Inspection Reports for
Lynwood Rehabilitation and Healthcare Center

The complaint investigation was triggered by complaint/report number AL00047058 regarding allegations of sexual abuse and inappropriate sexual behaviors by RI #320 toward staff and another resident. The facility failed to timely report the abuse allegation to the State Agency within two hours and failed to conduct a thorough investigation. The facility implemented corrective actions including staff education and monitoring starting 06/12/2024.

The facility failed to notify the Medical Director or CRNPs about RI #320's inappropriate sexual behaviors on 02/19/2024, failed to timely report an allegation of sexual abuse involving RI #320 and RI #71 within the required two-hour timeframe, and did not conduct a thorough investigation including obtaining witness statements from all staff. Additionally, the facility failed to implement appropriate behavioral interventions after the incidents.

The complaint investigation involved allegations of inappropriate sexual behaviors by Resident Identifier (RI) #320 on 02/19/2024 and sexual abuse involving RI #320 and RI #71 on 02/22/2024. The facility failed to notify appropriate medical staff, failed to timely report the abuse to the State Agency within two hours, and failed to conduct a thorough investigation with witness statements. The investigation was triggered by complaint/report number AL00047058.

The facility failed to notify the Medical Director or CRNPs about inappropriate sexual behaviors by RI #320 on 02/19/2024, failed to timely report sexual abuse allegations involving RI #320 and RI #71 on 02/22/2024, did not conduct a thorough investigation of the abuse incident, inaccurately coded an MDS assessment for RI #70, failed to implement appropriate behavioral interventions for RI #320, and failed to provide adequate portions and proper reheating of pureed food items.

The complaint investigation was triggered by complaint/report number AL00047058 regarding allegations of sexual abuse and inappropriate sexual behaviors by RI #320. The facility failed to timely report the abuse incident to the State Agency and did not conduct a thorough investigation. The investigation revealed conflicting information and incomplete witness statements. The facility implemented corrective actions including staff education and monitoring.

The facility failed to notify the Medical Director or Certified Registered Nurse Practitioners of RI #320's inappropriate sexual behaviors on 02/19/2024, failed to timely report an allegation of sexual abuse involving RI #320 and RI #71 on 02/22/2024 within the required two-hour timeframe, and did not conduct a thorough investigation or obtain witness statements from all staff regarding the abuse incident. Additionally, the facility failed to implement appropriate behavioral interventions for RI #320's sexually inappropriate behaviors.

The complaint investigation was triggered by allegations of sexual abuse and inappropriate sexual behaviors by Resident Identifier (RI) #320, including incidents on 02/19/2024 and 02/22/2024 involving staff and another resident (RI #71). The facility failed to notify medical staff timely, failed to report the abuse allegation within the required two-hour timeframe, and failed to conduct a thorough investigation with witness statements. The investigation included interviews with staff, review of policies, progress notes, and video footage.

The facility failed to notify the Medical Director or Certified Registered Nurse Practitioners of RI #320's inappropriate sexual behaviors on 02/19/2024, failed to timely report an allegation of sexual abuse involving RI #320 and RI #71 on 02/22/2024, and failed to conduct a thorough investigation including obtaining witness statements. Additionally, the facility failed to accurately code a resident's medication assessment and failed to provide appropriate behavioral health interventions for RI #320's behaviors. Nutritional deficiencies were also noted related to puree diet portions and improper reheating of food.

The facility was found deficient in allowing a resident to participate in care plan meetings, assessing and treating a resident's skin condition, monitoring side effects of psychotropic medications for residents, and maintaining medication error rates below 5%. Several medication errors were observed during medication administration.

The facility was found deficient in allowing a resident to participate in care plan meetings, assessing and treating a resident's skin condition, monitoring side effects of psychotropic medications for residents, and maintaining medication error rates below 5%. Several medication errors were observed during medication administration.

The facility was found deficient in multiple areas including failure to serve residents meals simultaneously at the same table, failure to notify family/sponsor of resident refusals of care, improper medication storage and handling, expired medications stored, inadequate food labeling, incomplete wound care documentation, improper sorting of soiled linens, and failure to use barriers when placing medication cards on bedside tables.

The facility was found deficient in multiple areas including failure to serve residents meals simultaneously at the same table, failure to notify sponsors of resident refusals of care, improper medication storage and handling, expired medications in storage, inadequate food labeling, incomplete wound care documentation, improper sorting of soiled linens, and lapses in infection control practices such as placing medication cards on bedside tables without barriers.