The Lennwood Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Lennwood Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF580Jul 1, 2024

  Based on interview and record review, the facility failed to immediately consult with the residents' physicians when there was a significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications; or when there is a need to alter treatment significantly, for two (Residents ##3 and #4) of five residents reviewed for resident rights. 1. The facility failed to consult with the physician when Resident #3 had a change in condition which resulted in a dangerously low blood sugar of 40. Resident #3 died at the facility unexpectedly within 24 hours of his change of condition. 2. […]

• Immediate jeopardy, patternF684Jul 1, 2024

  Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for two (Residents #3 and #4) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #3 was accurately assessed, monitored, and treated for a change of condition he had with a blood sugar of 40 at 8:15 AM during the morning shift on [DATE]. There was no documented evidence the facility monitored the residents' change of condition after that shift. Resident #3 died later that night on the overnight shift around 2:05 AM with a cause of death as unknown. 2. […]

• Immediate jeopardy, isolatedF689May 7, 2025

  Based on observations, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history if eloping and wore a wandergaurd, was provided with adequate supervision to prevent him from eloping from the facility on 03/28/25. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. 2. The facility failed to complete an elopement assessment for Resident #1 prior to his elopement on 03/28/25 The non-compliance was identified as past non-compliance. […]

• Immediate jeopardy, isolatedF678Nov 27, 2021

  Based on interviews, record review, and facility policy review, it was determined the facility failed to care for residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for one (Resident #10) of three residents reviewed for code status. The facility failed to immediately provide potentially life-saving cardiopulmonary resuscitation (CPR) for Resident #10, who was found unresponsive on [DATE] at 3:30 PM and, at the time, was to receive CPR in the absence of a properly executed do-not-resuscitate (DNR) directive. Resident #10 was pronounced dead on [DATE] at 9:56 PM. An Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. […]

• Actual harm, isolatedF697Nov 27, 2021

  Based on record review and interviews, it was determined the facility failed to provide pain relief medications as needed for one (Resident #1) of three residents reviewed for pain management. Resident #1 was not able to receive pain medications as prescribed consistently while at the facility, which resulted in Resident #1 being in severe pain and having to go to the emergency room twice during the 12 days while admitted to the facility, in order to receive pain medication. This deficient practice had the potential to affect all residents at the facility should they experience pain and require pain medication. […]