Lynwood Nursing and Rehabilitation

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 10 of 19 residents in that: The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/11/26 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerators (2) and freezers (2), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the iced tea machine's outer surface was free from dirt and stains. 3) The facility failed to ensure the refrigerators (2) and freezers (2) outer handle surface were free from greasy stains. These failures could place residents at risk for food-borne illness and cross contamination. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 1/11/26 for 1 of 1 meal (the lunch service on 1/11/26) reviewed for nutritional adequacy. The facility failed to follow the lunch menu for 1/11/2026 and did not inform the residents that a substitute would be served. This failure could place residents at risk of not receiving adequate nutritive food value needed to promote/maintain health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #27) reviewed for wound care. RN A failed to change her gloves during wound care for Resident #27. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 (Resident # 1) residents reviewed for pharmaceutical services. The facility failed to ensure MA A completed the medication administration for Resident #1 according to standard of practice when she placed the medications in Resident #1's mouth during the breakfast meal and left prior to observing that Resident #1 had swallowed the medications. Resident #1's medications were found in a cup beside the resident's breakfast tray by the resident's family member who assisted Resident #1 to finish taking the medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision of Resident #1 who was newly admitted to the facility on [DATE] and was exhibiting signs of confusion and exit-seeking behavior. Resident #1 then eloped from the facility approximately 27 (twenty-seven) hours later on 07/20/25 between 7:45 PM and 8:00 PM. Staff were unaware of Resident #1's elopement when the facility was notified by a citizen of the community via telephone on 07/20/25 at approximately 8:15 PM that the resident had wandered to a nearby apartment complex and appeared confused. The noncompliance was identified as PNC. The IJ began on 07/20/25 and ended on 07/21/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 8 residents (Resident #2 and #3) reviewed for respect. CNA D failed to treat residents with respect and dignity when she told Resident #2 and Resident #3, she did not have to take them out to smoke, on an unknown date in July 2025. These failures could place the residents at risk of feeling disrespected.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents reviewed for resident rights. CNA B failed to allow Resident #1 to call her Family Member when Resident #1 requested to make that call at approximately 2:30 AM on 01/24/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 7 residents (Resident #1) reviewed for hygiene, in that. 1. The facility failed to provide incontinence care on three separate opportunities for Resident #1 on 1/26/2025. These failures could place residents at risk for skin breakdown and infections.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 10 (4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 10 days 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024). This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 2 (Residents #40 and #114) of 2 residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #40 and Resident #114's oxygen tubing was replaced every week on Sunday, according to physician's orders. These failures could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 20% based on 6 out of 30 opportunities, which involved 2 of 4 residents (Residents #58 and #55) reviewed for medication administration, in that: 1. The facility failed to ensure Resident #55 had Xifaxa n (helps prevent a brain condition that can occur with severe liver disease )550mg, available for administration, resulting in a missed dose. 2. Med Aide C failed to verify the dosage and amount on Resident #55's Lactulos e (treats constipation) resulting in Resident #55 being underdosed. 3. Med Aide C failed to verify the dosage for Resident #58's Magnesium 200mg (treats low magnesium levels), and thiamin B1 (treats low thiamine) 50mg resulting in an incorrect dose given. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to store pans upside down on shelfs. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #4 and #38) and 2 of 2 (LVN A and LVN B) staff reviewed for infection control. LVN A failed to wash hands between glove changes during wound care for Resident #38. LVN B failed to wash or sanitize hands after reaching in his pocket and prior to starting wound care. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 15 confidential residents. The facility failed to ensure 7 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, was provided access to the Grievance form, was provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the treatment cart for 1 of 1 treatment carts observed for drug storage. The facility failed to ensure 2 bottles of wound cleaners was not left on top of the treatment cart unattended. This failure could place residents at risk of access and ingestion of non-narcotic medications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to have a care plan in place to accurately address Resident #1's wound care. The facility failed to have a care plan in place to accurately address Resident #2's oxygen use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 7 residents (Resident #1) reviewed for MDS assessment accuracy. Resident #1's quarterly MDS assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly Significant Change assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans as follows: 1. Resident #1 did not have a care plan for her ongoing behavior for wandering that had occurred since her admission on [DATE]. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed and pureed under sanitary conditions, 2) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean, and 3) The facility failed to ensure foods were stored in a manner to prevent contamination, These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 5 common baths (100/200, 300, 500 and 600), reviewed for environment, in that: The facility failed to ensure resident use common areas were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 4 of 5 Baths (100/200, 300, 400 and 500) and 1 of 22 resident rooms (room [ROOM NUMBER]) reviewed, in that: The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113.5 to 117.9 F, and The facility failed to ensure chemicals were stored in a manner to prevent contamination of resident use items. This failure could place residents at risk for injuries related to chemical contact and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical soft and pureed) at 1 of 1 meal observed (9/20/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 20 (Resident #19) residents in that: CNA A failed to provide Resident #19 privacy during incontinent care. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 18 residents (Residents #35 and #45) reviewed for PASRR screening, in that: Residents #35 and #45 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #24 and #32) reviewed for incontinent care. 1. CNA B failed to properly clean labia (middle of vaginal area) and wash hands between glove changes while providing incontinent care to Resident #24. 2. CNA C failed to change gloves and wash hands when going from dirty to clean while providing incontinent care to Resident #32. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 4 dumpsters (#1) and 2 of 2 grease barrels, in that: The facility failed to maintain the dumpster/refuse disposal containers in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the third quarter April 1, 2023, to June 30, 2023). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the third quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #24 and #32) and 1 of 1 (CNA B) staff reviewed for infection control. 1. CNA B failed to properly serve residents meals by touching the rim of glasses and bowls. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #24. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased interview and record review, the facility failed to ensure MDS automated data processing requirements were followed regarding encoding data and transmitting data for a discharge of 1 of 1 resident reviewed (Resident #58), in that: 1)The facility failed to submit a discharge MDS for Resident #58 who discharged from the facility on 5/19/23. These failures could lead to inaccuracies in resident MDS records.