Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lynwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide correct portion sizes for puree diets, combining puree bread with meat, leading to non-compliance with menu standards. This affected five residents receiving puree diets, as they were not provided with adequate nutrients. The Registered Dietitian confirmed the issue, noting that the combined portions did not meet menu requirements.
The facility failed to reheat Puree Scalloped Potatoes to the required 165°F for 15 seconds, as per FDA guidelines and facility policy. During lunch service preparations, the potatoes were found at 125°F and were only reheated to 146°F, which was incorrectly accepted by staff. This oversight potentially affected five residents on puree diets, risking bacterial growth and illness.
A resident's MDS assessment was inaccurately coded to show receipt of an anticoagulant medication, when the resident was actually on Aspirin, an antiplatelet, for Coronary Artery Disease. The MDS Coordinator confirmed the error during an interview, affecting one of 47 sampled residents.
A resident with a history of inappropriate sexual behavior attempted to touch a CNA and grabbed a therapist, but the facility failed to notify the MD or CRNPs as required by policy. The resident, with severely impaired cognition and a history of such behavior, was not reported to the medical team, despite the facility's policy mandating prompt notification for significant changes in condition.
The facility failed to report an allegation of sexual abuse involving two residents within the required two-hour timeframe. A CNA informed the ADON of the incident, but the ADON did not report it to the Administrator, believing it had already been reported. As a result, the Administrator was not informed until nearly 24 hours later, delaying the report to the State Agency.
A facility failed to conduct a thorough investigation into an alleged inappropriate touching incident between two residents. The investigation lacked complete witness statements and contained conflicting information about the incident's timing. Despite a video review suggesting no inappropriate contact, the facility did not obtain all necessary witness statements, and the timeline of events was insufficiently detailed.
A resident with a history of inappropriate sexual behaviors was admitted to the facility, and despite a care plan being developed, the facility failed to implement new interventions or notify medical staff after incidents of inappropriate touching occurred. The facility's policy required appropriate services for residents with adjustment difficulties, but no new actions were taken following the incidents, highlighting a lapse in communication and intervention.
Deficiency in Puree Diet Portion Sizes
Penalty
Summary
The facility failed to provide the approved portions of puree meat and puree bread for residents on puree diets during lunch on two consecutive days. The facility's policies for menu planning and tray line service require that meals meet nutritional needs and be served in accordance with the menu. However, observations revealed that the puree bread was combined with the puree meat, resulting in incorrect portion sizes being served. Specifically, on the first day, puree bread was mixed with puree ham, and on the second day, puree bread was mixed with puree baked chicken, both served with a 3 oz spoodle instead of the required 5 oz. The Registered Dietitian confirmed that the serving sizes did not meet the menu requirements, as the puree bread and meat were combined into a single portion rather than being served separately in the correct amounts. This deficiency had the potential to affect all five residents receiving puree diets, as they were not provided with the adequate nutrients specified in the facility's menu. The Registered Dietitian acknowledged that the residents had previously complained about the taste of pureed bread when served alone, leading to the decision to combine it with the meat, but this adjustment resulted in non-compliance with the established menu standards.
Inadequate Reheating of Puree Scalloped Potatoes
Penalty
Summary
The facility failed to ensure that Puree Scalloped Potatoes were reheated to the required temperature of 165 degrees Fahrenheit for 15 seconds after cooling to 125 degrees Fahrenheit, as per the 2022 U.S. FDA Food Code and the facility's own policies. This deficiency was observed during the lunch meal service preparations on 10/08/2024. The Puree Scalloped Potatoes, intended for five residents on puree diets, were initially found to be at 125 degrees Fahrenheit. They were then reheated to only 146 degrees Fahrenheit by the AM Cook, which was incorrectly deemed acceptable by the Assistant Dietary Manager. The Dietary Manager later confirmed that the reheating was inadequate, as the food should have been reheated to 165 degrees Fahrenheit. The Registered Dietitian also acknowledged the error, stating that reheating to only 146 degrees Fahrenheit could lead to bacterial growth, potentially making residents sick. This oversight had the potential to affect five residents who received pureed meals, out of a total of 108 residents receiving meals from the facility kitchen.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident identified as RI #70. The deficiency was identified during a review of the resident's Significant Change Minimum Data Set (MDS) assessment, which had an Assessment Reference Date (ARD) of 08/29/2024. The MDS was incorrectly coded to indicate that the resident received an anticoagulant medication during the look-back period, which was not the case. Instead, the resident was on Aspirin, an antiplatelet medication, for Coronary Artery Disease. The error was confirmed during an interview with the MDS Coordinator, who acknowledged completing the MDS assessment for RI #70. The coordinator admitted that the assessment was mistakenly coded to reflect the administration of an anticoagulant, whereas it should have been coded as an antiplatelet. This coding error affected one of the 47 sampled residents whose MDS assessments were reviewed, highlighting a lapse in the facility's assessment accuracy.
