Lenbrook

In the surveyor’s words

From the most serious findings on record at Lenbrook, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Feb 26, 2026

  Based on observations, staff and resident interviews, record review, and review of the facility policies titled, Infection Prevention and Control Program, Wound Care, and Handwashing/Hand Hygiene, the facility failed to maintain appropriate infection control practices for two of 29 sampled residents (R) (R8 and R28). Specifically, the facility failed to ensure the Infection Prevention and Control Program policy was reviewed and updated annually, conduct required infection surveillance audits, maintain proper infection control practices by not disinfecting reusable items after wound care, follow standard infection control procedures during medication administration, and perform hand hygiene between glove changes. […]

• No harm, potential for more than minimal, isolatedF688Feb 26, 2026

  Based on observations, record review, staff interviews, and review of the facility policy titled, Restorative Nursing Services, the facility failed to provide evidence that restorative nursing services for splinting and range of motion (ROM) were consistently provided for one of 29 sampled residents (R) (R61).Findings include:Review of the facility policy title, Restorative Nursing Services dated July 2017 revealed under Policy Interpretation and Implementation: Restorative nursing consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., Physical, occupational, or speech therapies).Review of R61's electronic medical record (EMR) revealed that the resident was admitted with diagnoses including but not limited to contracture, left… […]

• No harm, potential for more than minimal, isolatedF695Jan 19, 2025

  Based on observations, staff interviews, record review, and review of the facility's policy titled Departmental Respiratory Therapy - Prevention of Infection, the facility failed to prevent the spread of infections by not replacing or cleaning a nasal cannula for one of five residents (R) (R9) requiring oxygen therapy. This failure had the potential to increase the risk for infection and medical complications. Findings include: Review of the facility's undated policy titled Departmental Respiratory Therapy - Prevention of Infection, under the section titled Purpose revealed, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. […]

• No harm, potential for more than minimal, isolatedF758Jan 19, 2025

  Based on staff interviews, record review, and review of the facility's policy titled Psychotropic Medication Use, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two of five residents (R) (R7 and R21) reviewed for unnecessary medications. Findings include: A review of the facility policy titled Psychotropic Medication Use, dated July 2022, under the section titled, Policy Interpretation and Implementation revealed, 12. (a.) PRN (as-needed) orders for psychotropic medications are limited to 14 days. 1. […]