Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including epilepsy, DM2, HTN, weakness, gait difficulty, and a prior sacral fracture, was being transported in a wheelchair van from an outside appointment. The facility driver anchored the wheelchair to the van floor but did not ensure that the van seat belt was applied to the resident. While driving, the driver encountered backed-up traffic around a blind corner and braked hard, causing the resident to be thrown from the wheelchair onto the van floor. The resident was subsequently transported to a hospital and later readmitted with new fractures of the distal femur, fibula, and bimalleolar ankle.
A resident suffered a second-degree burn from hot coffee served at unsafe temperatures, with facility records showing inconsistent temperature monitoring. Additionally, two residents lacked proper smoking assessments, increasing injury risks. The facility's policies did not adequately address these issues.
The facility failed to provide palatable food products to 66 residents, leading to potential nutritional decline. Observations showed food items were not kept at safe temperatures, with milk at 47.8°F and other items below 135°F. Residents expressed dissatisfaction with the food quality, describing it as mushy and overcooked. The facility's policies on food safety were not followed, contributing to the deficiency.
The facility failed to maintain cleanliness and proper maintenance in its food service operations, affecting 66 residents. Issues included a missing tile surface, a loose ice machine door, and a malfunctioning cooler door closer. Opened food containers lacked proper date marking, and equipment was found soiled with food residue, increasing the risk of foodborne illness.
The facility failed to ensure that two LPNs completed the required initial and annual competency evaluations. The personnel records for these LPNs lacked documentation of necessary evaluations, and the facility's policy on Competency Evaluation was found to be inadequate. The DON confirmed the deficiency, and the facility was unable to provide the required evaluations by the time of the survey exit.
The facility failed to maintain a clean and safe environment, affecting 66 residents. Observations included damaged drywall, non-functional ventilation, and slow-draining sinks. Interviews revealed a lack of documented work orders addressing these issues, despite existing policies for regular cleaning and maintenance.
A facility failed to provide timely financial statements to a resident's responsible person, resulting in a lack of information about the resident's personal funds. The resident, with severe cognitive impairment, had a financial account managed by the facility. The responsible person, holding the Durable Power of Attorney, reported not receiving any quarterly financial statements. The Business Office Manager admitted that the facility had not received or mailed out quarterly statements for an undetermined amount of time.
A resident with multiple sclerosis and malnutrition sustained a burn from spilled hot coffee. Initially treated as a second-degree burn, the burn's condition worsened, resembling a third-degree burn. The facility failed to notify the physician of this change, resulting in a deficiency.
A facility failed to provide a resident with necessary Medicare non-coverage notices after a change in payment source from Medicare to pending Medicaid. Despite being cognitively intact, the resident did not receive a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) before the end of Medicare Part A services. The social worker responsible for issuing these notices could not explain the oversight.
A facility failed to provide wound care per physician orders for a resident, leading to the likelihood of infection and delayed healing. The resident had saturated dressings on both arms, dated five days prior, despite orders for wound care every Monday, Wednesday, and Friday. Staff interviews revealed confusion and miscommunication about responsibility for changing the dressings, resulting in a deficiency.
A resident with a history of traumatic brain injury and stroke was not provided with restorative ambulation services, despite recommendations for staff assistance. The facility lacked a restorative nursing program, and staff interviews confirmed no ambulation assistance was given, leading to the resident's sadness and fear of losing mobility.
A resident with multiple sclerosis and severe malnutrition experienced significant weight loss due to the facility's failure to provide a prescribed therapeutic diet. Despite a physician's order for double protein portions, the resident's meal did not include the required portions, as confirmed by a registered dietitian.
A resident with sleep apnea and other health conditions was not using a CPAP machine due to a missing part. The facility had no physician orders for the CPAP and was unaware of its necessity until contacting the resident's power of attorney.
