A list of the most recent deficiencies for Embassy of Lyndhurst. 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? |
|---|---|---|---|---|
| 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 | 2023-11-23 | 2024-01-12 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-23 | 2024-01-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-23 | 2024-01-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-23 | 2024-01-12 | 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 | 2023-11-23 | 2024-01-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-21 | 2024-01-12 | 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 | 2023-11-21 | 2024-01-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-21 | 2024-01-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-12 | 2023-10-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-26 | Y |
| 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 | 2023-09-22 | 2023-10-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-22 | 2023-10-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-27 | 2023-07-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-06 | 2023-07-29 | Y |
| 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 | 2023-07-06 | 2023-07-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-06 | 2023-07-29 | Y |
| Provide appropriate foot care. | Health | 2023-07-06 | 2023-07-29 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-07-06 | 2023-07-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-06 | 2023-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-19 | 2023-01-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-19 | 2023-01-02 | Y |
| 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 | 2022-12-19 | 2023-01-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-01 | 2022-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-09-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-01 | 2022-09-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-01 | 2022-09-27 | 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 | 2022-09-01 | 2022-09-27 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-09-01 | 2022-09-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-01 | 2022-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-09-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-01 | 2022-09-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-13 | 2022-09-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-13 | 2022-09-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-13 | 2022-09-27 | 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 | 2022-07-13 | 2022-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-09-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-09-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-02 | 2022-09-27 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-02 | 2022-09-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-02 | 2022-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-09-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-30 | 2022-04-15 | Y |
| 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 | 2022-01-26 | 2022-02-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-26 | 2022-02-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-21 | 2022-02-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-21 | 2022-02-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-26 | 2021-11-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-20 | 2021-05-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-20 | 2021-05-04 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-04-20 | 2021-05-04 | 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 | 2021-04-20 | 2021-05-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-05-14 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-02-27 | 2020-03-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-27 | 2020-03-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-27 | 2020-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-27 | 2020-03-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-27 | 2020-03-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-25 | 2020-03-27 | 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 | 2020-02-25 | 2020-03-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-25 | 2020-03-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-13 | 2019-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-13 | 2019-01-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-13 | 2019-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-13 | 2019-01-31 | 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 | 2018-12-12 | 2019-01-31 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-12 | 2019-01-31 | 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 | 2018-12-12 | 2019-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-12 | 2019-01-31 | N |
