A list of the most recent deficiencies for The Estates at Lynnhurst 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-07 | 2024-03-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-07 | 2024-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-07 | 2024-03-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-07 | 2024-03-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-07 | 2024-03-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-07 | 2024-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-07 | 2024-03-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-07 | 2024-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-07 | 2024-03-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-07 | 2024-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-07 | 2024-03-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-07 | 2024-03-15 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2024-02-07 | 2024-03-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-08 | 2024-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | 2024-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | 2024-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-08 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-20 | 2023-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-20 | 2023-12-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-20 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-18 | 2023-09-22 | 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 | 2023-08-18 | 2023-09-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-18 | 2023-09-22 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-18 | 2023-09-22 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-07-07 | 2023-07-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-11 | 2023-06-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-11 | 2023-06-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-21 | 2023-02-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-10 | 2022-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-14 | 2022-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-25 | 2022-02-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-25 | 2022-02-22 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-25 | 2022-02-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-14 | 2021-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-12-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-14 | 2021-12-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-14 | 2021-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-14 | 2021-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-03 | 2021-08-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-27 | 2021-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-06-09 | Y |