A facility failed to maintain a medication error rate below 5%, with errors involving two residents. An LPN left a MiraLAX solution unattended for a resident with dysphagia, and incorrectly administered crushed medications through a feeding tube for another resident, against facility policy. The Director of Nursing confirmed these actions were not compliant with established procedures.
A resident with dietary restrictions due to renal dialysis and diabetes was served meals containing allergens and intolerances, such as peppers and tomato products, despite clear instructions on her meal tray ticket. Additionally, the resident did not receive the appropriate breakfast on dialysis days, as the kitchen failed to provide the specified sack breakfast items, leaving her without food until late morning.
Failure to Secure Resident With Seat Belt During Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate accident-prevention interventions during transport for one cognitively intact resident. The resident was admitted with multiple diagnoses including left knee pain, diverticulosis, bone density disorder, epilepsy, hyperlipidemia, hypertension, type 2 diabetes, weakness, difficulty walking, lack of coordination, and a sacral fracture. The resident was later discharged from the facility following an incident that occurred while being transported back from an outside appointment. Upon readmission, the resident had new diagnoses of distal femur fracture, fibula fracture, and bimalleolar ankle fracture. According to the facility’s investigation and staff interview, the facility driver placed the resident in the facility van and anchored the wheelchair to the floor using the appropriate strap devices but did not ensure that the van seat belt was applied to the resident. While returning to the facility, the driver encountered backed-up traffic around a corner with a significant blind spot and had to brake hard. As a result, the resident came out of the wheelchair and landed on the van floor. The driver then pulled into a business parking lot, assessed the resident, contacted the facility, and was directed to call 911, after which the resident was transported to a hospital. The driver later stated he thought the seat belt had been applied but had apparently forgotten to do so.
Failure to Ensure Safe Coffee Temperatures and Smoking Assessments
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature, resulting in a second-degree burn for a resident. The resident, who had multiple sclerosis and severe protein-calorie malnutrition, reported that hot coffee spilled on his leg, causing a burn. The coffee was served with a lid that did not seal properly, leading to the spill. The facility's records did not document the coffee temperature at the time of the incident, and the coffee temperature logs showed temperatures exceeding the facility's policy. The facility's investigation into the incident did not include a root cause analysis or identify the staff member who provided the coffee. Interviews with staff revealed inconsistencies in the temperature monitoring process, with coffee temperatures often exceeding safe limits. The dietary manager acknowledged that the coffee machine brewed coffee at temperatures higher than the policy allowed, and there was no consistent monitoring of self-serve coffee stations. Additionally, the facility failed to perform safe smoking assessments for two residents, increasing the likelihood of injuries. One resident was observed with vaping devices, but their care plan did not address vaping. Another resident's smoking assessment did not mention vaping, and staff were unaware of the resident's vaping habits. The facility's smoking policy lacked guidance on vaping, and the residents were not included on the facility's list of smokers.
Removal Plan
- The NHA called an Ad Hoc QAPI meeting, which included the DON, Medical Director, Assistant Director of Nursing, MDS Coordinator, Registered Dietitian, and Dietary Manager. A root cause analysis was completed for the burn to Resident #28.
- Dietary Manager and Registered Dietitian educated dietary staff on proper temping and serving of hot beverages. Hot beverages must be temped and logged prior to and during meal service. The temperature of hot beverages must be taken prior to any request by residents between meals. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents.
- The DON and Social Services Director educated all staff that only dietary staff is permitted to serve hot beverages, with the exception that only a nurse on duty is permitted to serve hot beverages to residents.
- The DON educated nurses on correct process for temping and serving hot beverages. Hot beverages must be temped and logged prior to serving to residents. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents.
- Signs were placed at both kitchen doors by the Registered Dietitian, stating only nurses can serve hot beverages to residents. The Activity Director was instructed to inform residents of this at the next Resident Council Meeting.
