Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lost Creek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Unsafe Smoking Supervision and Oxygen Use: Staff failed to maintain a safe smoking environment when a CNA handed cigarettes and a vape to residents and lit the cigarettes in the smoking area. A resident was observed smoking while seated in a wheelchair with an O2 tank attached, and staff confirmed she had smoked with oxygen on on multiple occasions despite the facility policy prohibiting oxygen use in smoking areas and requiring supervision while smoking.
An LPN left a medication cart unattended and unsecured in the hallway while administering meds to two residents, with the top drawer slightly open and the keys left in the lock. The LPN confirmed the cart was left unsecured twice, and facility policy required medication compartments to be locked when not in use.
Improper Authorization for Resident Funds Account: A resident with schizophrenia, dementia, epilepsy, and moderate cognitive impairment had a guardian appointed by the county board, but the facility kept resident fund management authorization forms signed by the resident instead of the legal guardian. The BOM and county case manager confirmed the guardian had not signed the later forms, despite facility policy requiring authorization from the resident or representative to manage funds.
The facility failed to develop comprehensive person-centered care plans for three residents. One resident with HF and AKI had no ADL care plan despite needing substantial ADL assistance. Another resident with dementia, dysphagia, and CP had documented poor dentition and dental hygiene concerns, but no dental care plan was developed. A third resident with CP, mood disorder, ID, and epilepsy had documented refusal of ADL help from CNAs, yet the care plan did not reflect the resident’s refusal of personal care assistance.
Failure to assess, document, and treat resident wounds. Two residents had skin issues that were not properly monitored or documented. One resident with cerebral palsy and obesity had repeated shower-sheet documentation of open, red, moist, and bleeding areas on the buttocks and gluteal folds, but weekly skin assessments lacked measurements or wound details, and staff confirmed no treatment had been initiated before the wound physician evaluated the areas. Another resident with diabetes and hemiplegia had a left arm skin tear with four scabbed areas, but the record lacked a skin assessment, progress note, or treatment order, despite staff confirming the wound had been present for days.
A resident with multiple chronic conditions, including CHF, HTN, anemia, and morbid obesity, had standing orders for periodic lab monitoring, including Vitamin D levels, and daily Vitamin D3 supplementation. The facility did not obtain the ordered Vitamin D labs as directed, and the DON confirmed the last documented Vitamin D result was the only one available in the record.
Failure to provide timely dental services for two residents. One resident with COPD, DM2, CHF, hemiplegia, and impaired cognition had a dental order for a surgical referral, but the referral was delayed and not followed up on promptly. Another resident with vascular dementia, dysphagia, and cerebral palsy had poor oral health, broken/carious teeth, and severe cognitive impairment, yet there was no documentation of a dentist visit after admission and the DON confirmed the resident had not been seen by a dentist.
A facility failed to include all pertinent information in an SRI for a resident with impaired cognition and dependence for care. The resident reported that a CNA was rough during brief care and spanked the resident, and the investigation documented a skin tear on the left upper arm, but the SRI stated the assessment had negative outcomes and did not mention the skin tear.
Failure to Follow Antibiotic Stewardship Program: The facility did not follow its antibiotic stewardship policy for three residents receiving antibiotics. A resident with a wound infection received Bactrim DS without a documented wound culture, a resident with pharyngitis received Cefdinir without a culture or McGeer's assessment, and a resident with respiratory symptoms received Azithromycin despite McGeer's criteria not being met. The DON confirmed cultures and other diagnostic checks were not completed and stated she does not question physicians on antibiotic use.
A resident with multiple risk factors for skin breakdown developed a stage four pressure ulcer on the right calf due to inadequate monitoring and lack of daily skin assessments under a knee brace. Despite care plan interventions and physician orders, staff did not consistently remove the brace or inspect the skin, leading to a deep tissue injury that progressed to a severe wound requiring surgical debridement.
The facility did not ensure that two CNAs completed the federally required 12 hours of annual in-service training, as confirmed by missing documentation in their education files. This deficiency was identified during a review of employee records and verified by the staff responsible for medical records, potentially impacting all residents.
The facility did not consistently hold quarterly care conferences with the required interdisciplinary team, residents, and their families or representatives. Several residents and families reported not being invited or involved, and documentation was lacking for invitations and participation. Staff confirmed that care conferences were sometimes held without nurses or aides and that proper notice was not always given, resulting in noncompliance with care planning requirements.
Surveyors found that two residents, both care planned as fall risks, did not have their call lights within reach as required by facility policy. One resident with severe cognitive impairment had the call light hooked to a privacy curtain out of reach, while another resident with Parkinson's and muscle weakness had the call light on the bed and inaccessible while needing assistance. The activity director confirmed the call lights were not accessible in both cases.
A resident with multiple diagnoses and intact cognition had conflicting advance directive information in their records, with the physician order indicating full code while the hard chart and care plan documented DNR CCA status. The DON confirmed the inconsistency between the physician order and the hard chart, contrary to facility policy requiring clear documentation of advance directives.
The facility did not provide required discharge and transfer notifications or summaries to two residents, their representatives, or the Ombudsman following hospital transfers, as confirmed by staff interviews and record review.
