Inspection Reports for
Lynwood Manor
730 Kimole Ln, Adrian, MI 49221, United States, MI, 49221
Back to Facility Profile7 CMS Surveys
Inspection Report — Jun 4, 2025
Plan of Correction
Date: Jun 4, 2025
Visit Reason
Plan of correction acceptance letter regarding deficiencies cited in the nursing home survey.
Findings
The facility failed to limit the duration of a PRN psychotropic medication to 14 days and/or ensure physician documentation for extension for one resident. Additional deficiencies included failure to develop comprehensive care plans, failure to properly communicate hospice services, failure to follow physician orders and properly complete catheter care, failure to secure smoking paraphernalia for multiple residents, and failure to maintain food service equipment in a sanitary condition.
Deficiencies (5)
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: Resident #2 had Ativan PRN ordered without a stop date and no documentation of reassessment beyond 14 days as required by the State Operation Manual.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepare, review, and revise by a team of health professionals: Residents #18 and #2 had incomplete or missing care plans related to smoking supervision and hospice services.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #38 had improper catheter care with a penile tear, failure to switch to leg bag as ordered, and inadequate cleaning of catheter site.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Residents #14, #18, #35, and #37 had cigarettes, lighters, and vapes stored unsecured in their rooms despite some requiring locked storage per smoking assessments.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Food service equipment including ice machine, ovens, can opener, griddle, and dish machine were observed soiled, broken, or not maintained at proper temperatures, increasing risk of contamination.
Report Facts
Medication duration limit: 14
Care plan development time: 7
Dish machine wash temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse F | Licensed Practical Nurse | Named in catheter care deficiency for Resident #38 and smoking paraphernalia supervision for Resident #18 |
| Director of Nursing B | Director of Nursing | Named in multiple deficiencies including medication orders, smoking paraphernalia supervision, and hospice documentation |
| Social Work Director C | Social Work Director | Named in hospice services coordination deficiency |
| Dietary Director G | Dietary Director | Named in food service equipment maintenance deficiency |
Inspection Report — Jul 12, 2024
Complaint Investigation
Date: Jul 12, 2024
Visit Reason
Investigation of a complaint received on 2024-04-18 about hot liquid safety and smoking/vaping assessments.
Complaint Details
Hot liquid served at unsafe temperature causing burn: established. Failure to assess smoking and vaping safety: established.
Findings
The facility failed to ensure hot liquids were served at a safe temperature, resulting in a second-degree thermal burn to Resident #28. The facility also failed to adequately assess smoking and vaping safety for Residents #29 and #4. Immediate Jeopardy was identified and later removed after corrective actions.
Deficiencies (2)
F 0689 Hot Liquid Safety: the facility failed to ensure hot liquids were served at a safe temperature, resulting in Resident #28 sustaining a second-degree thermal burn on his left thigh from coffee served at an unsafe temperature.
F 0689 Smoking and Vaping Assessments: the facility failed to perform safe smoking assessments for Residents #29 and #4, including lack of care plans addressing vaping and incomplete smoking screen assessments.
Report Facts
Burn measurement length: 20
Burn measurement width: 7
Pain level: 8
Coffee temperature maximum: 180
Coffee temperature minimum: 135
Burn measurement length: 1.5
Burn measurement width: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide T | Dietary Aide | Named as the staff who provided the coffee that burned Resident #28 |
| Director of Nursing B | Director of Nursing | Interviewed regarding smoking privileges and coffee burn incident |
| Licensed Practical Nurse L | Licensed Practical Nurse | Resident #28's nurse who provided care after the burn and educated staff |
| Dietary Manager D | Dietary Manager | Reported on coffee temperature practices and logs |
Inspection Report — Jul 12, 2024
Complaint Investigation
Date: Jul 12, 2024
Visit Reason
Investigation of a complaint received on 2024-04-18 about hot liquid burn, medication errors, food service, and resident care.
Complaint Details
Hot liquid burn to Resident #28: established. Medication errors for Residents #58 and #60: established. Failure to provide therapeutic diet to Resident #28: established. Failure to honor food preferences for Resident #39: established. Inadequate respiratory care for Resident #22: established. Additional findings: poor food temperature control, staff competency deficiencies, and environmental maintenance issues.
