Lynwood Post Acute Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF925Aug 26, 2021

  Based on observation, interview, and record review the facility failed to maintain four of four sampled resident's rooms (Rooms A, B, C, and D) free of cockroaches (also called roaches, small insects that carry infectious bacteria) and failed to conduct an ongoing monitoring for cockroaches in the resident's rooms (34 rooms) for 88 of 88 residents (Resident 1 to 88). These deficient practices had the potential to result in disease transmission to the residents that could lead to life threatening complications and or death. On 8/23/2021 at 4:20 p.m. […]

• Immediate jeopardy, patternF684May 11, 2021

  Based on interview, and record review, the facility failed to provide quality nursing care (nursing care that results in desirable outcome and are consistent with current professional knowledge and practice) for 21 of 21 residents by failing to: 1. Monitor and document blood sugar (BS) levels on the Medication Administration Record (MAR) from 4/1/21 thru 5/10/21 for 21 of 21 residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322). 2. Administer and document insulin (medication used to regulate BS levels) doses on the MAR from 4/1/21 to 5/10/21 for twenty-one of twenty-one residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322) 3. […]

• Immediate jeopardy, patternF760May 11, 2021

  Based on interview, and record review, the facility failed to administer insulin (medication used to treat and regulate high blood sugar [BS] levels) doses and document on the Medication Administration Record (MAR) for 21 of 21 sampled residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322) through the period starting 4/1/2021 thru 5/10/2021 as followed: 1) Resident 2 did not received seven (7) doses of [MEDICATION(S)] insulin (long-acting medication used to control elevated Blood Sugar [BS]) 20 units ([U] units of measurement), and 18 doses of [MEDICATION(S)] R (type of insulin) subcutaneously (under the skin) as per sliding scale (insulin dose dependent on the BS level). […]

• Immediate jeopardy, isolatedF689Oct 31, 2022

  Based on observation, interview, and record review, the facility failed to supervise and prevent the elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization) of one of two sampled residents (Resident 1) who was cognitively (ability to think and reason) impaired and displayed behaviors of wandering (walking around aimlessly without a fixed plan) in the facility, and had previously attempted to elope on 10/2/2022. On 10/10/2022 the facility ' s security alarm sounded, the facility ' s staff conducted a count for all residents and Resident 1 was identified as missing from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 10/10/2022 at approximately 6:30 p.m. […]

• Immediate jeopardy, isolatedF600Sep 7, 2021

  Based on observation, interview and record review, the facility failed to follow its policy titled, Abuse Prohibition and Prevention, thoroughly investigate two alleged physical abuse incidents, and place staff on suspension during the investigation for one of three sample residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse 1 (LVN 1) roughly took chips away from his hand and mouth on 7/20/2021 and on 8/11/2021 Certified Nurse Assistant 1 (CNA 1) threw water at Resident 1, and yelled at Resident 1 stating, Shut the F@@@-up and go to sleep. This deficient practice resulted in Resident 1 feeling afraid of LVN 1 and CNA 1 possibly retaliating a third time. […]