The Estates at Lynnhurst LLC

Inspectors wroteBased on interview and document review, the facility failed to ensure sufficient dietary staff were available to prepare and serve meals in accordance with the planned menu and residents' physician-ordered diets for 5 of 5 residents (R1, R61, R52, R62, R23) interviewed regarding food services. This had the potential to affect all 68 residents resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 resident (R3) reviewed with an indwelling catheter; and the facility failed to ensure hand hygiene was performed during medication administration for 3 of 4 residents (R8, R44, R54) observed to receive their medications; and the facility failed to ensure laundry services were conducted in a manner to promote sanitary conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a calm, comfortable, low-stimulation environment appropriate to the needs of residents residing on the secured unit by allowing loud, violent television programming to be played in the common dining area for 2 of 2 residents (R2, R46) reviewed for quality of life. This deficient practice had the potential to adversely affect all 27 residents residing on the secured unit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to replace a torn, stained mattress and ensure urine-soiled bedding was changed timely for 1 of 1 resident (R46) reviewed for activities of daily living; and failed to remove residents' meal plates, beverages, and utensils from institutional serving trays before meal service for all 27 residents residing on the secured unit.

Inspectors wroteBased on interview and document review, the facility failed to develop and revise comprehensive, person-centered care plans to address resident-specific interventions for leaves of absence (LOAs), including interventions to promote resident safety and staff direction when residents left the facility without notifying staff or signing out, for 2 of 2 residents (R10, R37) reviewed for supervision.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure licensed nursing staff followed manufacturers recommendations when preparing insulin via a NovoLog FlexPen for 1 of 2 residents (R63) reviewed for insulin administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance with toileting and elimination by ensuring a resident's urinal was emptied and removed before the resident entered common areas for 1 of 4 residents (R33) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with dressing and personal hygiene, including offering a clean gown and morning grooming, for 1 of 4 residents (R3) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to provide the care and services needed to safely manage diabetes for 1 of 3 residents (R23) reviewed for diabetes management by failing to assess and monitor the resident after the resident reported concern about low blood sugar during the night following a rapid decrease in blood glucose.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for 1 of 1 resident (R46) reviewed for accident hazards; and the facility failed to ensure fall interventions were followed for 1 of 4 residents (R13) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for 1 of 2 residents (R3) reviewed for indwelling catheter care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide appropriate dementia care treatment and services by failing to comprehensively evaluate repeated resident-to-resident altercations, identify behavioral triggers, and develop and implement individualized interventions to prevent recurrence for 1 of 6 residents (R41) reviewed for dementia care; and failed to follow established dementia care interventions for 1 of 6 residents (R13) reviewed for dementia care.

Inspectors wroteBased on interview and document review, the facility failed to assess pain, and failed to offer or attempt non-pharmacological pain interventions (interventions other than medications), prior to the administration of as-needed (PRN) pain medications for 3 of 4 residents (R1, R2, R4) reviewed for pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately provide resident protections and initiate an investigation for an allegation of unwanted inappropriate physical contact for 1 of 3 residents (R1) who reported R4 inappropriately touched him.

Inspectors wroteBased on interview and document review, the facility staff failed to report an allegation of sexual abuse to the administrator and to the State Agency (SA) within the two (2) hours for 1 of 1 (R4) resident reviewed who had allegations of sexual abuse.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise skin integrity care plan for 1 of 3 residents (R2) reviewed for pressure ulcers who had refusal of pressure relieving interventions. R2's face sheet dated 6/26/25, identified the following diagnoses, diabetes, heart failure, presence of prosthetic heart valve, chronic right heel wound, and status post open reduction internal fixation of right hip following a fall. R2's quarterly Minimum Data Set, dated [DATE], indicated intact cognition. R2 had limitations to one side of his lower extremities and used a walker and wheelchair. R2 required maximal assist for person and toilet hygiene, shower and bathing, and transfers. R4 did not walk due to medical condition. R2 had diabetic foot ulcer(s) and surgical wound(s) and received surgical wound cares and application of dressings to feet. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess, monitor, and implement pressure relieving interventions to prevent and/or reduce the risk of re-current pressure ulcers, new pressure ulcers, and/or deterioration for 1 of 3 residents (R3) reviewed for pressure ulcers. Deep-Tissue Injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. Unstageable pressure ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. R3's quarterly Minimum Data Set, dated [DATE], indicated severe impaired cognition, with diagnoses of Alzheimer's left femur fracture and schizophrenia. [...]

Inspectors wroteBased on interview and document review the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since 3/26/24, which had the potential to affect all 65 residents who resided in the facility. During interview on 4/9/25 at 11:30 a.m., the registered dietician (RD) stated she worked full time, overseeing 5 buildings but only worked 8 hours a week at this facility. During interview on 4/9/25 at 11:45 a.m., the Culinary Director (CD) stated he had been working for the facility for almost a year and had been asked about starting training for his Certified Dietary Manager's certificate (CDM) but he wanted to wait a little bit and wasn't ready to start the training yet. During interview on 4/10/25 at 12:44 p.m. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure dietary staff was wearing beard guards when preparing food This had the potential to affect all 65 residents who reside at the facility and consume food from the kitchen. During observation on 10/7/25 at 11:49 a.m. the Culinary Director (CD) was in the kitchen cutting up fruit. He had a beard but was not wearing a beard guard/restraint. During interview on 4/9/25 at 10:41 a.m., the CD verified he was not wearing a beard guard/restraint while prepping food stating it was hard to determine if the facility wanted staff to wear them or not. The CD further stated the facility did not have any beard guards for staff to wear, but he could get some if needed. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure resident and resident guardian's participation in the development and review of care plans 1 of 1 residents, (R8) reviewed who voiced concerns about care conference participation.