Findings
Multiple deficiencies were found including failure to ensure safe hot liquid temperatures resulting in a second-degree burn, medication administration errors, failure to provide therapeutic diet and honor food preferences, inadequate respiratory care, lack of staff competency evaluations, unsafe food temperatures and handling, and poor maintenance and cleanliness of the facility.
Deficiencies (12)
F 0689 Hot liquid safety: facility failed to ensure hot liquid was served at a safe temperature, causing Resident #28 to sustain a second-degree thermal burn on his left thigh.
F 0684 Wound care: facility failed to provide wound care per physician orders for Resident #29, resulting in likelihood of infection and delayed healing.
F 0688 Restorative ambulation: facility failed to provide restorative ambulation services to Resident #4, resulting in sadness and fear of loss of ability to walk.
F 0689 Smoking safety: facility failed to perform safe smoking assessments for Residents #29 and #4, not addressing vaping hazards.
F 0692 Nutrition: facility failed to provide therapeutic diet with double protein portions to Resident #28, who experienced significant weight loss.
F 0695 Respiratory care: facility failed to provide respiratory treatment for Resident #22 who did not use CPAP due to missing equipment and lack of physician orders.
F 0726 Staff competency: facility failed to ensure Licensed Practical Nurses DD and L had required initial and annual competency evaluations.
F 0759 Medication administration: facility failed to maintain medication error rate below 5%, with three errors observed involving Residents #58 and #60.
F 0804 Food temperature and palatability: facility failed to maintain safe food temperatures and provide palatable food, with multiple food items served below safe temperature and residents reporting poor food quality.
F 0806 Food preferences: facility failed to honor food preferences and dietary restrictions for Resident #39, serving tomato products despite documented intolerance.
F 0812 Food service sanitation and date marking: facility failed to effectively clean food service equipment, date mark ready-to-eat foods, and maintain kitchen flooring, increasing risk of contamination.
F 0921 Environmental maintenance: facility failed to maintain physical plant including damaged drywall, non-functional ventilation, damaged doors, and slow draining sink, increasing risk of contamination and poor air quality.
Report Facts
Weight loss percentage: 16.05
Medication error rate: 11.54
Hot liquid safety temperature limit: 135
Hot liquid safety temperature limit: 140
Burn measurement length: 20
Burn measurement width: 7
Burn measurement depth: 0.1
Inspection Report — Feb 15, 2024
Complaint Investigation
Date: Feb 15, 2024
Visit Reason
Investigation of a complaint received about medication self-administration, weight monitoring, and dialysis care.
Complaint Details
Resident #9 medication self-administration and coffee pot safety: established. Resident #1 weight monitoring failure: established. Resident #7 and #8 dialysis communication failure: established.
Findings
Three deficiencies were found related to failure to assess resident safety for self-administering medications and use of appliances, failure to monitor significant weight loss, and failure to ensure ongoing communication and collaboration with the dialysis facility.
Deficiencies (3)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to assess Resident #9 for safety in self-administering medications and use of a coffee pot, resulting in medication errors and fire/burn hazard.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to monitor Resident #1's weight loss, resulting in a significant 12.8 percent weight loss without timely reweight.
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: the facility failed to ensure ongoing communication and collaboration with the dialysis facility for Residents #7 and #8, resulting in decreased quality of care.
Inspection Report — May 31, 2023
Complaint Investigation
Date: May 31, 2023
Visit Reason
Investigation of a complaint received about transfer and discharge procedures for Resident #3.
Findings
Two deficiencies were cited related to failure to provide written notice of transfer or discharge and failure to allow a resident to return to the facility after hospitalization.
Deficiencies (2)
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide a written notice of transfer or discharge to the responsible party for Resident #3.
F 0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy: the facility failed to allow Resident #3 to return after being sent to the emergency room, resulting in the resident remaining in the ER until alternate placement was found.
