Lily Springs Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Lily Springs Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 19, 2024

  Based on observation, inter, and record review, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pressure ulcers. The facility failed to: 1) - Provide treatment and services to heal Resident #2's PUs on the gluteus, sacrum, and left heel and the wounds became larger. - Provide treatment and services to prevent infection to Resident #2's sacral PU and it became infected. An IJ situation was identified on 03/18/24.L The IJ template was provided to the facility on [DATE] at 2:40 PM. […]

• Immediate jeopardy, isolatedF689May 5, 2025

  Based on observation interview and record review the facility failed to ensure residents had adequate supervision and assistance devices to prevent accidents for 1 (resident #51) of 10 residents reviewed for accidents and hazards. The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall and fracture to the right femur. This has led to anxiety around shower times, and a reduced quality of life. An IJ was identified on 05/02/2025 at 4:30 PM. The initial IJ template was provided to the facility on [DATE] at 4:38 PM. While the IJ was removed on 05/04/25 at 12:21 pm, the facility remained out of compliance at the scope of isolated and a severity of no actual harm due to the injury sustained by Resident #51. […]

• Immediate jeopardy, isolatedF656Mar 3, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan which reflected Resident #1's Advanced Directive was full. Resident # 1 expired at the facility on [DATE] and there was no CPR performed . An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• Immediate jeopardy, isolatedF678Mar 3, 2025

  Based on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel and related physician orders and the residents advance directives for one of seven (Resident #1) residents reviewed for CPR . The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, which included CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 fell back in his bed while talking to Emergency Medical Services and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• Immediate jeopardy, isolatedF689May 3, 2023

  Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for (Resident #1) of 5 residents reviewed for accidents and supervision. Resident # 1 eloped from facility on 2/5/2023 and fractured her left rib. An (IJ) Immediate Jeopardy was identified on 4/12/2023 at 4:45PM. While the (IJ) Immediate Jeopardy was removed on 4/13/2023 at 6:00PM, the facility remained out of compliance at a level of actual harm that was not immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their corrective systems. […]