Lyngblomsten Care Center

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 1 of 3 residents (R13) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure freedom of movement was not restricted for 1 of 1 resident (R143) who was reviewed for physical restraints.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect discharge status for 1 of 1 resident (R200) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and document review, the facility failed to consistently utilize a communication device or provide an interpreter for 1 of 1 resident (176) reviewed who was deaf and used ASL to communicate care needs. Findings Include: R176's significant change Minimum Data Set (MDS) assessment dated [DATE], identified no cognitive impairment, primary language was American sign language (ASL), and an interpreter was needed to communicate with doctors and health care staff. R176's care plan revised on 12/3/24, identified impaired communication. R176's care plan identified methods for communicating such as short, direct simple phrases, visual aids, and indicated please provide me with an ASL interpreter for all significant meetings/interactions such as care conferences, cognitive/mood assessments, etc. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 2 of 4 residents (R88 and R143) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess transfers with a mechanical lift or develop and implement policies to ensure the safety and supervision for 1 of 4 residents (R20) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (R115) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure complaint investigation survey results were readily accessible and available for review within the campus. This had potential to affect all 207 residents, visitors, and their families who could wish to review the information. Findings Include: During the recertification survey on 6/2/25 at 12:21 p.m., a binder labeled survey results hung on the wall to the left of the information board located in a hallway on the 1st floor, adjacent to the front desk and contained the following results: Recertification survey dated 3/14/24 Abbreviated complaint survey results dated 5/21/24. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the Physician Order for Life Sustaining Treatment (POLST) accurately reflected current resuscitation wishes for 2 of 4 residents (R1, R4) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R4 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R1's POLST dated [DATE] indicated full code status with comfort cares contrary to R1's wishes for do not resuscitate (DNR) status with comfort cares. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:25 p.m. The IJ was removed on [DATE] at 4:33 p.m. when the facility had implemented corrective action, however; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a safe transfer assessment for the use of sit-to-stand mechanical lift and follow manufacturer instructions and maintenance of the lift for 1 of 1 resident (R1) which resulted in a fall from the lift with a fracture. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when R1 became tired and weak from standing in the lift while staff changed out two batteries and were unaware of the emergency lowering features which resulted in R1 letting go sustaining left arm fracture and left wrist tendon tear. The Administrator and director of nursing (DON) were notified of the IJ on [DATE] at 5:24 p.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 212 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine shaving for 1 of 1 resident (R36) reviewed for activities of daily living (ADL) who was dependent on staff for cares.

Inspectors wroteBased on interview and document review, the facility failed to make a follow-up appointment for 1 of 2 residents(R54) reviewed for vision.

Inspectors wroteBased on interview, observation and document review, the facility failed to have ongoing communication and collaboration with dialysis facility for 1 of 2 residents (R54) reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to label, date opened containers of food stored, ensure expired food were identified and removed from walk-in produce refrigerator and dry good storage room. Furthermore, the facility failed to ensure food was served under sanitary conditions, proper sanitization of thermometer when temping foods; and failed to ensure dishes and food preparation equipment were appropriately air dried. This had the potential to affect all 211 residents who were served food and beverages from the facility kitchen.

Inspectors wroteBased on observation, interview, and document review the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19, when during a Covid-19 outbreak and high Covid-19 community transmission, residents, visitors and staff were observed not wearing appropriate personal protective equipment (PPE), specifically masks. This had the potential to affect all 211 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to immediately report to the administrator and no later than 2 hours, to the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident verbal abuse and an allegation of resident to resident abuse for 2 of 2 residents (R27, R192) who was reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to complete a thorough investigation for a resident to resident altercation and to assure residents were safe and prevent further potential abuse by allowing the alleged perpetrator (AP) to continue to have access to other vulnerable adults following an allegation of abuse, for 2 of 2 residents (R162, R169) investigated for abuse.

Inspectors wroteBased on document review and interview, the facility failed to develop a comprehensive person-centered care plan which included care for an indwelling Foley catheter for 1 of 2 resident (R199) reviewed for catheter care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide routine catheter hygiene care for 1 of 2 residents (R138), reviewed for catheter care; who had an indwelling catheter, was at risk for infection, and had a history of urinary tract infections (UTIs).