Inspection Report — Apr 17, 2023
Complaint Investigation
Date: Apr 17, 2023
Visit Reason
Investigation of complaints received about resident care, safety, and facility conditions.
Complaint Details
Binding arbitration agreements: Residents #34, #45, and #53 - non-compliant. Infection control: hand hygiene lapses during medication pass. Smoking safety: Residents #6 and #25 - unsafe storage of smoking materials. Care plans: Residents #1, #2, #12 - not updated after significant changes. Wound care: Resident #51 - dressing changes not performed as ordered. Facility maintenance: multiple physical plant and food service equipment issues.
Findings
Three binding arbitration agreements were found non-compliant with state requirements. Multiple infection control lapses were observed during medication pass. Unsafe storage of smoking materials was noted for two residents. Several care plan deficiencies were identified including failure to update plans after significant changes. Wound care was not performed as ordered for one resident. Facility physical plant and food service equipment were poorly maintained and in need of repair.
Deficiencies (10)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: LPN S spoke aggressively to Resident #11 during medication administration, causing distress.
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: Advance directive forms for Residents #6 and #48 were incomplete, missing required witness signatures.
F 0641 Ensure each resident receives an accurate assessment: Minimum Data Set assessments for Residents #6 and #19 were inaccurate, failing to reflect true physical impairments and wound care status.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: Care plans for Residents #1, #2, and #12 were not updated to reflect significant changes such as behavioral symptoms, smoking status, and fall with injury.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #51's wound care dressing changes were not performed as ordered, with dressings observed to be several days old.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Residents #6 and #25 had unsafe smoking practices with lighters and cigarettes not stored securely as required by facility policy and care plans.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Food service equipment was poorly maintained with leaking condensate lines, pooling water, ice accumulation, and damaged ceiling and wall tiles.
F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse: Binding arbitration agreements for Residents #34, #45, and #53 did not comply with requirements, including incorrect rescission period and lack of informed consent.
F 0880 Provide and implement an infection prevention and control program: Medication pass observed with staff failing to perform hand hygiene before and after administering medications to residents.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Numerous physical plant deficiencies were observed including cracked and stained flooring tiles, loose commode supports, worn and torn window screens, slow draining sinks, damaged drywall, and soiled surfaces throughout resident rooms and common areas.
Inspection Report — Mar 8, 2023
Complaint Investigation
Date: Mar 8, 2023
Visit Reason
Investigation of complaints received regarding misappropriation of resident property, failure to report abuse allegations, and failure to develop a comprehensive discharge plan.
Complaint Details
Grievances not properly investigated or resolved: Resident #7. Misappropriation of controlled medication: Residents #10, #11, #12. Failure to timely report abuse allegations: Residents #10, #11, #12. Failure to thoroughly investigate abuse allegations and protect residents: Residents #4, #10, #11, #12. Failure to develop discharge plan: Resident #13.
Findings
The facility failed to ensure grievances were properly investigated and resolved, failed to prevent misappropriation of residents' controlled medication, failed to timely report allegations of abuse to the State Agency, failed to thoroughly investigate abuse allegations, and failed to develop a comprehensive discharge plan for one resident.
Deficiencies (5)
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. The facility failed to ensure grievances were properly investigated, monitored, tracked, and resolved for Resident #7.
F 0602 Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to prevent misappropriation of residents' controlled medication for Residents #10, #11, and #12, including falsified signatures on medication records and lack of proper investigation.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The facility failed to report allegations of abuse for Residents #10, #11, and #12 in a timely manner and failed to thoroughly investigate the allegations.
F 0610 Respond appropriately to all alleged violations. The facility failed to thoroughly investigate allegations of abuse, implement interventions to prevent further potential abuse for Residents #4, #10, #11, and #12, and failed to protect residents pending investigation.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to develop a comprehensive discharge plan of care for Resident #13, resulting in potential for unmet care needs or inadequate resident care.
Report Facts
Assessment Reference Date: Dec 6, 2022
Assessment Reference Date: Mar 3, 2023
Assessment Reference Date: Feb 2, 2023
Assessment Reference Date: Jan 5, 2023
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