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.