Lyonsview Health And Rehabilitation Center

Based on facility policy review, observation, and interview, the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The facility's failure had the potential to affect 166 of 168 residents.The findings include: Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, revealed, .All equipment used in handling food shall be cleaned and sanitized, and handled in a manor [manner] to prevent contamination .Staff shall follow facility procedures for .cleaning fixed cooking equipment . During an observation on 5/17/2026 at 10:40 AM, with the Dietary Manager (DM) revealed a line of fixed kitchen cooking equipment which included a convection oven, tilt skillet, and a front oven. Each piece of equipment was observed in unclean and in unsanitary conditions as evidence by dried, dark brown food debris located on multiple surface areas of each piece of equipment. The debris appeared on the front and sides of the units. During an interview on 5/17/2026 at 10:48 AM, the DM confirmed the convection oven, tilt skillet, and front oven had dark,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, and interview, the facility failed to ensure the facility's main dining room was open for resident use for 2 of 7 days of the week. The findings include: Review of the facility's policy titled, Resident Rights, dated 3/7/2023, revealed .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity or expression .The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility . During the initial tour of the facility on 5/17/2026, the activity calendar was observed to have in-room only dining for the weekends. During an interview on 5/19/2026 3:55 PM, Resident #77 stated .I would like to be able to eat in there with everybody else on the weekends. Some people want to bring their families and want to see everybody . During an interview on 5/19/2026 3:59 PM, Resident #58 .I would like the option to eat in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 1 resident (Resident #20) of 33 residents reviewed for MDS assessments.The findings include: Review of the MDS 3.0 RAI Manual version 20.1, dated 10/2025, revealed, .The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment .The MDS completion date for quarterly assessments must be no later than 14 days after the ARD [Assessment Reference Date] . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Diabetes Mellitus Type 2, and Old Myocardial Infarction. Review of the quarterly MDS assessment dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to maintain ongoing communication and collaboration with the dialysis facility and failed to document the status of the resident upon return to the facility for 1 resident (Resident #113) of 4 residents reviewed for Hemodialysis. The findings include:Review of the facility's policy titled, Hemodialysis, undated, revealed .The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with the professional standards of practice. This will include .ongoing assessment of the resident's condition and monitoring before and after dialysis treatments .ongoing assessment and oversight of the resident before during and after dialysis treatments .communication with the dialysis facility regarding dialysis care and services .the nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on job description review, employee file review, and interviews the facility failed to ensure the Dietary Manager completed accredited course work in dietetic training and certification.The findings include: Review of the Food Service Manager (Dietary Manager) job description, undated, revealed .The primary purpose of your position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Service Department .Qualifications .a high school diploma .Graduate of an accredited course in dietetic training approved by the American Dietetic Association . Review of the employee file for the Dietary Manager (DM), revealed no certificate of completion of course work which would satisfy the job description requirement. Further review revealed The DM had been in his current role since 3/13/2018. During an interview on 5/17/2026 at 11:37 AM, the DM stated .I'm working on it [dietary certification] . when asked if he had completed the accredited course work for dietetic training and certification. During employee file review and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, facility investigation documentation review, police report review, and interview, the facility failed to protect the residents' right to be free from physical abuse for 3 residents (Resident #2, Resident #4, and Resident #6) of 21 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, effective 8/2023, revealed .Purpose: To prohibit and prevent abuse, neglect, exploitation .and to ensure reporting of alleged violations . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Type 2 Diabetes Mellitus, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Continued review revealed no behaviors were observed during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review and interview the facility failed to ensure Medical Director duties were coordinated to clearly delineate responsibilities of the facility's Medical Directors. The facility's failure to implement and coordinate resident care created an environment which impaired the nursing staff to effectively provide patient care and services which had the potential to affect all 144 residents in the facility. The findings include: Review of the Medical Director Agreement signed by Medical Director #1 showed . Physician [reference to Medical Director/Physician] shall guide, approve, and help oversee the development, implementation, and monitoring/evaluation of Facility's resident care policies and procedures in the following areas: .admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the Facility to provide the services and care to meet their needs .Mechanisms for communicating and resolving issues related to medical care . Physician shall be responsible for coordination of medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to protect 2 Residents (#56 and #17) from physical abuse of 30 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse Prevention/Reporting Policy and Procedure, dated 2018, showed .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents .Abuse is defined as willful infliction of injury . Resident #56 was admitted to the facility 10/1/2021, with diagnoses including Vascular Dementia without Behavioral Disturbance, Hypertension, Type II Diabetes Mellitus, Major Depressive Disorder and Chronic Kidney Disease. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment, a short and long term memory problem, and displayed inattention and disorganized thinking during the assessment. Resident #56 required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to provide interpretation services or an effective communication service for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed. The findings include: Review of the facility's policy titled, Translation and/or Interpretation, revised 5/2017, showed .This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility .the types of language access services provided by this facility shall be determined by the following factors .The size .of the eligible LEP population served by the facility .The frequency with which the particular LEP population is in contact with the facility .The nature and/or importance of the information or service that needs to be conveyed .The point of contact regarding facility's language access program is the Director of Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement an individualized and activities program to meet the needs for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed for activities. The findings include: Review of the facility's policy titled, Activity Programs, revised 8/2006, showed Activity programs designed to meet the needs of each resident are available on a daily basis .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs .Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum .Activities that stimulate the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to ensure 2 residents (#55 and #53) remained free from abuse of 14 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prevention/Reporting Policy and Procedure dated 8/15/2017 showed .Every resident has the right to be free from abuse, neglect, misappropriation .exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents . Medical record review showed Resident #55 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Adult Failure to Thrive, Anxiety Disorder, and Palliative Care. Medical record review showed Resident #77 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit and Dementia Medical record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.