Lyndon Crossing, LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF656Mar 16, 2023

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for fourteen (14) of ninety-two (92) sampled residents. (Residents #5, #17, #32, #56, #61, #73, #74, #89, #93, #97, #112, #138, #271, and #821). The facility assessed Resident #138 as a fall risk, however, did not implement care plan interventions which resulted in Resident #138 sustaining multiple falls. The resident fell on [DATE], requiring sutures to his/her head. […]

• Immediate jeopardy, widespreadF689Mar 16, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' environment was as free of accident hazards as possible and failed to provide the necessary supervision to avert accidents for fifteen (15) of ninety-four (94) sampled residents. (Residents #5, #61, #73, #74, #80, #93, #96, #97, #106, #128, #131, #134, #138, #371 and #821). 1. The facility failed to ensure it had a system in place for adequate supervision and monitoring to prevent accidents/falls, to determine the root cause of falls, to evaluate falls and implement individualized interventions and to monitor the effectiveness of interventions to prevent additional falls for fourteen (14) of ninety-four (94) sampled residents (Residents #5, #61,… […]

• Immediate jeopardy, widespreadF725Mar 16, 2023

  Based on observation, interview, record review, and review of the facility's assessment and policies, it was determined the facility failed to have an effective system in place to ensure sufficient nursing staff were available at all times Based on observation, interview, record review, and review of the facility's assessment and policies, it was determined the facility failed to have an effective system in place to ensure sufficient nursing staff were available at all times to ensure resident care needs were met for forty-two (42) of ninety-three (93) sampled residents. […]

• Immediate jeopardy, patternF656Jun 2, 2023

  Based on observation, interview, record review, review of the facility's policies, and review of the Plan of Correction for the 03/16/2023 and 04/04/2023 surveys, it was determined the facility failed to develop and implement care plans with individualized person-centered interventions for ten (10) of thirty-three (33) sampled residents: to prevent falls for six (6) residents (Residents #20, #35, #90, #97, #146, and #821). 1 a) The facility admitted Resident #821 on 12/22/2022 with a history of falls. Resident #821 regularly tried to ambulate to the bathroom without assistance. One fall that occurred on 03/03/2023 resulted in a hematoma to the head which measured approximately ten (10) centimeters in size. […]

• Immediate jeopardy, patternF689Jun 2, 2023

  Based on observation, interview, record review, review of the facility's policy and Plan of Correction, it was determined the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents. The facility failed to identify risks and hazards; failed to establish root cause analyses of previous falls; and failed to implement and evaluate interventions to prevent further falls for six (6) of thirty-three (33) sampled residents (Residents #20, #35, #90, #97, #146 and #821). Additionally, the facility failed to ensure potentially harmful cleaning products were kept locked and not accessible to residents. 1. […]