- The DON assessed all current residents for safe handling of hot beverages using the Hot Liquid Evaluation. Occupational Therapy was then notified for safety screening per written order for those deemed necessary. The Dietary department was notified to use spill proof cups via Dietary Communication forms for those deemed necessary. Tray tickets and care plans were updated as needed by the Registered Dietitian.
- The Dietary Manager/designee will observe dietary staff at all meals to ensure proper temping and logging of hot beverages until assured that all dietary staff know the proper process.
- The Dietary Manager/designee will audit temperature logs daily to ensure the process is being followed and temperatures are at approved levels for hot beverages.
- The NHA will audit hot beverage logs to ensure compliance.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide palatable food products to 66 residents, which increased the likelihood of decreased food acceptance and nutritional decline. Observations and temperature checks revealed that food items were not maintained at safe and appetizing temperatures. For instance, the temperature of 2% milk was recorded at 47.8°F, which is above the recommended maximum of 41°F. Similarly, other food items like Capri Blend Vegetables and Garlic Toast were served below the required temperature of 135°F. These temperature discrepancies were observed during the delivery of food trays to different halls using non-insulated transport carts. Interviews with residents highlighted dissatisfaction with the quality and temperature of the food. One resident described the mashed potatoes as mushy and the scrambled eggs as overcooked and rubbery. Another resident expressed dissatisfaction with the overcooked chicken and unappetizing breakfast options like sausage, gravy, and biscuits. These comments indicate that the food was not only served at incorrect temperatures but also lacked palatability, affecting the residents' dining experience. The facility's policies on maintaining a sanitary tray line and hot liquid safety were reviewed, revealing a lack of adherence to proper food handling and temperature maintenance guidelines. The policy emphasized the importance of monitoring food temperatures throughout meal service to prevent foodborne illnesses. However, the observed practices did not align with these guidelines, as evidenced by the recorded temperatures and resident feedback. The failure to maintain appropriate food temperatures and palatability contributed to the deficiency identified by the surveyors.
Deficiencies in Food Service Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain proper cleanliness and maintenance standards in its food service operations, affecting 66 residents. During an inspection, several deficiencies were noted, including a missing tile surface beneath a reach-in cooler, a loose ice machine door, and a malfunctioning walk-in cooler door closer. These issues were not addressed promptly, increasing the risk of cross-contamination and bacterial harborage. Additionally, opened containers of sour cream and cottage cheese were found without proper date marking, violating the FDA Model Food Code requirements for time/temperature control for safety food. Further observations revealed that the Cobra Head beverage dispensers and the interior of the Employee Breakroom Whirlpool refrigerator were soiled with accumulated food residue. The facility's policies on date marking and maintaining a clean dietary department were not effectively implemented, as evidenced by the lack of date marking on food products and the unclean state of food-contact surfaces. These lapses in adherence to professional standards and facility policies contributed to the increased likelihood of resident foodborne illness.
Failure to Complete Competency Evaluations for LPNs
Penalty
Summary
The facility failed to ensure that two out of five Licensed Practical Nurses (LPNs) had completed the required initial and annual competency evaluations. This deficiency was identified through interviews and record reviews. Specifically, the personnel records for LPN L and LPN DD did not demonstrate completion of the necessary competency evaluations. LPN L's file lacked documentation of both a new hire competency and an annual skills competency, while LPN DD's file did not show completion of a competency evaluation after orientation or an annual evaluation. The Director of Nursing (DON) confirmed during interviews that all nursing staff are supposed to receive competency evaluations after orientation and annually, which are completed by observing the skills performed. However, the facility's policy on Competency Evaluation was found to be lacking, as it did not include implementation or review dates, and it stated that subsequent and/or annual competency evaluations are determined by the facility's assessment and job performance evaluations. Despite attempts to locate the missing documents, the facility was unable to provide the required annual skills competency evaluations for LPN L and LPN DD by the time of the survey exit.
