Lyon Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 11, 2023

  Based on clinical record, facility policy, family interview, and staff interview, the facility failed to provide supervision during transportation for 1 of 3 residents reviewed (Resident #4). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents.The facilty reported a census of 40 residents. The facility was notified of the Immediate Jeopardy and given the IJ Template on January 5, 2023 at 5:10 PM. The facility corrected the Immediate Jeopardy on 1/6/23 by educating staff that prior to transportation each resident will be reviewed for accomendation of needs including assistance, if required a family or facility employee will be assigned as escort for the duration of the trip to ensure the residents safety. […]

• No harm, potential for more than minimal, patternF609Feb 2, 2026

  Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #1). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of non- Alzheimer's Dementia, anxiety disorder and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF610Feb 2, 2026

  Based on clinical record review, staff interviews and facility record review, the facility failed to separate vulnerable residents from the staff member of an alleged abuse incident (Residents #1). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of non- Alzheimer's Dementia, anxiety disorder and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 8 indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF803Jul 25, 2024

  Based on review of the menu, observation, and staff interviews the facility failed to serve the full portions of food and failed to consistently fill and empty scoop utensils when preparing meals for residents (Resident #1 and #30). The facility identified a census of 37 residents. Findings included: The facility's Week 1 menu identified the following items as part of the planned menu for the lunch meal on 7/24/24 for residents on a regular diet: Open faced turkey sandwich Mashed potatoes 1/2 cup Turkey gravy 2 ounces Mixed vegetables 1/2 cup Melon 1 cup The facility's Week 1 menu identified the following items as part of the planned menu for the lunch meal on 7/24/24 for residents on a mechanical diet: Open faced ground turkey sandwich Mashed potatoes 1/2 cup Turkey gravy 2 ounces Mixed… […]

• No harm, potential for more than minimal, patternF725May 24, 2023

  Based on facility records, facility policy, resident interview, and staff interview, the facility failed to provide adequate staffing to care for residents. The facility reported a census of 39 residents. Findings include: In an interview on 5/24/23 at 12:57 PM, Resident #17 reported that it can take 30 minutes for her call light to be answered, therapy staff answers her call light since her room is next to the therapy room, and that sometimes there is only 2 Certified Nurse Assistants (CNAs) working during daytime hours. In the same interview, the resident reported that her husband does not get toileted frequently due to lack of staffing and as a result has incontinent episodes at least twice daily and has sat in soiled disposable briefs. […]