A list of the most recent deficiencies for Lyndon Woods Care and Rehab, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-10 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-02 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-02 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-04 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-09-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-29 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-02 | 2023-07-28 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-02 | 2023-07-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-02 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-02 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-06-02 | 2023-07-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-02 | 2023-07-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-06-02 | 2023-07-28 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-02 | 2023-07-28 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-02 | 2023-07-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-02 | 2023-07-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-02 | 2023-07-28 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-06-02 | 2023-07-28 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-02 | 2023-07-28 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-02 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-04 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-04 | 2023-07-28 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-04-04 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-16 | 2023-07-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-16 | 2023-07-28 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-16 | 2023-07-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-16 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-03-16 | 2023-07-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-16 | 2023-07-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-03-16 | 2023-07-28 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-07-28 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-16 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-07-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-16 | 2023-07-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-07-28 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-03-16 | 2023-07-28 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-03-16 | 2023-07-28 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-07-28 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-21 | 2023-07-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-21 | 2023-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-21 | 2023-07-12 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-04 | 2023-04-16 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-04-04 | 2023-04-16 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-03-16 | 2023-04-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-16 | 2023-04-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-16 | 2023-04-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-16 | 2023-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-16 | 2023-04-16 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-16 | 2023-04-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-16 | 2023-04-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-16 | 2023-04-16 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-21 | 2023-04-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-15 | 2021-11-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-15 | 2021-11-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-15 | 2021-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-15 | 2021-11-15 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-18 | 2021-06-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-18 | 2021-06-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-18 | 2021-06-11 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-05-18 | 2021-06-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-18 | 2021-06-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-16 | 2019-09-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-16 | 2019-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-16 | 2019-09-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-16 | 2019-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-16 | 2019-09-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-16 | 2019-09-12 | N |
| Post nurse staffing information every day. | Health | 2019-08-16 | 2019-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-14 | 2019-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-14 | 2019-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-14 | 2019-09-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-14 | 2019-09-12 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-08-14 | 2019-09-12 | N |