Facility Maintenance and Cleaning Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 66 residents and increasing the likelihood of cross-contamination, bacterial harborage, and decreased air quality. During an environmental tour, several deficiencies were noted, including damaged drywall in the lobby, non-functional return-air-exhaust ventilation in the soiled utility room, and etched, scored, and particulate surfaces on exit doors in the main dining room, food production kitchen, and sunroom. Additionally, a slow-draining hand sink basin was observed in a resident's restroom. Interviews and record reviews revealed that the facility's maintenance work order system did not have specific entries related to these maintenance concerns for the last 60 days. The facility's policies and procedures for cleaning and disinfecting resident rooms and maintenance services were reviewed, indicating that housekeeping surfaces should be cleaned regularly and maintenance should ensure the building is safe and operable at all times. However, the lack of documented work orders suggests a failure to address these issues promptly.
Failure to Provide Timely Financial Statements
Penalty
Summary
The facility failed to provide timely financial statements to a resident's responsible person, resulting in a lack of information about the resident's personal funds. The resident, who was admitted to the facility with multiple diagnoses including severe cognitive impairment, had a financial account managed by the facility. The responsible person, who held the Durable Power of Attorney for the resident, reported not receiving any quarterly financial statements from the facility, which was confirmed during a telephone interview. The Business Office Manager explained that the facility used a third-party contractor to manage resident accounts and that statements were supposed to be mailed to the facility and then forwarded to the residents or their responsible parties. However, the Business Office Manager was unable to provide documentation that the statements had been mailed to the resident's responsible person and admitted that the facility had not received or mailed out quarterly statements for an undetermined amount of time. A review of the resident's financial statement showed a current balance, indicating that statements should have been regularly provided.
Failure to Notify Physician of Burn Condition Change
Penalty
Summary
The facility failed to notify the physician of a change in the tissue appearance of a burn sustained by a resident. The resident, who had multiple sclerosis and severe protein-calorie malnutrition, reported spilling hot coffee on his leg, resulting in a burn. Initially, the burn was treated with medihoney and covered with a dressing. The burn was assessed as a second-degree burn with blisters and a raised, red area. However, over time, the burn's appearance changed, with more dead tissue present, resembling a third-degree burn. Despite these changes, there was no documentation of the physician being notified about the change in the burn's appearance. The Assistant Director of Nursing acknowledged the lack of documentation and believed medihoney was still appropriate for treatment. The wound provider later assessed the burn and changed the treatment to silvadene. The failure to notify the physician of the change in the burn's condition constitutes a deficiency in the facility's care for the resident.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare coverage to a resident, identified as Resident #14, who was admitted with multiple health conditions including type 2 diabetes, weakness, and heart disease. The resident's payment source changed from Medicare to pending Medicaid, but the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) before the termination of Medicare Part A services. This oversight occurred despite the resident being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The deficiency was identified during a review of the resident's medical records and an interview with the facility's social worker, who was responsible for providing these notices. The social worker acknowledged the responsibility but could not explain why the required notifications were not given to the resident. This lapse in procedure resulted in the resident not being informed of the change in coverage and potential financial liability for services not covered by Medicare.
Failure to Provide Wound Care Per Physician Orders
Penalty
Summary
The facility failed to provide wound care per physician orders for a resident, resulting in the likelihood of infection and delayed wound healing. The resident, who was cognitively intact, had multiple diagnoses including heart failure, high blood pressure, end-stage renal disease requiring dialysis, lung disease, skin tears, and moisture-associated skin damage. Observations revealed that the resident had heavily saturated dressings on both arms, dated five days prior to the observation, indicating a lack of timely wound care. The physician's orders required wound care to be performed every Monday, Wednesday, and Friday, but the Treatment Administration Record (TAR) showed discrepancies in the documentation of these treatments. Interviews with nursing staff revealed confusion and miscommunication regarding the responsibility for changing the dressings, with one nurse documenting a code to avoid a red flag in the electronic medical record, and another nurse not completing the treatment due to a lack of assistance. This lack of adherence to the care plan and documentation led to the deficiency.
