Lynwood Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, the facility's 2024-2025 Fall/Winter Menu, the facility's recipe for Pureed Bread, the facility's Scoop Size chart, the facility's Diet Master, and the facility's policies for Menu Planning and Accuracy and Quality of Tray Line Service; the facility failed to provide the approved portions of puree meat and puree bread for Lunch on 10/08/2024 and 10/09/2024. This had the potential to affect 5 of 5 residents receiving Puree Diets.

Inspectors wroteBased on observation, interview, the facility's 2024-2025 Fall/Winter Menu, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, the facility's Diet Master, and the facility's policies for Purpose and Objectives of the Food and Nutrition Services Department and Resource: Minimum Cooking, Holding and Reheating Temperatures; the facility failed to ensure Puree Scalloped Potatoes were reheated to a minimum of 165 degrees (°) Fahrenheit (F) for 15 seconds after cooling to 125°F on 10/08/2024, prior to the residents' Lunch service. This had the potential to affect 5 residents who received pureed meals from the kitchen out of 108 residents receiving meals from the facility kitchen.

Inspectors wroteBased on interviews, medical record review, hospital record review, and review of a facility policy titled, Change in Medical Condition of Residents, the facility failed to ensure the Medical Director (MD) and/or Certified Registered Nurse Practitioners (CRNPs) were notified when Resident Identifier (RI) #320, a resident with a history of inappropriate sexual behaviors, attempted to touch a Certified Nursing Assistant (CNA) between her legs and grabbed a therapist on the buttocks on 02/19/2024. Findings Include: Review of a facility policy titled, Change in Medical Condition of Residents, with an effective date of 01/22/2024, revealed the following: PURPOSE: To keep the physician, who is in charge of medical care . informed of the residents medical condition so they may direct the plan of care as needed. STANDARD: Notification of the physician . [...]

Inspectors wroteBased on an interview, review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, review of the facility's investigative file and review of a Facility Reported Incident (FRI) received by the State Agency, the facility failed to ensure an allegation of sexual abuse involving Resident Identifier (RI) #320 and RI #71 on 02/22/2024, was submitted to the State Agency within the required timeframe of two hours. This deficient practiced affected one of 17 FRIs reviewed for timely reporting of allegations of abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00047058. Findings Include: [...]

Inspectors wroteBased on interviews, medical record review, review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, and review of the facility's investigative file, the facility failed to conduct a thorough investigation and obtain witness statements from all staff who witnessed Resident Identifier (RI) #320 put his/her hand under RI #71's blouse on 02/22/2024. Interviews with staff, the facility's timeline of events, and investigative documentation contained conflicting information. Findings Include: Review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with a revision date of 05/01/2024, revealed the following: PURPOSE: . The facility will investigate and document all incidents and accidents involving residents . [...]

Inspectors wroteBased on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #70's Significant Change (SC) Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/29/2024, was coded accurately. The MDS indicated that RI #70 received an anticoagulant medication during that look back assessment period, but RI #70 did not. This deficient practice affected RI #70, one of 47 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, revealed the following: . SECTION N: MEDICATIONS . Coding Instructions . N0410E, Anticoagulant . [...]

Inspectors wroteBased on interviews, medical record review and review of a facility policy titled, Distressed Behavior Management Program, the facility failed to ensure Resident Identifier (RI) #320's sexually inappropriate behaviors were addressed and managed with appropriate interventions. On 02/09/2024, the facility admitted RI #320 who had a documented history of inappropriate behaviors including groping. On 02/12/2024 a care plan was developed to address inappropriate sexual advances toward females. On 02/19/2024, RI #320 attempted to place his/her hands between a Certified Nursing Assistant's (CNA's) legs and placed his/her hands on a physical therapist's buttocks. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's Psychotropic Medication Use policy, the facility failed to ensure two (Resident Identifiers [RI] #20 and #92) of five sampled residents reviewed for unnecessary medications who received an antipsychotic and/or antidepressant medication were monitored for side effects of the medications. This had the potential to affect 36 residents whom the Resident Census and Conditions of Residents, dated 02/10/2022, indicated received antipsychotic medication and 70 residents who received antidepressant medication.

