The Estates at Lynnhurst LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Lynnhurst LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 25, 2022

  Based on observation, interview and document review, the facility failed to implement appropriate isolation and transmission based precautions on the second floor secured unit for 2 of 2 residents (R11 and R14) who were positive for COVID-19. In addition, the facility failed to implement proper use of personal protective equipment (PPE) per Centers for Disease Control and Prevention (CDC) CDC to prevent and/or minimize further spread of COVID-19. Further, the facility failed to provide appropriative cleaning of bathrooms between resident use during a COVID-19 outbreak. This deficient practice resulted in an immediate jeopardy (IJ) which had the potential to affect all 51 residents, staff, family, and visitors in the facility. […]

• Immediate jeopardy, widespreadF886Jan 25, 2022

  Based on interview and document review, the facility failed to complete outbreak COVID-19 testing of all staff according to Center for Disease Control (CDC) guidelines for outbreak testing. As a result the facility was in outbreak status on 1/08/22. This practice resulted in an immediate jeopardy (IJ) situation related to the high likelihood of serious illness, harm or death that had the potential to affect all 51 residents, staff, family and visitors in the facility. The immediate jeopardy began on 1/8/22, when the facility failed to test all staff during a COVID-19 outbreak which began on 1/8/22. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 6:48 p.m. on 1/24/22. The immediate jeopardy was removed on 1/25/22, at 4:50 p.m. […]

• Immediate jeopardy, isolatedF805Feb 21, 2023

  Based on interview and document review, the facility failed to provide a pureed diet in accordance with residents needs for 1 of 3 residents (R1), reviewed for diet modifications. This resulted in an immediate jeopardy (IJ) when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver and cardiopulmonary resuscitation (CPR). The facility immediately implemented corrective action so the deficient practice was issued at past noncompliance. The IJ began on [DATE], when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver and cardiopulmonary resuscitation (CPR) and was identified on [DATE]. […]

• Immediate jeopardy, isolatedF689Jun 11, 2021

  Based on interview and document review, the facility failed to ensure the safety interventions for elopement were implemented for 1 of 3 residents (R1) reviewed for elopement. This failure resulted in an immediate jeopardy (IJ) when R1 followed an outside provider from the secured unit down an elevator and eloped out the front door. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. The IJ began on 6/4/21, at 5:45 p.m. when R1 left the facility after following an outside provider from the secured unit down the elevator and out the front door of the building. The administrator and director of nursing (DON) were notified of the IJ on 6/10/21, at 12:30 p.m. […]

• Actual harm, isolatedF600Aug 17, 2026

  Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 5 residents (R2, R3) when another resident (R9) who when intoxicated made sexually inappropriate comments toward the residents, touched their arms, legs and attempted to touch their breasts. R9 was intoxicated nearly every day and had care planned interventions for alcohol use but did not have interventions for sexually abusing residents. Even though the facility notified the police and educated staff on abuse, residents continue to fear R9's sexual abusive behaviors. Findings include: R2's nursing progress note dated 7/25/26 at 8:03 p.m. indicated R2 arrived at the facility at approximately 11:30 a.m. R2 understood her wound management and neck mobility restrictions. […]