A resident with multiple psychiatric diagnoses and prescribed psychotropic medications was admitted, but the PASARR only listed mood and anxiety disorders, omitting other diagnoses and all psychotropic medications. The Managed Care Coordinator confirmed these omissions, and the facility's policy requiring accurate PASARR coordination was not followed.
A resident admitted with multiple complex conditions, including an active infection requiring IV antibiotics, a PICC line, and a wearable cardioverter defibrillator, did not have these care needs addressed in the baseline care plan. The DON confirmed these omissions, which were present from admission and not reflected in the care planning.
Surveyors identified that the facility did not ensure residents had the mental capacity to sign arbitration agreements and failed to explain these agreements in a way residents could understand. One resident with severe cognitive impairment signed an agreement without involvement of a power of attorney, while two cognitively intact residents either did not recall signing or misunderstood the agreement. Staff interviews revealed inconsistent explanation practices and lack of verification of resident understanding.
Surveyors observed that two residents did not receive care in accordance with infection control protocols. An LPN failed to perform hand hygiene before donning gloves and did not change gloves or sanitize hands at appropriate times during feeding tube care. An RN, while providing wound care, did not sanitize scissors taken from a student's pocket before use and did not change gloves or wash hands before handling wound dressings. These lapses in hand hygiene, glove use, and equipment cleaning were confirmed by staff interviews.
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 maintain proper emergency lighting documentation, failing to record the duration of monthly tests and omitting the required annual 90-minute test, potentially affecting 39 residents. Additionally, the facility did not ensure that cooking facilities met NFPA fire protection and ventilation standards, as observed during the survey and confirmed by staff interviews.
Surveyors found that a movable natural gas stove in the kitchen lacked required chock devices to ensure proper alignment with fire suppression nozzles and did not have a chain or restraint to prevent overextension of the gas line. These deficiencies were confirmed by maintenance staff and were not in compliance with NFPA standards, potentially affecting all residents.
Surveyors found that the designated smoking area in the courtyard gazebo lacked metal containers with self-closing covers for emptying ashtrays, as required by NFPA 101. This deficiency was confirmed by maintenance staff and had the potential to affect staff and 39 residents.
Surveyors found a corridor door held open by an unapproved chain and magnet, which interfered with the door's latching mechanism and did not meet NFPA requirements for smoke resistance and positive latching, potentially affecting 13 residents.
Surveyors found multiple penetrations in smoke barriers sealed with non-fire-rated materials and one unsealed pipe, compromising the required fire and smoke resistance in several corridors and the attic. Maintenance leadership confirmed uncertainty about the materials used, and these deficiencies had the potential to affect all 39 residents.
Two residents suffered falls and fractures due to inadequate supervision and failure to follow safety protocols during transfers. One resident fell during a mechanical lift transfer conducted by a single staff member, contrary to the facility's policy requiring two staff members. Another resident fell out of bed when left unattended after the bed was elevated for care, resulting in bilateral femur fractures. These incidents highlight a failure to adhere to safety protocols and care plans, leading to significant harm.
Unsafe Smoking Supervision and Oxygen Use
Penalty
Summary
The facility failed to ensure a safe smoking environment and did not maintain adequate supervision for residents while smoking. During observation, Resident #33 was seen sitting in a wheelchair in the smoking area with an oxygen tank attached to the back of the wheelchair. Two other residents were also in the smoking area, and CNA #221 handed one resident a vape and handed another resident and Resident #33 cigarettes, then lit the cigarettes for them. During interview, CNA #221 confirmed it was staff responsibility to ensure residents were safe while smoking and stated Resident #33 should not be allowed to smoke while wearing oxygen or when an oxygen tank was present in the smoking area. CNA #221 also stated Resident #33 had smoked on multiple occasions with oxygen on and had hidden the oxygen tank by covering it with a jacket while smoking. The Social Services Director confirmed Resident #33 had been educated not to use oxygen while smoking after being observed smoking off the property with oxygen on. The Administrator confirmed the facility expectation was that no oxygen is allowed in the smoking area, and the smoking policy stated oxygen use is prohibited in smoking areas and all residents will have supervision while smoking.
Unsecured Medication Cart During Medication Administration
Penalty
Summary
Medication storage was left unsecured during medication administration on the 200-hall. During an observation at 7:16 A.M., an LPN was preparing medications for Resident #33 and then took the medication cup into the room, leaving the medication cart unattended in the hallway with the drawers facing the hall, the top drawer open approximately one inch, and the keys hanging from the lock. A second observation at 7:39 A.M. showed the same LPN preparing medications for Resident #3 and again leaving the medication cart unattended and unsecured in the hallway with the top drawer slightly open and the keys left in the lock. During interview at 7:57 A.M., the LPN confirmed the cart had been left unattended and unsecured twice while medications were being administered. The facility policy titled Storage of Medications stated that compartments containing drugs and biologics shall be locked when not in use and shall not be left unattended if open or potentially available to others.
