Inspection Reports for Lynwood Manor
730 Kimole Ln, Adrian, MI 49221, United States, MI, 49221
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 5
Date: Jun 4, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication use, care planning, hospice services coordination, catheter care, smoking safety, and food service sanitation at Lynwood Manor Healthcare Center.
Findings
The facility was found deficient in limiting the duration of PRN psychotropic medications, developing comprehensive care plans, coordinating hospice services, properly completing catheter care, securing smoking paraphernalia, and maintaining food service equipment cleanliness and sanitation.
Deficiencies (5)
Failed to limit the duration of a PRN psychotropic medication to 14 days and/or ensure physician documented rationale to extend use for Resident #2.
Failed to develop comprehensive care plans within 7 days of assessment for Residents #18 and #2, resulting in unmet care needs.
Failed to ensure proper communication and documentation of hospice services for Residents #42 and #2, and failed to follow physician orders and properly complete catheter care for Resident #38.
Failed to ensure cigarettes, lighters, and vapes were stored in a secured manner for Residents #14, #18, #35, and #37.
Failed to effectively clean and maintain food service equipment, resulting in increased likelihood for cross-contamination and bacterial harborage affecting 71 residents.
Report Facts
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 4
Residents affected: 71
BIMS score: 11
BIMS score: 13
BIMS score: 2
BIMS score: 14
Medication start date: 2025
Medication administration count: 3
Medication maximum daily amount: 4
Medication dosage: 0.5
Medication dosage: 0.25
Medication dosage: 5
Medication start date: 2025
Medication start date: 2025
Medication start date: 2025
Medication start date: 2025
Temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Provided information on medication orders, smoking assessments, and hospice documentation |
| SWD C | Social Work Director | Provided information on medication consents and hospice documentation |
| LPN F | Licensed Practical Nurse | Provided information on smoking paraphernalia and catheter care |
| DD G | Dietary Director | Provided information on food service equipment deficiencies |
| NP (nurse practitioner) | Provided clinical assessment and treatment plan for Resident #38 |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Jul 12, 2024
Visit Reason
The inspection was conducted based on complaint intake MI00144424 and other regulatory oversight to investigate multiple concerns including resident financial management, injury from hot liquid burn, notification failures, wound care, restorative ambulation, smoking safety, medication administration errors, food safety and preferences, respiratory care, staff competency, and facility maintenance.
Complaint Details
The complaint investigation included intake MI00144424 which triggered review of multiple resident care and facility operation concerns including a hot liquid burn injury to Resident #28.
Findings
The facility was found deficient in multiple areas including failure to provide timely financial statements to a resident's responsible party, failure to notify physician of a resident's burn status change, failure to provide required beneficiary notifications, failure to provide wound care per orders, failure to provide restorative ambulation, failure to perform safe smoking assessments, medication administration errors, failure to provide therapeutic diet and honor food preferences, failure to provide respiratory care equipment, failure to ensure staff competency evaluations, failure to maintain food safety and palatability, and failure to maintain the physical plant and equipment.
Deficiencies (15)
Failed to provide timely financial statements to one resident's responsible person regarding resident trust fund.
Failed to notify physician of a change in tissue appearance for a hot liquid thermal burn for one resident.
Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for one resident.
Failed to provide wound care per physician orders for one resident, resulting in likelihood of infection and delayed healing.
Failed to provide restorative ambulation services to maintain mobility for one resident, resulting in sadness and fear of loss of ability to walk.
Failed to perform safe smoking assessments for two residents, resulting in likelihood for injuries.
Failed to ensure hot liquid was served at a safe and appropriate temperature, resulting in immediate jeopardy when a resident sustained a second-degree thermal burn.
Failed to provide a therapeutic diet to one resident, resulting in significant weight loss.
Failed to provide respiratory treatment for one resident due to missing CPAP machine part.
Failed to ensure two licensed practical nurses had required initial and annual competency evaluations.
Failed to ensure medication error rates were less than 5%, with three medication errors observed for two residents.
Failed to provide palatable food products and maintain safe food temperatures, resulting in increased likelihood for decreased resident food acceptance and nutritional decline.
