Failure to Update Posted Survey Results
Summary
The facility failed to ensure that posted survey results were updated with the most recent survey findings. Observation of the facility's survey results binder revealed that the last included survey was dated 06/10/22, despite multiple surveys having been conducted since then, including eleven complaint surveys, an annual survey, and fifteen Focused Infection Control surveys. Review of the facility's survey history confirmed these additional surveys occurred between 06/10/22 and 04/28/25. During an interview, the Administrator confirmed that no survey results had been added to the binder since 06/10/22. This deficiency had the potential to affect all 55 residents in the facility, whose census at the time was 55.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Survey Results Not Readily Accessible: Residents stated they did not know where the State Inspection results were located, and staff at the main entrance/reception desk could not identify the Survey Results binder or its location. No signage was posted at the entrance or in the activities room, where the binder was later found on a counter. The facility handbook required the most recent survey results to be posted in a place readily accessible to residents, family members, and legal representatives.
Survey results were not readily accessible for resident and visitor review. The lobby binder titled Resident Information Book contained only federal and state survey results from 2020 through 2021, with no reports posted after the 03/04/2021 complaint survey. The REC confirmed there were no other lobby locations for survey reports, the DON expected survey information to be easily available, and the ADM confirmed the most recent survey reports were not in the binder or otherwise easily accessible.
Survey results were not clearly posted or easily accessible, as the binder containing them was not easily identifiable and lacked proper signage in the lobby. This affected all residents, as required postings and notifications were not in place.
The facility did not make survey results readily accessible to residents. A resident was unaware of where to find the survey results, and an observation revealed that the most recent survey results were missing from the lobby binder. Another binder with recent results was found at the nurse's station but was not accessible to residents. This issue was identified during a complaint investigation.
The facility did not post a notice of the availability of survey results from the past three years in prominent and accessible areas. Observations and interviews revealed that residents and staff were unaware of the survey results binder's location, which was placed outside the locked doors at the facility entrance without any signage. This affected all 67 residents.
The facility failed to ensure that state survey results were readily accessible, affecting all 45 residents. Observations revealed that the most recent health inspection was completed on a past date, and complaint inspections were completed on various dates. However, the facility did not post the survey results for the complaint investigations completed on these dates. The facility's posting corkboard did not include the plan of correction for the most recent health inspection survey results, and no survey results were available for review after a certain date.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. During a Resident Council Task Meeting interview, Residents #14, #86, and #119 stated they had no knowledge of where the State Inspection results were located. During an observation and interview at the main entrance/receptionist desk, there was no signage directing people to the Survey Results binder and no binder was present there; Receptionist #368 stated they did not know what the Survey Results binder was or where it was located and verified there was no signage identifying its location. A later observation found the Survey Results Binder on a counter in the first floor activities room, and there was still no signage in that room identifying where the binder was located. Review of the facility handbook titled Resident's Rights and Facility Responsibilities stated the facility must post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives, and must also post notice of the availability of such reports in prominent and accessible public areas.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys were readily accessible for resident and visitor review. On 5 survey days, observations in the lobby showed a binder titled Resident Information Book that contained federal and state survey results only for 2020 through 2021, with no survey results posted after the complaint survey dated 03/04/2021. The facility census was 111, and the deficiency had the potential to affect all residents. During interviews, the receptionist confirmed there were no additional locations in the lobby where survey reports were available to residents and the public, and the administrator confirmed the last report in the binder was from 2021. Although a notice on a third-floor bulletin board stated survey information was located on the kitchen counter of [NAME] Hall, an observation of that kitchen counter did not reveal any survey information, and the wound care clinician stated there was no survey information there. No postings related to the availability of survey inspection reports were observed on Sycamore Hall, and the administrator stated the most recent survey inspection reports were not in the binder nor easily accessible to residents and the public.
