Lost Creek Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Lost Creek Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 9, 2025

  Based on medical record review, observation, staff interviews, and review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, the facility failed to monitor a resident's leg where a brace was applied. This resulted in actual harm when the resident developed a Deep Tissue Injury (DTI) later resulting in a stage four pressure ulcer (deep wound that may impact muscle, tendons, ligaments, and bone) that ultimately required two surgical debridements in an attempt to promote wound healing. This affected one (#9) of three residents reviewed for pressure wounds. […]

• Actual harm, isolatedF689Jun 27, 2024

  Based on observation, medical record review, resident and staff interviews, review of hospital documentation, revealed of fall investigations, review of manufacturer's guidelines, and review of a facility policy, the facility failed to ensure residents dependent for transfers and activities of daily living were kept free from falls. This resulted in actual harm when Resident #10 sustained a fall during a mechanical lift transfer on 06/12/24 which was being completed by one staff member and Resident #2 sustained a fall on 06/07/24 when the resident was left unattended in bed after it was elevated to perform incontinence care. Consequently, Resident #10 suffered a fractured left femur requiring surgery and Resident #2 suffered fractures to both femurs. […]

• Actual harm, isolatedF686Nov 21, 2022

  Based on observation, staff interview, record review and policy review, the facility failed to assess newly identified skin breakdown, implement interventions/treatments to aid in the healing of the existing skin breakdown, and conduct ongoing monitoring of the skin breakdown. This resulted in Actual Harm when Resident #32 was found to have a Stage III pressure ulcer to coccyx on 11/14/22 and deep tissue injuries (DTI) to right lateral foot and right lateral fifth toe. This affected one (#32) of one resident reviewed for pressure ulcers. There were a total of two residents identified by the facility with pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF947Jun 9, 2025

  Based on employee file review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of inservices annually. This affected two (CNA #510 and CNA #519) of three CNA employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 39. Findings include: Review of employee file for CNA #510 revealed a hire date of 01.09/23. Review of education file revealed the CNA #510 did not complete 12 hours of inservices annually. Review of employee file for CNA #519 revealed a hire date of 10/10/23. Review of education file revealed the CNA #519 did not complete 12 hours of inservices annually. Interview on 06/09/25 at 11:05 A.M. […]

• No harm, potential for more than minimal, widespreadF880Nov 21, 2022

  Based on observation, staff interview, review of facility policy, review of community transmission rate, review of Centers of Medicare and Medicaid Services (CMS) memorandum QSO-23-02-ALL, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore face masks as required to potentially prevent the spread of Coronavirus 2019 (COVID-19). This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the CDC COVID-19 Integrated County View revealed on 11/14/22, the facility's county community transmission rate was high. Observation on 11/14/22 at 7:58 A.M. revealed upon entrance to the facility, unidentified staff and residents were in the common area with no face masks applied. […]