Failed to honor food preferences for one resident, resulting in consumption of foods that aggravated medical conditions.
Failed to effectively clean and maintain food service equipment, date mark all potentially hazardous ready-to-eat food products, and maintain food production kitchen flooring surface.
Failed to effectively clean and maintain the physical plant, resulting in increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.
Report Facts
Resident weight loss percentage: 16.05
Medication error rate: 11.54
Burn measurement length: 20
Burn measurement width: 7
Burn pain level: 8
Burn measurement depth: 0.1
Coffee temperature: 180
Coffee temperature: 148
Coffee temperature: 178
Coffee temperature: 147
Coffee temperature: 135
Medication administration observation time: 7.59
Medication administration observation time: 8.19
Medication administration observation time: 9.07
Food temperature: 185.5
Food temperature: 147.8
Food temperature: 140
Food temperature: 56.1
Food temperature: 47.8
Food temperature: 148.1
Food temperature: 110.7
Food temperature: 105.1
Food temperature: 56.7
Food temperature: 59.1
Food temperature: 122.1
Food temperature: 130
Food temperature: 120.1
Food temperature: 56.7
Food temperature: 59.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Family Member E | Durable Power of Attorney | Named in financial statement deficiency for Resident #26 |
| Business Office Manager H | Business Office Manager | Interviewed regarding financial statement mailing process |
| Licensed Practical Nurse L | Licensed Practical Nurse | Nurse at time of Resident #28 coffee burn and medication administration observation |
| Assistant Director of Nursing R | Assistant Director of Nursing | Interviewed regarding burn assessment and wound care |
| Social Worker C | Social Worker | Responsible for providing beneficiary notification letters |
| Registered Nurse Z | Registered Nurse | Interviewed regarding wound care |
| Licensed Practical Nurse M | Licensed Practical Nurse | Interviewed regarding wound care |
| Director of Nursing B | Director of Nursing | Interviewed regarding restorative nursing program, smoking policy, medication administration, staff competency, and burn incident |
| Rehabilitation Director Y | Rehabilitation Director | Interviewed regarding restorative ambulation |
| Certified Nurse Assistant W | Certified Nurse Assistant | Interviewed regarding ambulation and smoking |
| Certified Nurse Assistant X | Certified Nurse Assistant | Interviewed regarding smoking |
| Certified Nurse Assistant Q | Certified Nurse Assistant | Interviewed regarding ambulation |
| Dietary Manager D | Dietary Manager | Interviewed regarding coffee temperature and food service |
| Registered Dietitian I | Registered Dietitian | Interviewed regarding food service and burn incident education |
| Dietary Aide T | Dietary Aide | Interviewed regarding coffee temperature and burn incident |
| Licensed Practical Nurse DD | Licensed Practical Nurse | Personnel record reviewed for competency evaluation |
| Licensed Practical Nurse L | Licensed Practical Nurse | Personnel record reviewed for competency evaluation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding unsafe smoking assessments and unsafe serving of hot liquids, resulting in injuries to residents.
Complaint Details
The complaint investigation revealed failures in smoking safety assessments for residents #29 and #4, and an incident where resident #28 was burned by hot coffee served at an unsafe temperature, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to perform safe smoking assessments for residents using vaping devices and failed to ensure hot liquids were served at safe temperatures, resulting in a resident sustaining a second-degree thermal burn from hot coffee. The facility's policies and practices regarding smoking assessments and hot beverage temperature monitoring were inadequate.
Deficiencies (2)
Failed to perform safe smoking assessments for residents using vaping devices, resulting in potential injury risk.
Failed to ensure hot liquid was served at a safe and appropriate temperature, causing a resident to sustain a second-degree thermal burn.