Inspectors wroteBased on interview and document review the facility failed to timely provide the required liability and appeal rights notices prior to discharge from Medicare Part A services for 1 of 3 residents (R170) reviewed for beneficiary notices.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal privacy was maintained for 1 of 2 residents (R29) who required staff assistance with personal cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to review and revise the care plan with input from the resident to meet a resident's vision needs for 1 of 1 residents reviewed for reassessment of the care plan.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents were provided incontinence care in a timely manner for 1 of 1 resident (R9) reviewed for activities of daily living (ADL).

Inspectors wroteBased on interview and document review the facility failed to follow up on 1 of 1 residents (R55) Urology referral.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow-up on consults for vision-related appointments for 1 of 3 residents (R21) and failed to provide assistive devices to maintain hearing for 1 of 3 residents (R29) reviewed for communication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure podiatry services were obtained or 1 of 1 resident (R8) reviewed for foot care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fall prevention interventions were implemented consistently according to the comprehensive care plan for 1 of 1 residents (47) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to ensure an antipsychotic medication had an appropriate indication for use for 1 of 5 residents (R6) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure proper personal protective equipment (PPE) was utilized for 1 of 2 residents (R14) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a personal refrigerator was monitored and kept sanitary in a resident's (R47) shared room.

Inspectors wroteIn addition, a resident (R1) was observed to have flies in his room and there were flies flying around throughout the facility. R1's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, disorganized thinking, hallucinations, delusions, and a diagnosis of schizoaffective disorder. It further indicated, R1 required substantial assistance from staff with most activities of daily living (ADL) and mobility. During observation on 7/22/24 at 10:20 a.m., R1 was sitting in his room in his wheelchair. The light on the wall next to his closet had approximately 20-30 small flies on it and there were several flying around the room. During observation and interview on 7/22/24 at 10:25 a.m., licensed practical nurse (LPN)-A verified there were flies on the light in R1's room stating they are (the facility) working with an exterminator. [...]

Inspectors wroteBased on interview and document review, the facility failed to revise and update a care plan to ensure it was individualized and comprehensive after a resident was admitted on to a locked behavioral unit for 1 of 1 resident (R1) reviewed for transfer from non-secure to secure unit.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to environmental concerns and medication errors which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R7, R19, R45, and R114) whose vaccinations histories were reviewed.

Inspectors wroteDuring observation and interview, the facility failed to ensure handrails on the second floor were securely attached to the wall and in good repair. This had the potential to affect resident R40 and all residents, staff, and visitors who had access to the handrails.

Inspectors wroteBased on interview and document review, the facility failed to allow active residents and resident representatives participation in the development and review of care plan for 2 of 2 residents (R19 and R113) reviewed for care conferences.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R7) observed with medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide nail care for 1 of 2 residents (R15) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure timely assistance with repositioning for 1 of 1 resident (R4) who was at risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents knee brace was applied per doctor's orders for 1 of 1 resident (R6) reviewed for mobility and range of motion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure catheter drainage bags were maintained in accordance with professional standards of practice for 1 of 1 resident (R25) reviewed for catheters. The Center for Disease Control (CDC) Catheter-Associated Urinary Tract Infections (CAUTI) guideline dated 11/5/2015, identified after aseptic insertion of the urinary catheter, a closed drainage system should be maintained. If the aseptic technique was broken, disconnected, or if leakage occurred, the catheter and collecting system should be replaced with aseptic technique and sterile equipment used R25's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of obstructive uropathy. R38 had an indwelling catheter and required supervision with one person assist for toileting. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a rationale was documented for the extended order of an as needed (PRN) psychotropic medication beyond 14 days for 1 of 2 residents (R25) reviewed who had PRN psychotropic medications ordered.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities involving 2 of 7 residents (R115 and R12) who were observed during medication administration.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were accessible to residents for 2 of 2 residents (R15, R190)

Inspectors wroteBased on observation, interview, and record review the facility failed to failed to follow the comprehensive care plan for supervision for 1 of 1 resident (R2) reviewed for accidents.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess skin for 1 of 1 resident (R4) who had injury of unknown source, additionally failed to notify physician in a timely manner.

Inspectors wroteBased on observation, interview, document review the facility failed to follow the care plan for pressure reducing/relieving interventions to prevent or mitigate the risk of deterioration or prevention of new pressure ulcer development for 1 of 1 residents (R4) who had impaired skin integrity and was at high risk for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe transfers for 1 of 1 residents (R2) who had to be lowered to the floor by staff because wheelchair breaks were not locked prior to the transfer.