Lynn Care Center

In the surveyor’s words

From the most serious findings on record at Lynn Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 12, 2026

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to protect the residents' right to be free from physical abuse by other residents for 11 of 52 residents in the survey sample, Residents #127, #94, #126, #128, #25, #13, #41, #68, and #58, resulting in the identification of immediate jeopardy; and for Residents #48 and #35. The findings include:1. For Resident #127 (R127), the facility staff failed to protect the resident's right to be free from physical abuse by Resident #99 on 2/1/25.A review of the facility's final synopsis of events dated 2/6/25 revealed, in part: On Saturday, February 1, 2025, it was alleged that [R99] became agitated, combative and struck [R127] in her left eye on the memory care unit. […]

• Immediate jeopardy, patternF689Jan 12, 2026

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care, services, and adequate supervision for resident safety for two of 52 residents in the survey sample, Resident #99, resulting in the identification of immediate jeopardy and for Resident #40, resulting in harm. The findings include:1. For Resident #99 (R99), on twelve occasions in 2025, the resident physically assaulted other residents on the memory care unit, despite being known to have had previous aggressive behaviors. The lack of adequate supervision of R99 resulted in injury to two victims, Residents #127 and #128. On 2/1/2025, R99 struck Resident #127 in the left eye resulting in redness to the eye. […]

• Actual harm, isolatedF689Jan 6, 2023

  Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide adequate supervision and monitoring during a transfer resulting in a fall and fracture which constitutes harm, for one of 44 residents in the survey sample; Resident #32. This was cited as past non-compliance. The findings include: The facility staff failed to provide adequate supervision and monitoring when transferring Resident #32 from the chair to the bed using a Hoyer (1) (mechanical) lift, resulting in a fall and fracture of the right elbow on 12/15/22. Resident #32 was admitted to the facility on [DATE] with diagnosis that included but not limited to: osteoporosis. […]

• Actual harm, isolatedF686Aug 31, 2021

  Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/9/20, a knee immobilizer was placed on Resident #6's right leg in the emergency department due to a fracture. The facility staff failed to obtain a physician's order regarding removal of the immobilizer for assessments/checks of the resident's skin beneath and the area surrounding the immobilizer, failed to conduct weekly body skin assessments or assessments of the skin surrounded by the immobilizer from 12/11/20 until 12/21/20. […]

• No harm, potential for more than minimal, patternF657Jan 12, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of 52 residents in the survey sample, Residents #94, #128, #25, and #13.The findings include:1. For Resident #94 (R94), the facility staff failed to revise the resident's care plan after she was abused by Resident #99 (R99).A review of the facility's final synopsis of events dated 2/20/25 revealed, in part: On Saturday, February 15, 2025, it was alleged that [R99] became combative and struck [R94] on the right side of her face on the memory care unit. […]