Report Facts
Burn measurement length: 20
Burn measurement width: 7
Burn pain level: 8
Coffee temperature: 180
Coffee temperature: 148
Coffee temperature: 178
Coffee temperature: 147
Coffee temperature: 135
Burn measurement length: 18
Burn measurement width: 6
Burn measurement length: 13.5
Burn measurement width: 3.2
Burn measurement length: 8.5
Burn measurement width: 2.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding smoking assessments and hot liquid incident |
| Certified Nurse Assistant X | Certified Nurse Assistant | Interviewed about resident #4's smoking and vaping supervision |
| Dietary Manager D | Dietary Manager | Interviewed about coffee serving practices and temperature monitoring |
| Licensed Practical Nurse L | Licensed Practical Nurse | Nurse for resident #28 at time of burn incident and educated staff on coffee temping |
| Nursing Home Administrator A | Nursing Home Administrator | Notified of Immediate Jeopardy and involved in corrective actions |
| Dietary Aide T | Dietary Aide | Provided coffee to resident #28 that caused burn |
| Registered Dietitian I | Registered Dietitian | Provided education to dietary staff on hot beverage temperature |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident safety, medication administration, weight monitoring, and dialysis care at Lynwood Manor Healthcare Center.
Findings
The facility failed to ensure appropriate assessments for resident safety and self-administration of medications, failed to monitor significant weight loss in a resident, and failed to maintain ongoing communication and collaboration with the dialysis facility for residents receiving dialysis, resulting in potential harm and decreased quality of care.
Deficiencies (3)
Failed to ensure appropriate assessments for safety using a coffee pot independently and self-administering of medications for Resident #9, resulting in a fire/burn hazard and medication errors.
Failed to monitor residents' weights, resulting in significant weight loss for Resident #1.
Failed to ensure ongoing communication and collaboration with the dialysis facility for Residents #7 and #8, resulting in decreased quality of care.
Report Facts
Weight loss percentage: 12.8
Medication administration times: 2
Dialysis schedule: 3
Dialysis communication form last sent: Oct 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Interviewed regarding medication administration and coffee pot approval for Resident #9. |
| DON B | Director of Nursing | Interviewed about Resident #9's medication administration, coffee pot removal, and dialysis communication issues. |
| RD C | Registered Dietitian | Interviewed about Resident #1's weight loss and dialysis communication. |
| RD D | Registered Dietitian | Dialysis center dietitian interviewed about communication with the nursing home regarding Resident #8. |
| SW F | Social Worker | Interviewed about communication with dialysis unit. |
| DS D | Dialysis Staff | Interviewed about communication problems with the nursing home. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint intake MI00136052 regarding the facility's failure to provide a written notice of transfer or discharge to the responsible party and failure to allow a resident to return to the facility after hospitalization.
Complaint Details
This complaint investigation pertains to intake MI00136052 involving Resident #3. The complaint was substantiated based on interviews and record reviews indicating failures in transfer/discharge notification and readmission procedures.
Findings
The facility failed to provide a written notice of transfer or discharge to the responsible party for Resident #3, resulting in potential uninformed transfer and appeal rights. Additionally, the facility did not allow Resident #3 to return after an ER visit, resulting in the resident remaining in the ER until alternate placement was found. Documentation and communication regarding these issues were lacking.
Deficiencies (2)
Failed to provide a written notice of transfer or discharge to the responsible party for Resident #3.
Failed to allow Resident #3 to return to the facility after hospitalization, resulting in denial of readmission and prolonged ER stay.
Report Facts
Assessment Reference Date: Feb 9, 2023
Date of Progress Note: Apr 25, 2023
Date of Survey Completion: May 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding transfer/discharge process and readmission issues for Resident #3 |
| DON B | Director of Nursing | Interviewed regarding transfer/discharge process and readmission issues for Resident #3; reported verbal notification practices and communication with hospital |
| HS D | Hospital Staff | Provided information about hospital physician's decision and facility refusal to readmit Resident #3 |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 17, 2023
Visit Reason
The inspection was a routine survey of Lynwood Manor Healthcare Center to assess compliance with regulatory requirements related to resident rights, advance directives, assessments, care planning, treatment, smoking safety, infection control, facility maintenance, and food service.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete advance directive documentation, inaccurate Minimum Data Set (MDS) assessments, failure to update care plans, failure to perform ordered wound care, unsafe storage of smoking materials, failure to ensure hand hygiene during medication administration, and inadequate maintenance and cleaning of the physical plant and food service equipment.
