Lyngblomsten Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Aug 29, 2024

  Based on interview and document review, the facility failed to ensure the Physician Order for Life Sustaining Treatment (POLST) accurately reflected current resuscitation wishes for 2 of 4 residents (R1, R4) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R4 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R1's POLST dated [DATE] indicated full code status with comfort cares contrary to R1's wishes for do not resuscitate (DNR) status with comfort cares. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:25 p.m. The IJ was removed on [DATE] at 4:33 p.m. […]

• Immediate jeopardy, isolatedF689May 21, 2024

  Based on observation, interview, and record review the facility failed to complete a safe transfer assessment for the use of sit-to-stand mechanical lift and follow manufacturer instructions and maintenance of the lift for 1 of 1 resident (R1) which resulted in a fall from the lift with a fracture. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when R1 became tired and weak from standing in the lift while staff changed out two batteries and were unaware of the emergency lowering features which resulted in R1 letting go sustaining left arm fracture and left wrist tendon tear. The Administrator and director of nursing (DON) were notified of the IJ on [DATE] at 5:24 p.m. […]

• Actual harm, isolatedF686Sep 17, 2021

  Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent additional pressure ulcers from developing for 1 of 1 residents (R173) who had two unstageable pressure ulcers (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). This resulted in actual harm for R173. Findings include: R173 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R173's admission minimum data set (MDS) dated [DATE], identified R 173 as having a baseline interview for mental status (BIMS) of 15 (cognitively intact). […]

• No harm, potential for more than minimal, widespreadF880Mar 14, 2024

  Based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 212 residents who resided in the facility. Findings include: During an interview on 3/14/24 at 8:07 a.m., the director of physical plant (DPP)-A, stated he was responsible for the water management program, however was unfamiliar with regulations for a water management program which would prevent growth of Legionella and other waterborne pathogens. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2023

  Based on observation, interview, and document review, the facility failed to label, date opened containers of food stored, ensure expired food were identified and removed from walk-in produce refrigerator and dry good storage room. Furthermore, the facility failed to ensure food was served under sanitary conditions, proper sanitization of thermometer when temping foods; and failed to ensure dishes and food preparation equipment were appropriately air dried. This had the potential to affect all 211 residents who were served food and beverages from the facility kitchen. […]