Lynwood Manor Healthcare Center

Inspectors wroteThis citation pertains to intake 2747712Based on observation, interview, and record review the facility failed to implement interventions to prevent accidents for one resident (#1) of three resident reviewed for accidents. Findings Included: Resident #1 (R1)Review of the medical record demonstrated that R1 was admitted [DATE] with diagnoses that included pain left knee, diverticulosis (the formation of small bulging pouches in the lining of the colon), disorder of bone density, epilepsy (chronic neurological disorder), hyperlipidemia (high fat content in blood), hypertension, type 2 diabetes, weakness, difficulty walking, lack of coordination, and fracture of the sacrum. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2026, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 71 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for four out of four residents (Resident #14, 18, 35 and 37) cigarettes, lighters, and vaps were stored in a secured manner. Findings Included: Resident #14 (R14): Review of a SMOKING-SAFETY SCREEN dated 2/20/2024, revealed R14 was screened to be safe to smoke independently and without supervision. The screen also revealed R14 did not require the facility to store his light or cigarettes. Review of a care plan that was in place with a Focus of (R14) is a smoker dated 2/20/24 and revised on 4/23/2024, revealed under the interventions, (R14's) smoking supplies are stored with (R14). The care plan did not include how R14 was to safely store the cigarettes and lighter to prevent other residents from obtaining the cigarettes and/or lighter while the products were stored in R14's room. Resident #35 (R35): [...]

Inspectors wroteBased on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #2) out of five reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two (Resident #18 and Resident #2) residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for all care needs not being met. Findings Include: Resident # 18 (R18) Review of the medical record reflected R18 was an initial admission to the facility on [DATE] and readmitted after a hospital stay on 03/24/2023. Diagnoses of heart failure, Dysphagia (difficulty swallowing), Aphasia (difficulty communicating due to stroke), muscle weakness, abnormal gait and a history of a stroke. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025 revealed R18 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to two (Resident #42 and Resident R2) of two resident reviewed for Hospice services, and the facility failed to follow physician orders and properly complete catheter care for one resident (Resident #38) of three residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #2) out of five reviewed for unnecessary medications.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS), A and B: DPS A: This citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to ensure hot liquid was served at a safe and appropriate temperature for one (Resident #28) of three reviewed for accident hazards, resulting in Immediate Jeopardy when R28 received coffee of an unknown temperature, which spilled, causing R28 to sustain a second-degree thermal burn (damage to outer and second layer of skin, causing blisters, pain and discoloration) on his left outer thigh and increased pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide palatable food products effecting 66 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, (2) effectively date mark all potentially hazardous ready-to-eat food products, and (3) maintain the food production kitchen flooring surface effecting 66 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 out of 5 Licensed Practical Nurses had the required initial competency evaluations and annual competency evaluation, including demonstration in skills and techniques necessary to care for residents resulting in the potential for staff to lack in the necessary training to adequately meet the needs of 66 residents that currently reside at the facility. Findings Include: Record review of the facility staff personnel records demonstrated Licensed Practical Nurse (LPN) L was currently employed by the facility. The personnel record of LPN L did not demonstrate that she had completed an annual competency evaluation. During an interview on 07/12/2024 at 12:31 p.m. Director of Nursing (DON) B explained that all nursing staff receives a competency evaluation after completion of orientation and annually. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 66 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on interview and record review the facility failed to provide timely financial statements to one Resident (#26)/responsible person of one Resident reviewed for Resident trust fund, resulting in the resident/responsible person being not informed about personal funds. Findings Included: [...]