Improper Authorization for Resident Funds Account
Penalty
Summary
The facility failed to ensure proper authorization was obtained for it to manage a resident’s funds account. Resident #9 was admitted with diagnoses including schizophrenia, dementia, and epilepsy, and later was found to have moderate cognitive impairment on a significant change MDS assessment. Guardianship papers dated 12/17/22 showed the resident was deemed incompetent and assigned to the county Guardianship Services Board as guardian. Review of the Resident Fund Management authorization forms showed one form signed on 06/22/18 by an attorney who was the resident’s legal guardian, but later forms dated 04/12/22 and 01/06/26 were signed by the resident. The Business Office Manager stated the resident had a legal guardian since 2018 and that guardianship changed in 2022 from the attorney to the county board, and confirmed the later authorization forms were signed by the resident rather than the legal guardian. The county case manager also confirmed she had taken over as guardian in 2022 and had not signed any Resident Fund Management authorization forms. The facility policy required a copy of the resident’s or representative’s authorization designating the facility to manage resident funds to be filed in the financial record.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents. Resident #5 was admitted with hypertensive heart disease with heart failure and acute kidney failure, and the admission MDS showed the resident was cognitively intact, required set-up assistance with eating, and substantial assistance from staff with all other ADLs. The care plan dated 03/23/26 did not include an ADL care plan, and an LPN confirmed that an ADL care plan should have been in place. Resident #32 was admitted with vascular dementia, dysphagia, and cerebral palsy. The admission evaluation documented that the resident had her own teeth with some broken or carious teeth, and the dental consent form listed poor dental hygiene as the reason for dental consult. The admission MDS later noted severely impaired cognition and no dental issues or concerns, and there was no documentation supporting a comprehensive person-centered dental care plan. Observation showed several missing teeth and several decayed teeth. Resident #37 was admitted with cerebral palsy, hypertensive heart disease without heart failure, mood disorder, mild intellectual disabilities, and epilepsy. The annual MDS showed the resident was cognitively intact and had behavioral symptoms not directed toward others, but the care plan did not document refusal of ADL assistance. CNAs stated the resident refused help with grooming facial hair and was resistant to staff assistance with ADL care, and the resident was observed with long facial hair on her chin and stated she did not allow staff to help with shower or grooming needs.
Failure to assess, document, and treat resident wounds
Penalty
Summary
The facility failed to assess, treat, and monitor wounds for two residents with skin issues. One resident was admitted with spastic diplegic cerebral palsy and morbid obesity and was identified in the care plan as being at risk for skin breakdown. Although shower sheets repeatedly documented open areas, redness, bleeding, blistering, and maceration on the buttocks, gluteal folds, abdominal folds, and posterior thigh over several months, the weekly skin assessments contained no documentation of skin concerns or wound measurements for those areas. During observation, the resident’s buttocks and gluteal area were red, moist, and macerated with open shallow areas, and staff confirmed the right gluteal fold area was not new and was related to the Hoyer pad. The DON later confirmed the wounds had been documented multiple times on shower sheets, had not been measured on weekly skin assessments, and had not been treated or documented before the wound physician evaluated them. The wound physician confirmed the resident had an area on the left buttocks caused by moisture associated skin damage and another area caused by a skin tear, and stated he had not treated the wounds prior to that date. Staff interviews also confirmed that the resident’s right gluteal fold area had not had a treatment in place and that antifungal cream had been applied to the bilateral buttocks. The record showed orders for weekly skin assessments and topical treatments, but the documentation did not reflect assessment, measurements, or treatment initiation for the open areas noted on the shower sheets. A second resident with diabetes mellitus type 2 and hemiplegia following cerebral infarction had a skin tear on the left upper arm that was observed as four distinct scabbed areas with a thin layer of betadine. Staff and leadership confirmed the skin tear had been present for several days, but there was no skin assessment in the medical record, no progress note describing the wound, and no treatment order documented for the skin tear. The facility policy required that when a skin tear is discovered, an incident report be completed, the wound be assessed, the physician be notified, and treatment be implemented immediately, but the record did not show that these steps were documented for this resident.
Failure to Obtain Ordered Vitamin D Laboratory Monitoring
Penalty
Summary
The facility failed to obtain laboratory values as ordered by the physician for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including anxiety, lymphedema, congestive heart failure, morbid obesity, hypertension, and anemia, and was cognitively intact on the quarterly MDS assessment. Physician orders included CBC, BMP, hepatic function, thyroid function, and Vitamin D levels every six months, along with daily Vitamin D3 supplementation. Review of the medical record showed no documentation that Vitamin D levels had been obtained since the last recorded result, and the DON confirmed that the facility had not obtained the ordered Vitamin D levels for the resident.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for two residents. One resident had an admission diagnosis history that included COPD, DM2, hemiplegia following cerebral infarction affecting the left non-dominant side, and CHF, with a BIMS score of 11 indicating impaired cognition. After a dental visit note documented a physician order for a surgical referral, the facility attempted to obtain the referral over several weeks, but the Social Services Designee stated he sent the referral four days after the dental visit and had not followed up on it. Documentation of the referral was not available at the time of interview, and the referral was only confirmed later after staff checked with the dental surgeon's office and learned an appointment had been scheduled. A second resident with vascular dementia, dysphagia, and cerebral palsy had severe cognitive impairment and was dependent on staff for oral hygiene. Admission records noted broken/carious teeth and poor dental hygiene, and the dental screen again documented own teeth with broken/carious teeth. Although a dental referral was present on admission, there was no documentation that the resident was ever seen by a dentist from admission through the survey date, and the resident was observed with several missing teeth and several decayed teeth. The DON confirmed the resident had not been seen by a dentist since admission and stated she did not know why the resident was not added to the dentist list.