Failure to Notify Medical Team of Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to notify the Medical Director (MD) and Certified Registered Nurse Practitioners (CRNPs) when a resident with a history of inappropriate sexual behaviors attempted to touch a Certified Nursing Assistant (CNA) inappropriately and grabbed a therapist on the buttocks. The incidents occurred on 02/19/2024, but there was no evidence in the resident's Progress Notes that the MD or CRNPs were informed. The facility's policy, effective 01/22/2024, requires prompt notification of the physician when there is a significant change in a resident's condition, including new behavioral problems. The resident, identified as having severely impaired cognition, was admitted with diagnoses including Cognitive Communication Deficit, Anxiety Disorder, and Dementia with Behavioral Disturbance. The resident had a history of inappropriate behavior, as noted in a hospital discharge summary. Despite the facility's policy and the resident's known history, the Assistant Director of Nursing (ADON) did not document notifying the MD or CRNPs about the incidents. Interviews with the ADON, Administrator, and CRNPs confirmed that the medical team was not informed, which could have led to further evaluation or intervention.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents within the required timeframe of two hours. The incident occurred on 02/22/2024, when a Certified Nursing Assistant (CNA) informed the Assistant Director of Nursing (ADON) that one resident attempted to put their hands in another resident's shirt. Despite this information being available, the ADON did not report the incident to the Administrator, who is also the Abuse Coordinator, because he believed someone else had already done so. Consequently, the Administrator was not informed of the incident until 02/23/2024, almost 24 hours later, resulting in a delay in reporting the incident to the State Agency. The facility's policy, titled 'Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation,' mandates that all allegations of abuse must be reported within two hours. During interviews, both the ADON and the Administrator acknowledged the requirement for immediate reporting of abuse. The failure to adhere to this policy was identified during the investigation of complaint/report number AL00047058, affecting one of the 17 Facility Reported Incidents (FRIs) reviewed for timely reporting of allegations of abuse.
Removal Plan
- The facility identified that the incident was reported late.
- The ADON and Registered Nurse (RN) #13 were provided 1:1 in-service on the facility's Abuse Policy and Procedure including timely reporting of all allegations.
- All staff were educated on the facility's Abuse Policy and Procedure including timely reporting of all allegations. All staff receive abuse training upon hire, quarterly, and as needed.
- The facility replaced existing Abuse Reporting signs with neon-colored signs that say REPORT ANY ABUSE TO and names and the contact information for who to notify.
- A new resident council template was developed to assist with identifying any abuse.
- Staff interviews will be conducted with 5 staff.
- Results will be reviewed in monthly QAA and then reassessed.
Inadequate Investigation of Alleged Inappropriate Touching Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of inappropriate touching between two residents. The incident involved one resident placing their hand under another resident's blouse, which was witnessed by a Certified Nursing Assistant (CNA). The facility's policy requires a complete investigation and obtaining witness statements, but the investigation was incomplete, with conflicting information regarding the time of the incident and missing witness statements. The facility's initial report and five-day summary contained discrepancies, and the timeline of events lacked specific details, such as names and times. The Administrator, responsible for the investigation, acknowledged the lack of thoroughness in the investigation. Although a video review suggested that the resident did not touch the other resident's breast, the facility did not obtain all necessary witness statements, including those from a Registered Nurse (RN) and another CNA who were present. The Administrator admitted that the timeline could have been more detailed to prevent questions, and there was no attempt to clarify the statement given by the CNA who witnessed the incident.
Failure to Address Resident's Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to manage and address the sexually inappropriate behaviors of a resident, identified as RI #320, who was admitted with a documented history of such behaviors, including groping. Despite the development of a care plan on 02/12/2024 to address these behaviors, the facility did not implement new interventions or notify the Medical Director or Certified Registered Nurse Practitioners after incidents on 02/19/2024, where RI #320 attempted to touch a CNA inappropriately and grabbed a physical therapist's buttocks. The facility's policy, titled Distressed Behavior Management Program, mandates that residents displaying mental or psychosocial adjustment difficulties should receive appropriate services to correct the problem. However, after the incidents on 02/19/2024, there was no evidence of discussions for behavior management or new interventions being implemented. The Director of Social Services acknowledged that new interventions should have been addressed in the care plan, such as a psychiatric evaluation or medication adjustment, but these actions were not taken. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that they were aware of RI #320's history and the incidents on 02/19/2024. However, no immediate actions were taken to address the behaviors, such as referring the resident for psychiatric evaluation or adjusting the care plan. The Medical Director stated that if he had been notified, he would have sent RI #320 for a psychiatric evaluation, indicating a lapse in communication and intervention following the incidents.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mobile
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knollwood Healthcare | 2.2 mi | — | 9 | 0 |
| Crowne Health Care Of Mobile | 2.8 mi | ★★★★★ | 0 | 0 |
| Springhill Senior Residence | 4.1 mi | ★★★★★ | 0 | 0 |
| Crowne Health Care Of Springhill | 4.1 mi | ★★★★★ | 0 | 0 |
| Gulf Coast Health And Rehabilitation, Llc | 5.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.