Failure to Provide Restorative Ambulation Services
Penalty
Summary
The facility failed to provide restorative ambulation services to a resident, resulting in sadness and fear of losing the ability to walk. The resident, who had a history of traumatic brain injury, stroke with hemiplegia, seizure disorder, anxiety, and depression, expressed a desire to participate in therapy but was informed that insurance would not cover it. Despite recommendations from the Rehabilitation Director for staff to assist the resident with ambulation in the hallway, the facility did not have a restorative nursing program in place, and the resident was not walked outside of her room. Interviews with staff, including CNAs and the Director of Nursing, revealed that there were no instructions or programs for ambulating the resident in the hallway. The resident's care plan did not include any directives for ambulation assistance, and staff confirmed that they did not supervise or assist the resident with walking outside her room. The lack of a structured walking program and the absence of restorative nursing activities contributed to the resident's emotional distress and fear of losing her mobility.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet to a resident with multiple sclerosis and severe protein-calorie malnutrition. The resident, who was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status, experienced a significant weight loss of 16.05% from January to July 2024. A physician's order required the resident to receive double protein portions at meals, starting in March 2024. However, during an observation in July 2024, the resident's lunch tray did not include the prescribed double protein portions, despite the order being highlighted on the tray ticket. This oversight was confirmed by a registered dietitian who observed the meal before it was consumed.
Failure to Provide Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident who required the use of a CPAP machine. During an observation, the resident was found not using the CPAP machine because it was missing a part. The resident, who had a moderate cognitive impairment, was diagnosed with sleep apnea, high blood pressure, Parkinsonism, anxiety, depression, dementia, and seizure disorder. Despite these conditions, there were no physician orders for the use of a CPAP machine, and the facility was unaware of the resident's need for it until they contacted the resident's power of attorney.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of 26 opportunities, resulting in an error rate of 11.54%. Two residents were involved in these errors. Resident #58, who has a range of medical conditions including dysphagia and anxiety, was not observed consuming her prescribed MiraLAX solution. The LPN left the medication on the resident's over-bed table without ensuring it was taken, contrary to facility policy which requires the nurse to remain with the resident until the medication is swallowed. Resident #60, who has a feeding tube and conditions such as cerebral infarction and hemiplegia, received her medications incorrectly. The LPN crushed and mixed Oxycodone and Gabapentin together before administering them through the feeding tube, which is against the facility's policy that mandates each medication be administered separately with a flush of water before and after each dose. These actions were not in compliance with the facility's medication administration policies, as confirmed by the Director of Nursing during an interview.
Failure to Honor Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to honor the food preferences and dietary restrictions of a resident, identified as Resident #39, who was admitted with diagnoses including dependence on renal dialysis and diabetes. The resident, who was cognitively intact, reported that her meal tray ticket specified her dietary restrictions, including an allergy to peppers and an intolerance to tomato products. Despite these specifications, she was served meals containing these ingredients, which aggravated her gallbladder and upset her stomach. Additionally, the resident reported that when she requested an alternate meal, she did not receive the accompanying dessert or side items. The resident also experienced issues with meal provision on her dialysis days. She was supposed to receive a sack breakfast before leaving for dialysis early in the morning, but the kitchen reportedly did not provide this, leaving her without food until her return around 11:00 AM. The Registered Dietitian (RD) had communicated the resident's breakfast preferences to the kitchen, including items like dry cereal, hard-boiled eggs, and yogurt, to be prepared the night before dialysis days. However, the RD was unaware if these items were actually being provided to the resident.
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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 Adrian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adrian Bay Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 5 | 0 |
| Springcreek Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 22 | 0 |
| Lenawee Medical Care Facility | 1.9 mi | ★★★★★ | 17 | 0 |
| Otterbein Sunset Village | 19.6 mi | ★★★★★ | 5 | 0 |
| Lakes Of Sylvania, The | 20.6 mi | ★★★★★ | 9 | 0 |
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