Survey Results Not Clearly Posted or Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were visibly posted and easily accessible to residents, family members, and legal representatives. During an observation in the front lobby, surveyors noted that three black letter holders were present on the wall between the business office and admissions office, containing a binder with a small label indicating 'survey results.' However, the binder was not easily identifiable as containing survey results unless someone was in close proximity to it, and there was no signage observed to indicate where the binder was located. An interview with the Administrator confirmed that there was no signage in the lobby or common area to direct individuals to the location of the survey results. This lack of visible posting and signage had the potential to affect all residents in the facility, as it did not comply with the requirement to make survey results readily accessible and to post notice of their availability in prominent and accessible areas. The facility census at the time was 39 residents. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Tag: F 0577 Facility will ensure there is a visible posting on where to locate the survey results. Posting was placed on 6/10/25 in a prominent location adjacent to the business office. No other required postings were identified as missing. Licensed administrator was educated on requirements of F0577 by RDO on 6/05/25. Administrator or designee will audit one time a week x4 weeks to ensure signage is in place. Audit results will be reported to QAPI committee for review and recommendations. F 0578 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0578 Request/Refuse/Dscntnue Tmnt; Formite Adv Dir Resident #27 code status was checked on 6/10/25 at 0900 by the Director of Nursing, and code status matched in hard chart and PCC. An initial audit was conducted on all residents on 6/11/25 by the Director of Nursing and all resident code status hard chart and electronic chart matched. All clinical staff were educated on checking code status on admission and with any code status change to ensure accuracy from hard chart to electronic chart on 6/11/25 by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all Residents initially and 2x weekly for any changes. Director of Nursing will also audit new admits and any return from hospital day of return or following day for any changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to make survey results readily accessible to residents, affecting all 71 residents. During an interview, a resident expressed a desire to view the facility's survey results but was unaware of their location or if access would be granted. An observation in the facility lobby revealed a binder containing survey results, but it only included results up to October 2023, omitting the four most recent surveys from April 2024 to July 2024. This was confirmed by the Regional Director of Operations (RDO) during the observation. Additionally, another binder with recent survey results was found at the first-floor nurse's station, but it was placed at the bottom of a stack of patient care binders, making it inaccessible to residents. The RDO verified that this binder was not readily accessible to residents. This deficiency was identified during a complaint investigation.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to post a notice of the availability of survey results from the preceding three years in areas that are prominent and accessible to the public. This deficiency was identified through observations and interviews conducted with residents and staff. During an observation on July 15, 2024, it was noted that there was no signage in the hallways regarding the location of the survey results binder or how to access it. Interviews with several residents revealed that they were unaware of the location of the survey results binder. Additionally, a State Tested Nurse Aide (STNA) confirmed that the binder was located on a bookshelf outside the locked doors at the facility entrance, but there was no posting indicating its location. Further interviews with the receptionist and the administrator verified the absence of signage or postings to inform residents or the public about the location of the survey binder. The receptionist mentioned that people would ask for the binder if they wanted to see it, while the administrator confirmed the binder's location at the front entrance but acknowledged the lack of signage. This oversight had the potential to affect all 67 residents of the facility, as the facility census was 67 at the time of the survey.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that state survey results were readily accessible for review, including the most recent survey of the facility. This deficiency had the potential to affect all 45 residents residing in the facility. Observations and reviews revealed that the most recent health inspection was completed on 09/23/22, and complaint inspections were completed on various dates, including 03/13/23, 05/04/23, 02/06/24, and 04/04/24. However, the facility did not post the survey results for the complaint investigations completed on 03/13/23, 02/06/24, or 04/04/24. During an observation on 06/25/24, it was noted that the facility's posting corkboard did not include the facility's plan of correction for the most recent posted health inspection survey results dated 09/23/22. Additionally, other survey results posted were dated from 12/05/19 through 05/04/23, with no other survey results available for review after the survey completed on 05/04/23. Further observations on 06/26/24 revealed that the most recent survey results available in the receptionist area were dated 09/23/22, and the Business Office Manager confirmed the lack of posted survey results for the more recent complaint investigations.
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