Lynwood Rehabilitation and Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF803Oct 16, 2024

  Based 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. Findings include: The facility's policy for Menu Planning, dated 2023, included the following: . Policy: Nutritional needs of individuals will be provided in accordance with the established national standards . through nourishing, well-balanced diets . Procedure: 1. Menu planning will be completed by the facility . a. […]

• No harm, potential for more than minimal, patternF812Oct 16, 2024

  Based 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. Findings include: The 2022 U.S. FDA Food Code included the following: . […]

• No harm, potential for more than minimal, patternF758Feb 11, 2022

  Based on record review, interviews, and review of the facility's [CONDITION(S)] 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. Findings included: The facility's [CONDITION(S)] Medication Use policy and procedure, revised 01/01/2022, documented . 8. All medications used to treat behaviors should be monitored for: . Efficacy, . Risks, . Benefits, and . […]

• No harm, potential for more than minimal, patternF759Feb 11, 2022

  Based 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. Findings included: The facility's General Dose Preparation and Medication Administration policy and procedure, revised 01/01/2013, section 3.7 indicated, Facility staff should verify that the medication name and dose are correct. […]

• No harm, potential for more than minimal, isolatedF580Oct 16, 2024

  Based 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 . […]