Incomplete SRI Documentation
Penalty
Summary
The facility failed to submit accurate and pertinent information in a Self-Reported Incident for one resident. Resident #8 was admitted on 02/26/25 and had diagnoses including hemiplegia following cerebral infarction affecting the left non-dominant side and congestive heart failure. The quarterly MDS showed impaired cognition and dependence on staff for toileting hygiene, bed mobility, and transfers. According to SRI #275931, the resident reported to the Behavioral Health Specialist that CNA #218 was rough while changing the resident’s brief and spanked the resident on the bottom. The SRI stated a head-to-toe assessment was completed with negative outcomes, but the facility’s investigation documented a skin tear on the left upper arm on the body diagram. The Administrator later verified that the SRI did not include the skin tear information and acknowledged that the person reviewing the SRI did not have all pertinent information regarding the incident.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship program and policy to ensure antibiotic use was appropriate for three residents reviewed for antibiotic use. Resident #1, who had diagnoses including anxiety disorder, essential hypertension, anemia, and metabolic encephalopathy, had an order for Bactrim DS twice daily for a coccyx wound infection. The infection log noted the wound order, and the McGeer's form described the wound as red and warm, but there was no documentation that a wound culture was completed. The DON confirmed the facility did not complete a wound culture and initiated the Bactrim DS, and stated she does not question physicians on antibiotic use. Resident #34, with diagnoses including chronic kidney disease stage 3, major depressive disorder, essential hypertension, and metabolic encephalopathy, had an order for Cefdinir twice daily for pharyngitis. The infection log did not list an antibiotic for pharyngitis, there was no documentation of a culture, and no McGeer's assessment was completed for antibiotic use. The DON confirmed the facility did not complete a culture related to pharyngitis and stated the resident's only complaint was a sore throat with no other signs or symptoms noted. Resident #36, who had chronic diastolic heart failure and osteoarthritis, had an order for Azithromycin for respiratory symptoms. The infection log did not list an antibiotic for upper respiratory infection, there was no documentation of a culture, and the McGeer's assessment stated respiratory infection criteria were not met with runny nose and sore throat. The DON confirmed no chest x-ray was completed related to the upper respiratory infection and stated the resident's only complaint was a sore throat with no other signs or symptoms noted.
Failure to Monitor and Prevent Pressure Ulcer from Medical Device
Penalty
Summary
A resident with multiple medical conditions, including a recent femur fracture, peripheral vascular disease, and muscle weakness, was admitted and required the use of a knee brace. Physician orders and the care plan indicated the need for skin assessments, monitoring for redness or open areas, and interventions to prevent skin breakdown, especially given the resident's risk factors. Despite these orders, there was no documented evidence that the facility staff consistently removed the brace and checked the skin under and around the device on a daily basis. The resident developed a skin tear on the right calf, which was initially treated with Steristrips and kerlix. Over the following days, the area worsened, becoming open and bleeding, and was later found to be a deep tissue injury that progressed to a stage four pressure ulcer. The wound was attributed to pressure from the knee brace, specifically where the dial of the brace contacted the skin. The wound ultimately required two surgical debridements and ongoing wound care. Interviews with the DON and ADON confirmed that the wound was caused by the brace and that additional padding could have been used to prevent pressure, but this was not done. Review of the facility's documentation and staff interviews revealed a lack of consistent monitoring and documentation regarding removal of the brace and assessment of the skin beneath it. The facility failed to follow best practices for prevention of medical device-related pressure injuries, such as daily inspection of the skin under devices and appropriate cushioning. This failure resulted in actual harm to the resident, who developed a severe pressure injury requiring extensive medical intervention.
Plan Of Correction
F 0686 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 an 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 0686 Treatment/Services to Prevent/Heal Pressure Ulcer: Resident #9 skin check was completed on 6/23/25 by the Director of Nursing, and no new skin areas of concern were noted. The wound is now improving, currently classified as stage IV, with wound doctor visits weekly. An initial audit was conducted on all residents with braces/splints on 6/23/25 by the Director of Nursing and Assistant Director of Nursing, and no skin issues or areas of concern were noted. An audit was conducted to ensure daily skin checks were listed as a treatment on the TAR by the Director of Nursing on 6/23/25. All clinical staff were educated on the importance of removing any and all braces and/or splints with daily skin checks and performing complete skin checks with hygiene and bathing on 6/23/25 by the Director of Nursing. Education also included daily documentation of braces and/or splints removal and skin checks daily in a progress note and/or TAR. The Director of Nursing will conduct an audit 3 times per week for 4 weeks to observe all residents with splints and/or braces to ensure daily skin checks are being completed. The Director of Nursing will observe brace removal and review nursing documentation (progress notes and/or the TAR) to ensure it is being completed daily. 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 Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service training annually, as mandated by federal regulations. During a review of employee files, it was found that two CNAs did not complete the annual in-service training hours. Specifically, the education files for these CNAs did not contain documentation showing completion of the required training for the relevant years. An interview with the staff member responsible for medical records confirmed that there was no documentation available to verify that the two CNAs had completed the 12-hour in-service requirement for the specified years. This deficiency was identified through a review of three CNA files, with two found to be non-compliant, potentially affecting all residents in the facility, which had a census of 39 at the time.