Deficiencies (10)
Failure to treat resident #11 with respect and dignity resulting in feelings of shame and negative psychosocial outcome.
Failure to ensure accurate completion of advance directive information for residents #6 and #48.
Failure to accurately complete Minimum Data Set (MDS) assessments for residents #6 and #19.
Failure to update and revise care plans for residents #1, #2, and #12 resulting in absence of updated interventions.
Failure to perform dressing changes as ordered for resident #51, risking wound worsening and infection.
Failure to ensure safe storage of smoking materials for residents #6 and #25, risking unsafe smoking practices.
Failure to ensure hand hygiene during medication administration for three residents.
Failure to effectively clean and maintain food service equipment, increasing risk of cross-contamination for 70 residents.
Failure to maintain nursing home physical plant in safe, clean, and comfortable condition, including plumbing leaks, damaged flooring, torn window screens, and loose commode supports.
Failure to ensure binding arbitration agreements complied with all requirements for residents #34, #45, and #53, resulting in residents not being informed of their rights.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 70
Residents affected: 70
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN S | Licensed Practical Nurse | Named in dignity deficiency for resident #11 for speaking with aggressive tone |
| DON B | Director of Nursing | Informed of dignity concern and acknowledged care plan and smoking plan deficiencies |
| ADON F | Assistant Director of Nursing | Informed of dignity concern and acknowledged care plan and smoking plan deficiencies |
| MDSD R | Minimum Data Set Director | Acknowledged errors in MDS assessments and care plan updates |
| SW P | Social Worker | Interviewed regarding advance directives and resident behavior |
| LPN K | Licensed Practical Nurse | Discussed smoking protocols and resident smoking materials |
| RN H | Registered Nurse | Reported missed wound dressing changes for resident #51 |
| NHA A | Nursing Home Administrator | Provided information on arbitration agreements and acknowledged policy discrepancy |
| CM J | Case Manager | Responsible for binding arbitration agreements |
| Registered Dietician C | Registered Dietician | Conducted food service tour and noted maintenance issues |
| Director of Maintenance D | Director of Maintenance | Conducted environmental tour and acknowledged maintenance issues |
| Director of Housekeeping and Laundry Services E | Director of Housekeeping and Laundry Services | Conducted environmental tour and acknowledged cleaning issues |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
Date: Mar 8, 2023
Visit Reason
The inspection was conducted based on complaint intakes MI00134603 and MI00133214, involving grievances not properly investigated and allegations of drug diversion and abuse.
Complaint Details
The complaint investigation was triggered by intake MI00134603 regarding grievances not properly handled for resident #7, and intake MI00133214 regarding drug diversion and abuse allegations involving residents #10, #11, and #12. The investigation found failures in grievance handling, medication misappropriation, abuse reporting, and investigation.
Findings
The facility failed to properly investigate and resolve resident grievances, failed to prevent and timely report misappropriation of controlled medications for three residents, and failed to thoroughly investigate and respond to allegations of abuse for multiple residents. Additionally, the facility failed to develop a comprehensive discharge plan for one resident.
Deficiencies (5)
Failed to ensure grievances were properly investigated, monitored, tracked, and resolved for one resident (#7).
Failed to prevent misappropriation of residents' controlled medication for three residents (#10, #11, #12).
Failed to timely report allegations of abuse (misappropriation of resident property) for three residents (#10, #11, #12).
Failed to thoroughly investigate allegations of abuse and implement interventions to prevent further abuse for residents #4, #10, #11, and #12.
Failed to develop a comprehensive discharge plan of care for one resident (#13).
Report Facts
Census: 65
Residents affected: 1
Residents affected: 3
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding grievance handling, drug diversion allegation, and abuse investigation |
| Director of Nursing B | Director of Nursing | Interviewed regarding drug diversion allegation, abuse investigation, and grievance handling |
| Licensed Practical Nurse G | Licensed Practical Nurse | Reported suspected drug diversion and provided documentation |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed resident #4 regarding abuse allegation |
| Activity Aide C | Activity Aide | Reported abuse allegation by resident #4 |
| Social Worker F | Social Worker | Interviewed regarding discharge planning for resident #13 |
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