Inspection Reports for
Lynwood Rehabilitation and Healthcare Center

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 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.