Plan Of Correction
Tag: F 0947 All nurse aides (#510 and #519) identified during the survey who had not completed the required 12 hours of in-service training for calendar year 2025 were immediately scheduled for and have now completed the missing training, including dementia care and abuse prevention modules. A facility-wide audit of all nurse aide training records for the past 12 months was conducted to identify any additional staff who were out of compliance with the annual in-service requirements. Any additional deficiencies found have been corrected as of 6/25/25. The administrator provided training to the HR director on 6/16/25 regarding requirements of CNAs to complete 12 CEUs annually. HR or designee will audit monthly for the next 3 months. Results of the audit will be provided to the QAPI committee for review and recommendation.
Failure to Hold Timely, Inclusive Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to ensure that quarterly care conferences were held in a timely manner and that the required interdisciplinary team (IDT), residents, and their families or representatives were included in the process. Multiple residents with varying diagnoses, including cognitive impairment, mental health disorders, and chronic medical conditions, were affected. Documentation revealed that care conferences were either not held at the required intervals, not attended by the full IDT, or did not include the resident and/or their representative, as required by regulation and facility policy. For several residents, care conferences were documented as occurring, but interviews with the residents and their families indicated they were not aware of or did not recall being invited to or participating in these meetings. In some cases, there was no documentation that residents or their families were invited, and no input or concerns from them were recorded. For one resident, no care conferences had been held since admission, and both the resident and their spouse confirmed they had never participated in such a meeting. Staff interviews confirmed that care conferences were sometimes held without the required nursing or aide staff, and that invitations to residents and families were not consistently documented or provided with adequate notice. The facility's policy required a seven-day advance notice for care conferences, with documentation of the date, time, method of contact, and input from the resident or representative if they could not attend. However, staff acknowledged that this process was not consistently followed, and that care conferences were often scheduled based on staff availability rather than resident or family participation. As a result, the facility did not meet regulatory requirements for timely, inclusive, and interdisciplinary care planning.
Plan Of Correction
Tag: F 0657 Care conferences were held with residents / sponsors for the following residents #10, #16, #35, #5, and #6 on or before 6/25/25. Social services or designee will review all current resident records by 6/25/25 to ensure that quarterly care conferences have been completed timely. If a care conference did not occur, one will be held by 6/25/25. The administrator provided education to the social services designee on 6/17/25 regarding the timely completion of quarterly care conferences, quarterly completion, and the requirement for IDT, resident, and sponsor involvement. The administrator or designee will audit 3 resident charts for the completion of timely care conferences weekly for 4 weeks to ensure timely completion and involvement of the resident, sponsor, and IDT. Results of the audit will be reviewed by the QAPI committee for further recommendations.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents, both of whom were care planned as being at risk for falls. For one resident with severe cognitive impairment and multiple diagnoses including dementia with agitation and paranoid schizophrenia, the call light was observed hooked to the privacy curtain and out of reach while the resident was lying in bed. The activity director confirmed that the resident uses the call light and verified it was not accessible at the time of observation. The resident's care plan specifically required that the call light be within reach and that the resident be encouraged to use it for assistance. For another resident, who was cognitively intact and had diagnoses including Parkinson's disease, muscle weakness, and difficulty walking, the call light was found lying on the bed and out of reach while the resident was sitting in a chair and expressing a need to use the bathroom. The activity director again confirmed the call light was not accessible. Facility policy required that call lights be within easy reach of residents when in bed or confined to a chair, but this was not followed in these instances.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that both the hard chart and the electronic medical record contained consistent and correct advance directive information for a resident. Specifically, the physician orders indicated the resident was a full code, while the hard chart documented the resident as Do Not Resuscitate Comfort Care Arrest (DNR CCA), and the care plan also reflected DNR CCA status. The Director of Nursing confirmed this discrepancy during an interview, verifying that the physician order was for full code, but the hard chart had a DNR CCA form signed by the physician. The resident involved was admitted with diagnoses including Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. The resident was assessed as cognitively intact, with a BIMS score of 15. Facility policy required that information about whether a resident has executed an advance directive be displayed prominently in the medical record, but this was not consistently done in this case, resulting in conflicting documentation regarding the resident's code status.
Failure to Provide Required Discharge and Transfer Notifications
Penalty
Summary
The facility failed to provide required discharge and transfer notifications to residents, their representatives, and the Ombudsman for two residents. In the first case, a resident with diagnoses including diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder was admitted to the facility and later transferred to the hospital following a change in condition and declining vital signs. Documentation showed the resident was transferred via emergency squad, but there was no evidence of a transfer summary or notification sent to the hospital, the resident, the resident's representative, or the Ombudsman during the relevant period. In the second case, another resident with a history of complications post femur fracture surgery, depression, and myeloma was admitted and subsequently discharged to the hospital after a syncopal episode and possible urinary tract infection. The transfer occurred after the resident was seen by an outside physician. Review of the medical records revealed no documentation of discharge or transfer notification to the resident, the resident's representative, or the Ombudsman. Interviews with facility staff, including a Managed Care Provider and the Administrator, confirmed that the required notifications and summaries were not completed or documented for either resident. The findings indicate that the facility did not meet regulatory requirements for communication and documentation during resident transfers and discharges.