Inspectors wroteBased on observations, record review, interview, and review of the facility's General Dose Preparation and Medication Administration policy, the facility failed to ensure a medication error rate of less than 5%. The facility had a medication error rate of 10%, which resulted from three errors in 30 opportunities and affected three (Resident Identifiers [RI] #19, #22, and #38) of six residents observed receiving medications during the medication pass observation. One hundred twelve residents resided in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident Identifier (RI) #35 was invited and allowed to participate in care plan conferences. This deficient practice affected RI #35, one of one resident reviewed for care plan participation.

Inspectors wroteBased on observation, interviews, record review, and facility procedure review titled, Skin Care Guideline, the facility failed to assess and treat a skin issue for Resident Identifier (RI) #35. The deficient practice affected RI #35, one of one resident reviewed for non-pressure related skin conditions.

Inspectors wroteBased on observation, interviews and review of a facility policy Frozen Storage the facility failed to ensure there were: 1. a use by date on opened country fried steak bag; 2. an open or use by date on liquid eggs and 3. an opened or use by date on an open bag of pork chops and hot dogs. This had the potential to affect 107 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Frozen Storage with an effective date of 1/1/17 revealed: POLICY It is the policy of this center to store, prepare and serve food in accordance with federal, state and local sanitary codes. PROCEDURE .3. Opened frozen food will be properly bagged, dated and labeled . On 8/05/19 at 4:40, the surveyor observed the walk in refrigerator and freezer with Employee Identifier (EI) #5, Dietary Manager (DM). [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy Dining and Meal Service, the facility failed to ensure Resident Identifier #5 and #25 were served their supper meal at the same time of the other residents at the same table. This occurred on 8/5/19 and affected two of four residents observed.

Inspectors wroteBased on medical record review and interviews, the facility failed to ensure notification of the sponsor was made when Resident Identifier (RI) #91 refused treatments, ADL care or medications, as the sponsor had requested. This deficient practice affected RI #91, one of thirty-two residents sampled during the initial screening. Findings Include: A review of the medical record revealed RI #91 was re-admitted to the facility on [DATE] with diagnoses to include Dementia with Behavioral Disturbances Symbolic Dysfunction and Cellulitis of Bilateral Lower Extremities. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed, RI #91 scored 7 out of a possible 15 on the Brief Interview for Mental Status review. This score indicated RI #91 was severely cognitively impaired for daily decision making skills. [...]

Inspectors wroteBased on observation, interviews, and review a facility policy titled, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, the facility failed to ensure: 1. a licensed staff did not leave medication on top of medication cart, unattended and out of view and 2. medication was not stored in the medication storage room with an expired date. This deficient practice affected one of three licensed nurses observed during medication pass.

Inspectors wroteBased on record review, interviews and review of a facility document titled, Purpose of the Patient Record, the facility failed to ensure wound care provided and parasite removal from a wound was documented by the nurse that performed the care. This affected Resident Identifier #91, one of thirty-two residents whose medical records were reviewed. Findings Include: A review of an undated facility document titled, Purpose of the Patient Record revealed, . Guidelines: To ensure Patient Clinical Health Information records are maintained in accordance with professional practice standards. Process: . Clinical records are maintained to provide complete and accurate patient information for continuity of care. The record shall contain sufficient information to identify the patient clearly, justify the diagnosis and treatment, and document results accurately. [...]

Inspectors wroteBased on observation, interviews and review of a document titled, DESCRIPTION OF STEPS IN THE LAUNDRY PROCESS, the facility failed to ensure soiled linen was not sorted outside of the wash room. This deficient practice had the potential to affect all residents who clothing and linens were processed by facility laundry staff. Furthermore, based on observation, interviews, record review and a review of facility policy titled, Policies and Practices-Infection Control the facility failed to ensure that a licensure staff did not place medication cards on a resident's bedside table without using a barrier, then return the medication cards to the medication cart. This deficient practice had the potential to effect one of two nurse observed during medication pass. Findings Include: 1. [...]