Inspectors wroteThis citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to notify the Physician of a change in tissue appearance for a hot liquid thermal burn for one (Resident #28) of one reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for one Resident (#14) out of three reviewed for Beneficiary Notification. Findings Included: Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility 02/08/2024 with diagnoses that included type 2 diabetes, weakness, difficulty walking, repeated falls, lack of coordination, dysphagia (difficulty swallowing), severe protein-calorie malnutrition, hypertension, hyperlipidemia (high fat content in blood), hypothyroidism (low thyroid hormone), heart disease, depression, chronic obstructive pulmonary disease (COPD), and shortness of breath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care per physician orders, in one of two residents reviewed for non-pressure wounds (Resident #29), resulting in the likelihood of infection, and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative ambulation services to maintain mobility, in one of one resident reviewed for mobility (Resident #4), resulting in sadness and fear of loss of ability to walk. Findings Include: Resident #4 (R4) R4 was observed sitting in a wheelchair in her room on 7/09/24 at 12:21 PM and 7/10/24 at 10:25 AM; and during an interview stated she wanted to participate in therapy, but insurance would not cover it. R4 stated she used to be able to walk, staff were supposed to walk with her up and down the hall; but staff did not let her walk outside of her room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a therapeutic diet to one (Resident #28) of three reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory treatment in one of two residents reviewed for respiratory services (Resident #22), resulting in the likelihood of decreased quality of sleep, increased risk of stroke, heart disease, and diabetes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication rate was less than 5% when three medication errors were observed form a total of 26 opportunities for two residents (#58,#60) of five reviewed for medication administration, resulting in a mediation error rate of 11.54%. Findings Included: Resident #58 (R58) Review of R58 medical record demonstrated that she was admitted to the facility 05/07/2024 with diagnoses that included constipation, muscle weakness, repeated falls, dysphagia (difficulty swallowing), anemia (low red blood cells) anxiety, osteoarthritis, atrial fibrillation, gastro-esophageal reflux, insomnia, osteoporosis (weak bones), vitamin D deficiency, hyperlipidemia (high fat in blood), hypoglycemia (low blood sugar), hypertension, and muscle spasms. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preferences for one (Resident #39) of 15 reviewed.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure appropriate assessments for safety using a coffee pot independently and self-administering of medications were completed for one (Resident #9) of three residents reviewed for medication availability resulting in a fire/burn hazard and medication errors.

Inspectors wroteThis citation pertains to intake MI00139686. Based on interview, and record review, the facility failed to monitor residents weights, in one of three residents reviewed for weight loss (Resident #1), resulting in a significant weight loss.

Inspectors wroteThis citation pertain to intake MI00137450. Based on observation, interview, and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility in two of three residents reviewed for dialysis services (Resident #7 and #8), resulting in decreased quality of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure binding arbitration agreements complied with all requirements for three (Resident #34, #45, and #53) of three residents reviewed, resulting in the residents and/or representatives to not be informed of their rights.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing leaks.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that 1 of 1 (R11) resident reviewed, were treated with respect and dignity by staff resulting in feelings of shame, helplessness and a negative psychosocial outcome. Findings Include: Resident #11 (R11) Review of the medical record reflected R11 was an initial admission to the facility on [DATE]. Diagnoses of Bullous Pemphigoid (autoimmune skin disease, blisters), Idiopathic Orofacial Dystonia (involuntary, forceful contractions of the jaw and tongue, often making it difficult to open or close the mouth), lack of coordination, Schizophrenia, Major Depression and Drug Induced Subacute Dyskinesia (uncontrolled movements in certain muscles). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate completion of advance directive information for 2 (Resident #6 and #48) of 3 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 2 (Resident #6 and #19) of 19 residents reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to update and revise care plans for three (R1, R2, R12) of 18 reviewed for care plans, resulting in the absence of updated interventions to assist with identified health concerns and the potential for all care needs not being met. Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of Anxiety, Depression, age related osteoporosis and abnormalities of gait and mobility. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0110, Activities of Daily Living (ADL) revealed R1 required minimal assistance with personal care provided. R1 could propel in her wheelchair independently throughout the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform dressing changes as ordered for one (Resident #51) of 18 reviewed for quality of care, resulting in the potential for a worsening wound and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of smoking materials for 2 (Resident #6 and #25) of 4 residents reviewed for smoking, resulting in the potential for unsafe smoking practices.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control protocols related to hand hygiene during medication (med) pass for three of 14 residents, resulting in the potential spread of infection among residents, staff and visitors.