Plan Of Correction
Tag: F 0628 Facility has provided resident #28 and #42 with transfer notices, as well as updated transfer log and sent to ombudsman. Administrator reviewed all transfer/discharges from 5/1/25 through 5/30/25 for corresponding notice of transfer/discharge. Administrator or designee will review discharged patients for the last 30 days to ensure they received a transfer/discharge notice. If they did not receive a notice, they will be issued one, this will occur on or before 6/25/25. Administrator provided education to social service designee on transfer/discharge notice requirements on 6/17/25. Administrator or designee will audit 3 discharge residents weekly x4 weeks to ensure proper notice of transfer/discharge. Results of audits will be reviewed by the QAPI committee for further recommendations.
Failure to Accurately Complete PASARR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with multiple psychiatric diagnoses. The resident was admitted with a history of bipolar disorder, schizoaffective disorder, visual and auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Despite these diagnoses and the use of several psychotropic medications, the PASARR completed for the resident only listed mood disorders and panic or other severe anxiety disorders, omitting other relevant diagnoses and all psychotropic medications. A review of the resident's Minimum Data Set (MDS) indicated the resident was cognitively intact, and current physician orders included multiple psychotropic medications for the management of their psychiatric conditions. During an interview, the Managed Care Coordinator confirmed that the PASARR did not include any psychotropic medications or additional diagnoses beyond mood disorder and panic or other severe anxiety disorders. The facility's policy requires coordination with the PASARR program to ensure accurate assessment and care planning for individuals with mental disorders, intellectual disabilities, or related conditions, but this was not followed in this case.
Plan Of Correction
Tag: F 0644 The facility will ensure the PASARR is completed accurately. PASARR for resident #10 has been updated by social service designee to include all diagnoses and antipsychotic medications. Social services or designee will complete a whole house audit to determine if PASARR is accurate by 6/25/25. Administrator will provide social service designee with education regarding PASARR process on 6/17/25. Administrator or designee will audit 3 PASARRs weekly for 4 weeks. Audit results will be reviewed by the QAPI committee for further recommendations.
Failure to Include Critical Admission Care Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that included all care concerns present at the time of admission for one resident. The resident was admitted with multiple significant diagnoses, including chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Upon admission, the resident had active physician orders for intravenous antibiotics (ampicillin sodium and ceftriaxone) to treat an implantable cardioverter-defibrillator (ICD) infection, required the use of a wearable cardioverter defibrillator (life vest) with specific battery and placement checks, and had a peripherally inserted central catheter (PICC) line with associated care instructions. A review of the baseline care plan dated the day of admission revealed that it did not address the PICC line, life vest, infection, or the administration of antibiotics, all of which were present and required care from the time of admission. The Director of Nursing confirmed in an interview that these care needs were present on admission and should have been included in the baseline care plan, but were not.
Plan Of Correction
F-0655 Baseline Care Plan Resident #96 Baseline care plan did not include instructions to provide effective and person-centered care on 6/10/25 by the Director of Nursing. An initial audit was conducted on all new residents on 6/10/25 by the Director of Nursing and all Baseline Care Plans were completed. All clinical staff were educated on 6/10/25 on baseline care plans needing to be completed on admission by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all new Residents for 4 weeks to ensure Baseline Care Plans reflect all minimum healthcare information needed to provide effective person-centered care. 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 Ensure Capacity and Understanding in Arbitration Agreements
Penalty
Summary
Surveyors found that the facility failed to ensure residents had the mental capacity to sign arbitration agreements and did not adequately explain these agreements in a manner or language the residents could understand. In one case, a resident with a BIMS score indicating severe cognitive impairment signed an arbitration agreement, despite the expectation that a power of attorney should have been involved. Interviews confirmed that the resident did not recall signing the agreement or understand its purpose. Another resident, who was cognitively intact according to their BIMS score, signed an arbitration agreement but could not recall if the agreement was explained or if they had signed it. This resident also did not understand what an arbitration agreement was. A third resident, also cognitively intact, misunderstood the arbitration process, believing it involved a judge and a court, and was unsure if they had signed such an agreement upon admission. Staff interviews revealed inconsistent practices in explaining arbitration agreements. The administrator stated that residents were told they did not have to sign if they did not understand, but typically had residents read the agreement themselves rather than providing a thorough explanation. The previous admissions director described explaining the voluntary nature of the agreement and the option to seek legal counsel, but would only involve a responsible party if the resident did not understand. The regional director confirmed that a resident with severe cognitive impairment should not have signed the agreement without the power of attorney.
Plan Of Correction
Tag: F 0847 Administrator or designee will review and explain the arbitration agreement to residents and/or sponsors of #9, #25, and #31 by 6/20/25. The administrator or designee will review the arbitration agreement log with identified residents to ensure choice and understanding by 6/20/25. RDO provided education to administrator on arbitration requirements on 6/5/25. Three new admissions will be audited weekly x4 weeks to ensure understanding and choice in regards to signing arbitration agreements. Results of audit will be provided to QAPI committee for review and recommendations.
