Lynwood Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lynwood Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 3, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Oct 29, 2024

  Based 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. Findings included: Record review of the CMS report PBJ Staffing Data Report dated 10/23/24 reflected no RN hours for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. […]

• No harm, potential for more than minimal, widespreadF812Sep 20, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727May 28, 2021

  Based on interview 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. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week. This failure placed all residents at risk for inconsistency in care and services. Findings include: Record review Individual Employee Time cards regarding RN coverage presented by the BOM revealed the following: The following days did not have RN coverage for at least eight consecutive hours a day, seven days a week: RN A - April 16 - 05:54 PM to 12:54 AM April 16 - 02:19 AM to 06:06 AM April 30 - 06:06 PM to 02:21 AM April 30 - 03:43 AM to 06:48 AM May 2 - 06:00 PM to 03:01 AM May 2 - 04:31 AM to 06:56 AM RN B - May 7 - 05:55 PM to 06:16… […]

• No harm, potential for more than minimal, widespreadF812May 28, 2021

  Based 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, for 2 of 2 dietary staff (A and B), in that: 1)Dietary Staff A failed to prevent contamination of foods and food contact surfaces during food processing. 2) Dietary Staff B failed to wash her hands between soiled and clean duties, and 3) Food contact surfaces were not maintained and stored in a clean manner (mixer, processor, plastic wrap). 4) The dishmachine was not functioning in a manner to produce clean dishes. The wash cycle was not dispensing detergent. These failures could result in cross contamination and the spread of foodborne illness in the facility. […]