Deficiency in Posting Survey Results and Ombudsman Information
Summary
The facility failed to properly post past survey results and ombudsman information in a readily accessible area for residents, family members, and legal representatives. A family member of a resident reported that the facility did not have the survey results or ombudsman notification information available, and the only ombudsman information sheet found was outdated and located by a locked unit. An observation revealed that only one copy of ombudsman information was present at the southeast entrance, but it was covered by another document and unreadable. Additionally, past survey results were found in a binder with a faded label in a hallway across from the kitchen, making it difficult to locate. The facility lacked a policy to ensure these documents were accessible, as confirmed by the Administrator's interview.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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The facility did not update its posted survey results binder with the most recent survey findings, leaving only outdated information available despite multiple complaint, annual, and infection control surveys having been completed. The Administrator confirmed that no new survey results had been added since the last entry, potentially affecting all 55 residents.
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.
The facility did not ensure that the results of complaint investigations by the state survey agency were available as required, affecting all 44 residents. The survey results binder in the main lobby contained only the last annual survey report, missing four complaint investigation results since then. The DON confirmed the binder should include both annual and complaint investigation results and needed updating.
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.
Failure to Update Posted Survey Results
Penalty
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.
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.
Failure to Update Survey Results Binder
Penalty
Summary
The facility failed to ensure that the results of complaint investigations conducted by the state survey agency were available as required, potentially affecting all 44 residents residing in the facility. An observation in the facility's main lobby area revealed a white binder intended to contain state survey results, but the most recent report in the binder was dated 04/23/23. A review of the facility's previous survey activity showed that the Ohio Department of Health conducted complaint investigation surveys on 11/03/23, 12/19/23, 02/07/24, and 04/09/24, but the results of these surveys were not present in the survey book at the time of the observation on 06/30/24. An interview with the Director of Nursing (DON) confirmed that the survey results binder contained only the results of the last annual survey and was missing the four complaint investigation results reports since the last annual survey. The DON acknowledged that the survey results book should include both annual and complaint investigation results and stated that the book needed to be updated.
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