Infection Control Deficiencies in Hand Hygiene, Glove Use, and Equipment Cleansing
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices during care provided to two residents. For one resident with impaired cognition and a feeding tube, an LPN prepared for tube feeding care by donning a gown and gloves but failed to sanitize hands before applying gloves. Throughout the procedure, the LPN did not change gloves or perform hand hygiene at appropriate intervals, including after handling potentially contaminated items and before applying a new bandage. The LPN only changed gloves once, without hand hygiene between glove changes, and later confirmed that protocol required more frequent handwashing and glove changes, which were not followed. For another resident with multiple medical conditions and a wound on the right upper lateral calf, an RN performed wound care with a nursing student present. The RN followed some hand hygiene steps, such as washing hands and changing gloves at certain points, but failed to sanitize or change gloves after touching the box of dressings and before placing the dressing into the wound bed. Additionally, scissors used to cut the dressing were taken from the student nurse's pocket and were not sanitized before use. The RN acknowledged these lapses during an interview, confirming that the scissors were not cleaned and that gloves were not changed or hands washed before handling the wound dressing. These observations demonstrate that the facility did not consistently ensure proper hand hygiene, glove use, and equipment cleansing during resident care, as required by infection prevention and control protocols. The lapses were directly observed by surveyors and confirmed by staff interviews, affecting two residents reviewed for infection control practices.
Plan Of Correction
F 0880 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 an 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 0880 Infection Prevention & Control Resident #23 & #9 dressing changes were monitored by the Director of Nursing on 6/12/25, and all infection control standards were followed. An initial audit was conducted on all residents with wounds on 6/13/25 by the Director of Nursing and all infection control standards were met. All clinical staff were educated on infection prevention and control on 6/11/25 by the Director of Nursing, including handwashing and EBP precautions. The Director of Nursing or Designee will conduct an audit with staff 3x a week x 4 weeks to watch dressing 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 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.
Deficiencies in Emergency Lighting and Cooking Facility Safety Standards
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 requirements. A review of the life safety documentation revealed that while twenty-three emergency lights were listed as "OK" on the emergency lighting log, the records did not indicate the duration of the monthly tests. Additionally, the section of the log designated for the required annual 90-minute test was not utilized. During an interview, the Regional Maintenance Director confirmed that the maintenance director was likely unaware of the specific testing requirements. This deficiency had the potential to affect 39 residents. The report also notes a failure to maintain cooking facilities in compliance with NFPA 101-2012 and related standards. The facility did not meet the requirements for protecting cooking equipment as outlined in the relevant NFPA codes. The observations and staff interviews indicated that the necessary fire protection and ventilation controls for cooking operations were not properly maintained, as required by the standards cited.
Plan Of Correction
Tag: K 0291 On 6/20/25, all 23 emergency lights were tested and found to be functional. All emergency lights will be appropriately tested and documented by the maintenance director or designee monthly. The administrator provided the maintenance director with education regarding emergency lighting requirements on 6/16/25. The maintenance director or designee will submit the emergency lighting log to the QAPI committee for review and recommendation for the next 3 months.
Failure to Maintain Safe Cooking Equipment Positioning and Restraints
Penalty
Summary
During a facility tour, surveyors observed a natural gas six-burner/griddle stove on wheels in the kitchen that was not equipped with chock devices to ensure proper alignment with the fire suppression system nozzles when the appliance was moved for cleaning or service. The absence of these chock devices meant that the required protection by the suppression system could not be guaranteed if the stove was not returned to its designated position after being moved. Additionally, the movable stove was not provided with a chain or restraint to prevent overextension of the gas line, as required by relevant NFPA standards. This lack of a restraining device could allow the gas line to be stretched or damaged during movement, which is not in compliance with the manufacturer's installation instructions and applicable codes. These deficiencies were confirmed through interviews with the Regional Maintenance Director and the Maintenance Director at the time of observation. The findings indicated that the facility failed to maintain its cooking facilities in accordance with multiple sections of NFPA 101, NFPA 54, NFPA 96, and NFPA 17A, potentially affecting all 39 residents in the facility.
Plan Of Correction
Tag: K 0324 The natural gas 6 burner griddle stove has been equipped with both chock devices and restraint to prevent over extension of gas line as of 6/20/25. There are no other natural gas moveable stoves in the facility. The administrator provided education to maintenance director on 6/16/25 regarding requirements NFPA 101 cooking facilities. The maintenance director or designee will audit the natural gas 6 burner griddle stove to ensure proper equipment and restraint weekly for the next 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Missing Self-Closing Metal Containers in Smoking Area
Penalty
Summary
During a facility tour, surveyors observed that the designated smoking area in the courtyard gazebo did not have metal containers with self-closing cover devices available for emptying ashtrays. This observation was confirmed in interviews with the Regional Maintenance Director and the Maintenance Director at the time of the survey. The absence of these containers is a violation of NFPA 101-2012 Edition, Section 19.7.4, which requires that such containers be readily available in all areas where smoking is permitted. The deficiency was identified as having the potential to affect an undetermined number of staff and 39 residents in the event of an emergency. The report does not mention any specific incidents involving residents or staff at the time of the observation, nor does it provide details about the medical history or condition of any individuals involved. The finding is based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Tag: K 0741 On or before 6/20/25, the designated smoking areas were equipped with self-closing cover metal devices. There are no other smoking areas on the property. The administrator provided the maintenance director with education regarding NFPA 101 smoking regulations. The maintenance director or designee will audit smoking areas for appropriate self-closing devices 3 times a week for 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Noncompliant Corridor Door Hold-Open Device
Penalty
Summary
The facility failed to ensure that all corridor doors were able to resist the passage of smoke and were provided with a suitable means for keeping the doors closed, as required by NFPA 101-2012 and NFPA 80-2010 standards. During a facility tour, surveyors observed a 20-minute fire-rated double-corridor door being held open by an unapproved chain with a magnet attached. This setup was not compliant with regulations, as the magnet on the chain could interfere with the door's latching mechanism and was not an approved device for holding the door open. The magnet, when the door closed, would swing on its chain and potentially interfere with the door's ability to latch properly. This deficiency was confirmed through interviews with the Regional Maintenance Director and the Maintenance Director, who acknowledged the findings at the time of observation. The improper use of the chain and magnet did not meet the requirement for corridor doors to have positive latching hardware and to resist the passage of smoke. The report specifies that this deficiency had the potential to affect 13 out of 39 residents in the facility. No additional details about the specific residents or their medical conditions were provided in the report. The deficiency was limited to the improper securing of a fire-rated corridor door, which did not comply with the required fire and smoke protection standards.
