Lyonsview Health and Rehabilitation Center

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The facility's failure had the potential to affect 166 of 168 residents.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure the facility's main dining room was open for resident use for 2 of 7 days of the week.

Inspectors wroteBased on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 1 resident (Resident #20) of 33 residents reviewed for MDS assessments.

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to maintain ongoing communication and collaboration with the dialysis facility and failed to document the status of the resident upon return to the facility for 1 resident (Resident #113) of 4 residents reviewed for Hemodialysis.

Inspectors wroteBased on job description review, employee file review, and interviews the facility failed to ensure the Dietary Manager completed accredited course work in dietetic training and certification.

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to ensure 1 of 8 (Resident #1) sampled residents reviewed for accident hazards received adequate supervision to prevent elopement (a situation where a resident leaves the premises or safe area without necessary supervision). On 12/10/2023, at approximately 10:50 PM, the facility staff observed Resident #1, a vulnerable and cognitively impaired resident with a history of wandering behaviors, outside the building next to a fence. [...]

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, police report review, and interview, the facility failed to protect the residents' right to be free from physical abuse for 3 residents (Resident #2, Resident #4, and Resident #6) of 21 residents reviewed for abuse.

Inspectors wroteBased on review of the Centers for Disease Control (CDC) and Prevention and U.S. Department of Housing and [NAME] Development Healthy Housing Reference Manual, job description review, facility documentation review, facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to maintain effective pest control in the kitchen as evidenced by the presence of live and dead roaches in the kitchen and food preparation areas which had the potential to affect all 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). [...]

Inspectors wroteBased on review of the facility policy review, Administrator's job description, review of the facility's Medical Director Agreements, facility documentation review, and interview the facility's Administration failed to manage its resources and operating budget to maintain an effective pest control program after an invoice was not paid to the pest control company which resulted in an interruption in services from 11/30/2022 - 4/4/2023 and an outbreak of pest in the facility's kitchen. The facility's failure did not maintain the highest practicable physical, mental, and psychosocial wellbeing of the 144 residents residing in the facility. The Regional [NAME] President of Operations failed to address facility concerns. [...]

Inspectors wroteBased on job description review, facility documentation, observations, and interviews the facility failed to produce evidence of an effective governing body (GB), failed to manage its financial resources to ensure an effective pest control program was maintained for 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office. [...]

Inspectors wroteBased on facility policy review, electronic communication review, observation, and interview the facility failed to maintain an effective pest control program potentially affecting 144 residents. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office. [...]

Inspectors wroteBased on the facility policy review, medical record review and interview, the facility failed to develop and implement care plans for 2 Residents (Residents #583 and #102) of 36 residents reviewed for care plans. The facility failure to implement Resident #583's care plan resulted in the resident having a critical lab value, the resident was transferred to the hospital and diagnosed with a GI (Gastrointestinal Bleed), Anemia, and required a blood transfusion which resulted in Harm for Resident #583. The facility failed to develop and implement an individualized and person-centered care plan related to activities for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed.

Inspectors wroteBased on the facility policy review, medical record review, and interview, the facility failed to follow a physician's order to obtain a weekly lab for medication monitoring for 1 resident (Resident 583) of 30 residents reviewed for quality of care. Resident #583's lab specimen clotted rendering the specimen unusable, and a new specimen was not obtained. The facility's failure to ensure Resident #583's lab was obtained per the physician order resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital, and required a blood transfusion, which resulted in Harm for Resident #583.

Inspectors wroteBased on the facility policy review, medical record review and interview, the facility failed to ensure 1 resident's (Resident #583) medical care was supervised by a physician of 36 residents reviewed for physician services. The facility's failure to monitor Resident #583's medical status resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital and required a blood transfusion, which resulted in Harm for Resident #583.

Inspectors wroteBased on facility policy review and interview the facility failed to ensure Medical Director duties were coordinated to clearly delineate responsibilities of the facility's Medical Directors. The facility's failure to implement and coordinate resident care created an environment which impaired the nursing staff to effectively provide patient care and services which had the potential to affect all 144 residents in the facility.

Inspectors wroteBased on facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to protect 2 Residents (#56 and #17) from physical abuse of 30 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide interpretation services or an effective communication service for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement an individualized and activities program to meet the needs for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed for activities.

Inspectors wroteBased on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to ensure 2 residents (#55 and #53) remained free from abuse of 14 residents reviewed for abuse.