm broader posting. He also stated he would need to see the print used for the Ombudsman contact number but would expect it to be large enough for residents to see. These observations and interviews showed that the facility did not adequately post the required State agency and advocacy group contact information, including the DHSS Elder Abuse and Neglect Hotline and Ombudsman program details, in a manner visible and accessible to residents.
Incomplete Required Postings for State Agencies and Complaint Procedures
Penalty
Summary
The facility failed to post complete and required contact information for the State Survey Agency, Adult Protective Services, and the Medicaid Fraud Unit on all three floors. Specifically, the postings did not include email addresses for these agencies as mandated by regulation. Additionally, the facility did not display a statement informing residents that they may file a complaint with the State Survey Agency regarding any suspected violation of state or federal nursing facility regulations. These deficiencies were identified during observations conducted on all three floors, and the absence of the required postings was confirmed in an interview with the Nursing Home Administrator. No information was provided in the report regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
No residents were directly affected by the posting, but they were corrected the week of survey. All postings were corrected so residents and families have the correct information available for their use if needed. Administrator or designee will educate administration staff on proper signage for state survey agencies, adult protective services, and the Medicaid fraud unit. Administrator or designee will audit the three postings weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
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