Plan Of Correction
Tag: K 0363 Chain and magnet on double corridor door modified to keep from impeding closure on 6/20/25. No other fire rated or smoke barrier doors found to be impeded from closing appropriately. Administrator educated maintenance director on NFPA 101 corridor doors on 6/16/25. Maintenance director or designee will audit all corridor doors weekly x 4 weeks. Audit results will be submitted to the QAPI committee for review and recommendations.
Failure to Maintain Smoke Barrier Integrity per NFPA 101
Penalty
Summary
The facility failed to maintain fire and smoke barriers in accordance with NFPA 101-2012 Edition, Section 19.3.7.3 and Section 8.5.6.2. During a facility tour, surveyors observed multiple penetrations in smoke barriers that were improperly sealed with non-fire-rated, rubber-like materials. These penetrations included aluminum conduits and black pipes located in the interstitial spaces between the ceiling and drop ceiling above several 20-minute fire-rated double corridors leading into various halls, including the 100, 200, 300, and 400 Halls, as well as the Service Hall. Additionally, one 3-inch black pipe was found completely unsealed in the attic space above a fire-rated double corridor leading into the attic. The materials used to seal the other penetrations were not fire-rated and did not meet the requirements for restricting the transfer of smoke as specified by the referenced NFPA standards. The Regional Maintenance Director confirmed at the time of discovery that he was unsure of the type of material used to seal the pipes. These deficiencies were identified during direct observation and staff interviews, and the findings were confirmed by facility maintenance leadership. The report notes that these failures had the potential to affect all 39 residents in the facility, as the integrity of the smoke barriers was compromised by the use of improper sealing materials and the presence of unsealed penetrations.
Plan Of Correction
Tag: K 0372 Both the pipe and conduits between the ceiling and drop ceiling above the fire-rated double corridor leading into 100 hall, 200 hall, 300 hall, 400 hall, service hallway, and into the attic space were repaired with fire-rated caulk on or before 6/20/25. There was no other conduit or pipes found to have penetrations not properly sealed. Administrator educated maintenance director on NFPA 101 subdivision of building spaces - smoke barrier construction on 6/16/25. Maintenance director or designee will audit pipes and conduits for penetration monthly x 3 months. Audits will be submitted to the QAPI committee for review and recommendations. K 0372
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures during resident transfers, resulting in falls and injuries. Resident #10, who required extensive assistance for transfers due to conditions such as obesity and chronic obstructive pulmonary disease, fell during a mechanical lift transfer conducted by a single staff member. The resident was supposed to be assisted by two staff members as per facility policy, but this was not adhered to, leading to a fall that resulted in a fractured left femur requiring surgery. The investigation revealed that the nurse aide involved was following the manufacturer's guidelines rather than the facility's policy, which mandates two staff members for such transfers. Resident #2, who had impaired cognition and was dependent on assistance for activities of daily living, fell out of bed when left unattended after the bed was elevated for incontinence care. The nurse aide had raised the bed to waist level and left the room to retrieve a lift, during which time the resident attempted to reach for items on the bedside table and fell, sustaining fractures to both femurs. The care plan for Resident #2 included keeping the bed in a low position and ensuring personal items were within reach, but these interventions were not followed at the time of the incident. Both incidents highlight a failure to adhere to established safety protocols and care plans, resulting in significant harm to the residents involved. The facility's policy required two staff members for mechanical lift transfers, which was not followed in the case of Resident #10. Similarly, the care plan interventions for Resident #2 were not implemented, leading to the resident's fall. These deficiencies were identified during the investigation of multiple complaints, indicating a pattern of non-compliance with safety and supervision standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Carecore At Lima | 2.9 mi | ★★★★★ | 18 | 0 |
| Springview Manor | 4.7 mi | ★★★★★ | 0 | 0 |
| Lima Convalescent Home | 5.7 mi | ★★★★★ | 1 | 0 |
| Shawnee Manor | 6.3 mi | ★★★★★ | 1 | 0 |
| Liberty Retirement Community Of Lima Inc | 6.6 mi | ★★★★★ | 34 | 1 |
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