Outdated State Agency Complaint and Posting Information
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 The phone number listed on the outdated postings was found to be the current complaint and incident intake number for HHSC, but the postings themselves had not been updated to identify HHSC as the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 She indicated she was unsure how she would know the postings were outdated and later stated she did not think having outdated postings would affect residents because the phone number was the same and the difference between agencies did not matter.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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Posting of Required State Agency and Complaint Information A facility failed to post complete contact information for the Office of the State LTC Ombudsman program and the Medicaid Fraud Unit, and failed to post a statement that residents may file a complaint with the State Survey Agency. During observations and an interview, Case Work Supervisor E18 confirmed the required information was missing on all three floors, including the First, Second, and Third Floors.
Failure to post required state agency and Ombudsman contact information in a prominent, accessible location was identified during survey observations and interviews. Several residents did not know what an Ombudsman was or where to find outside agency information, and staff gave inconsistent answers about the location, while the DON and Interim Administrator acknowledged the information was behind a locked door and not accessible to residents.
Failure to Post Required Consent Decree Program Information: Surveyors found no [NAME] and [NAME] Consent Decree signage on the first or second floor, even though 10 residents were enrolled in the program. Staff interviews showed uncertainty about who was responsible for the program, and the DON stated she was not familiar with it until the day before the interview.
The facility failed to post required contact information for State agencies and advocacy groups. During observations, no required complaint posting was found, and residents at a Resident Council meeting said they did not know how to contact the State Agency or APS or where to find the information. The Administrator stated the poster had not been posted since the facility opened.
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.
Incomplete Posting of Required State Agency and Complaint Information
Penalty
Summary
The facility failed to post complete contact information for the Office of the State Long-Term Care Ombudsman program and the Medicaid Fraud Unit, and failed to post a statement that residents may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. During observations and an interview completed on 7/17/26 at 9:50 a.m., Case Work Supervisor E18 confirmed that this required information was not posted on three of three floors, including the First, Second, and Third Floors, as required by 28 Pa. Code 201.14(a) and 201.18(e).
Failure to Post Required State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to display a list of names, addresses, and telephone numbers for pertinent State agencies and advocacy groups, along with a statement that residents may file a complaint with the State Survey Agency, in an accessible and prominent location. Survey observations on 7/8/26 at 2:37 PM found that the required contact information was not posted in a prominent or accessible area, and the facility did not have an accessible displayed directory for the state survey agency, licensure office, adult protective services, the State Long Term Care Ombudsman, or the Medicaid Fraud Control Unit in a format understandable to residents and their representatives. Interviews with residents and staff showed that multiple residents were unaware of the Ombudsman and did not know where outside agency information could be found. Resident #14 said they understood the Ombudsman but could not identify where the information was located, while Residents #19, #29, #31, and #33 reported they did not know the definition of an Ombudsman and were unaware of where such information could be posted. Staff also gave inconsistent responses: a CNA thought the information was in the copy machine room, and an RN stated they did not know what the Ombudsman was. The DON said the forms were at the front entrance vestibule, and the Interim Administrator acknowledged the information was behind a locked door and therefore not accessible or prominent for residents.
Failure to Post Required Consent Decree Program Information
Penalty
Summary
The facility failed to post the required [NAME] and [NAME] Consent Decree Program information in locations that were readily accessible to residents. During a surveyor round on 06/30/2026, no [NAME] and [NAME] Decree program signage was found on either the first or second floor. The report states that the deficiency had the potential to affect all 10 residents residing in the facility who participate in the program. Interviews with facility staff showed confusion about responsibility for the program and where the required information should be posted. The Social Service Director stated she received the list of residents under the program from the Director of Business Officer and was not responsible for the program. The Administrator later stated the facility was expected to post the signage so residents and families could see it, and that the Social Worker would take over the program from corporate office and receive training. The DON stated she was not familiar with the program until the day before and said the facility would comply by placing the proper signage on the bulletin board with other information for residents and families to see.
Missing State Agency Complaint Posting
Penalty
Summary
The facility failed to ensure that contact information for pertinent State agencies was posted and readily available to residents. Random observations from 6/22/26 through 6/24/26 from 8:00 AM to 5:00 PM found no required posting with State agency contact information for reporting complaints or other concerns. During a Resident Council meeting on 6/24/26 at 2:30 PM, 11 residents were present, and multiple residents stated they were not aware of how to contact the State Agency, Adult Protective Services, or where to locate that information in the facility. On 6/24/26 at 2:54 PM, the Administrator stated he was not aware the required posting was not in place and confirmed the poster had not been posted since the facility opened in 9/2025.
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.
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