The Commons at Lisle Creek Estates

In the surveyor’s words

From the most serious findings on record at The Commons at Lisle Creek Estates, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 14, 2023

  Based on observation, interview, and record review, the facility failed to follow safe transfer practices when utilizing a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring 2 lacerations to her head requiring staples to both lacerations. Findings include: The Admission Record documents R1 with diagnoses to include Parkinson's Disease, History of Falling and Muscle Weakness. R1's Minimum Data Set, dated dated [DATE], documents R1 as cognitively intact and requiring the extensive assistance of 2 staff for transfers. R1's Care Plan for Activities of Daily Living assistance, dated 7/27/2023, documents R1 to be transferred by 2 staff using a mechanical lift. […]

• Actual harm, isolatedF689Jun 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure two staff assisted a resident during a mechanical lift transfer, and failed to utilize the proper sized equipment. This failure resulted in R1 sustaining a leg laceration requiring 11 sutures. This applies to 1 of 5 residents (R1) reviewed for accidents and supervision in a sample of 5. The findings include: Face sheet, printed 6/12/23, shows R1's diagnoses include dementia without behavioral disturbance, anxiety, depression, syncope and collapse, urinary tract infection, and chronic kidney disease. […]

• Actual harm, isolatedF600Apr 13, 2023

  Based on observation, interview, and record review, the facility failed to prevent the verbal/mental abuse of a facility resident. This failure resulted in psychosocial harm to R1 as exhibited by crying, shaking, fear, feeling intimidated, vulnerable and threatened, and experiencing ongoing emotional anguish after the abusive event. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 4. The findings include: Face sheet, dated 4/12/23, shows R1's diagnoses includes closed fracture with routine healing, chronic migraine, anxiety disorder, muscle weakness, difficulty walking, mood disorder, major depressive disorder, and osteoarthritis. MDS (Minimum Data Set), dated 3/27/23, shows R1's cognition was intact. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 49 residents receiving dietary services.Findings include:The CMS 671, dated of 12/16/2025, shows a total of 49 residents residing in the facility.On 12/16/2025 at 9:36 AM, V17, Chef, confirmed all residents residing in the facility were receiving dietary service on the survey start date of 12/16/25.On 12/16/2025 9:36 AM, the kitchen tour began with V17, Chef. The following was observed:*Three red sanitization buckets were in use during food preparation. The sanitization strips that were utilized had the normal range listed as 272- 700 PPM (Parts Per Million). […]

• No harm, potential for more than minimal, widespreadF921Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to safely store hazardous chemicals and carbon dioxide cylinders in the kitchen and failed to maintain a clothes dryer in a safe manner.This applies to all 49 residents receiving dietary services. Findings include:The CMS 671, dated 12/16/2025, shows a total of 49 residents residing in the facility.1.On 12/16/2025 at 9:36 AM, during the kitchen tour with V17, Chef, ten new and capped carbon dioxide cylinders were unsecured and not restrained in a holder.V17 stated the carbon dioxide cylinders were for the soda machine. V17 stated the facility did not have any information on how to store the cylinders.2.Outside the dry storage was a washer / dryer unit with the wash tub filled with dirty textiles. […]