Lyndon Crossing, LLC

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure a comfortable, sanitary environment free from odors. The Men's Unit of the facility had ongoing, unpleasant odors of stale urine on all four days of the survey. In additions, feces and/or blood was observed to be smeared on different surfaces on one of the four days of the survey. The failure to maintain a comfortable, sanitary environment which was free from odors, had the potential to affect any of the 23 residents living on this locked unit, as well as staff and the public/visitors in the area.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one (Resident (R) 3) of 26 sampled residents had an admission Minimum Data Set (MDS) assessment completed within 14 days of admission. R3 was admitted on [DATE], and the MDS V200B date, signifying completion of the assessment, was not completed until 11/05/2025.

Inspectors wroteBased on interview, record, review, and review of facility policy, the facility failed to ensure that one (Resident (R) 38) of 26 sampled residents had a thorough, complete medical record which reflected the care that was provided. R38 had no documentation of medication administration or multiple contacts with the physician in accordance with physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a secure manner. Observations revealed medications on top of a medication cart, with no staff in view of the cart.

Inspectors wroteBased on interview, review of the clinical record, and review of the facility policy, the facility failed to implement the resident(s) care plan interventions for 1 out of 9 resident(s) sampled for elopement risk, Resident (R)1. The facility admitted R1 on 07/08/2025 and was assessed to be a risk for elopement. The resident was required to reside on the secured memory care unit, which required supervision while on the unit. Per the policy and the resident's care plan, this was for the resident's safety. Additionally, the resident's care plan interventions included providing structured activities. On 09/15/2025, R1 left the facility unsupervised and without staff knowledge. Interviews with staff revealed the resident's care plan was not implemented due to staff providing care to other residents on the unit. [...]

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision for 1 out of 9 sampled residents. Resident (R)1. On 07/08/2025, the facility admitted R1 and assessed the resident to require the need to reside on its memory care [secure] unit with supervision provided while on the unit. According to the facility's policy and R1's care plan, this was for the safety of the resident. However, on 09/15/2025 the resident left the facility unsupervised. The resident was found at the park, approximately .4 miles away from the facility, by concerned citizens who called 911 to alert the police of the missing resident. When the [NAME] Officer questioned staff about the resident, staff stated they were unaware the resident had left the facility. [...]

Inspectors wroteBased on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, it was determined the facility failed to store and serve food in a safe manner which had the potential to affect 126 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, review of the clinical record, and review of the facility policy the facility failed to develop the baseline care plan for 1 of 4 residents sampled for elopement and care plans out of the 33 total sampled residents, (Resident (R)401). The facility admitted R401 on 01/21/2025 and assessed the resident as at risk for elopement on that date. However, the facility failed to develop a baseline care plan with necessary interventions to address the resident's risk for elopement. R401 left the facility without staffs' knowledge on 01/24/2025. Immediate Jeopardy (IJ) was identified on 02/12/2025 and was determined to exist on 01/24/2025 in the area of 42 CFR §483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 02/12/2025 at 4:23 PM. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision for two of 12 sampled residents, Residents (R) 400 and R401. On 01/21/2025, the facility admitted R401 and assessed the resident as at risk for elopement; however, failed to address that risk in the baseline care plan. Therefore, on 01/24/2025 at approximately 10:30 PM, R401 left the facility without facility knowledge (which could be considered an elopement) and was not located until the next morning (of 01/25/2025) at a local hospital. Additionally, the facility failed to assess R400 for smoking safety and falls in its initial assessment of the resident upon admission. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide residents and/or guardians with resident personal funds account quarterly statements for 5 of 5 residents sampled for personal funds accounts, (Residents (R) 1, R6, R8, R22, and R49).

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the residents' environment was safe, clean, comfortable, and homelike. The facility failed to provide a functional and comfortable environment for residents related to cold water temperatures for 14 out of 19 resident rooms. (Rooms 101, 102, 103, 105, 106, 107, 108, 109, 110, 121, 122, 124, 125, and 126).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12-months for five out of five CNAs' personnel records reviewed, CNA #2, #18, #20, #31, and #32. Additionally, the facility failed to provide evidence of regular in-service education based on the outcome of these reviews for three of five records reviewed, CNA #18, #31, and #32.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure it electronically submitted complete and accurate direct care staffing information, to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters in 2024. The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September 2024.

Inspectors wroteBased on observation, interview, record review, and review of the facility's documentation and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections for 2 of 3 sampled residents (Resident (R) 20 and R67). Observations of Licensed Practical Nurse (LPN)6 of R20 and R67 during wound care revealed the LPN failed to perform hand hygiene when moving from a dirty task to a clean task. Additionally, the LPN failed to ensure a barrier was in place before placing supplies on the table. In an interview with the Wound Doctor, she stated this practice could contaminate the wound and cause an infection.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure its abuse prohibition policy was implemented by failing to verify and maintain documentation of screening and training, including criminal record checks required for pre-employment for 9 of 12 personnel files reviewed. The criminal background check, the nurse aide abuse registry check, and/or the Kentucky Adult Caregiver Misconduct Registry (KACMR) check was not completed for newly hired employees. Additionally, there was not documented evidence to support newly hired staff had received the abuse training required at the beginning of employment.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made for one of five sampled residents (Resident (R) 79). On12/09/2024, Certified Nursing Assistant (CNA) 14 alleged that while changing R79, the resident become combative and CNA13 was observed to have choked the resident at approximately 5:20 AM. CNA 14 reported the alleged abuse at 8:37 PM to administration, which was approxmiately 15 hours after the incident was observed and delayed the facility's investigation of abuse.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 22 sampled residents, (Resident (R) 22). The facility failed to develop R22's comprehensive care plan regarding a SoftPro Ambulating ankle foot orthoses (AFO) Boot (an ankle foot orthoses used to treat mild to moderate lost range of motion of the ankle/foot and to facilitate assisted weight bearing).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs were labeled in accordance with professional standards. Observations revealed undated, opened, unlabeled and expired medications in 1 of 5 medication carts and 1 of 2 treatment carts. Those medications included topical creams, and one oral pill.

Inspectors wroteBased on observation, interview, record review and review of facility documentation, policies, and Plan of Correction (POC), the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the Revisit Survey from 04/01/2025 through 04/04/2025, the State Survey Agency (SSA) identified continued non-compliance for the facility in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761). [...]