Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
Cell Phone Use During Resident Care: CNAs were reported to use personal cell phones while providing care, including peri-care, with 10 residents stating the behavior made them feel ignored, embarrassed, and that their privacy was violated. Residents said it happened on every shift, mainly nights, and the DON and ADM stated cell phones should not be used in resident rooms, hallways, or at nurses' stations during care.
Food was not palatable, attractive, or consistently served at a safe and appetizing temperature for residents on Regular, Mechanical Soft, and Pureed diets. Surveyors observed pureed chicken thighs and mac-n-cheese with a coarse, chunky appearance, and a test tray showed multiple items with texture, flavor, and temperature problems, including lukewarm mechanical sausage. Staff, including the RD, DM, ADM, and a cook, acknowledged the pureed foods did not look smooth or appropriate for a puree diet, and residents voiced concerns that rolls were raw and vegetables were overcooked.
Unlabeled Food and Dirty Kitchen Equipment: Surveyors observed an iced tea machine with dirt and stains and greasy stains on the doors of two refrigerators and two freezers. Multiple food items in the refrigerators and freezers were stored without labels or use-by dates. The RD, DM, an aide, and the ADM stated that staff were responsible for labeling, dating, and cleaning the equipment, and acknowledged that the undated food could result in serving food that was no longer good.
A facility failed to follow the posted lunch menu and did not clearly notify residents when the meal was changed. During observation, the planned lunch items were replaced with a different meal, and only dinner rolls and frosted cake were seen served from the original menu. Residents stated menus were rarely followed, were not posted for review, and that meal choices they made were sometimes not honored. The RD was unaware the menu was not followed, while the DM and ADM stated the substitution was communicated verbally.
Failure to change gloves during wound care was cited after an RN cleaned and treated a resident’s heel, ankle, and coccyx wounds without performing hand hygiene or changing gloves between wound sites. The resident was cognitively intact and had pressure injuries with wound care orders for the coccyx, left heel, and right ankle. The RN and DON both stated staff were expected to change gloves and use hand hygiene when moving from dirty to clean areas, and the facility policy for dressing changes required glove removal, hand hygiene, and clean gloves during wound cleansing.
A medication aide failed to verify that a resident with severe cognitive impairment and a history of medication refusal actually swallowed her prescribed oral medications. The aide placed the medications in the resident's mouth during breakfast but left without confirming ingestion, resulting in the medications being found in a cup beside the resident's tray by a family member, who then assisted the resident in taking them. Staff interviews confirmed that the aide did not follow established procedures for medication administration.
A resident with dementia and anxiety, newly admitted for respite care, began exhibiting confusion, wandering, and exit-seeking behaviors that were not promptly addressed by staff. Despite door alarms sounding, staff attributed them to other causes and did not verify the resident's whereabouts, resulting in the resident eloping from the facility and being found by a community member at a nearby location.
A CNA failed to treat two residents with respect and dignity during a delayed smoke break, using a stern and argumentative tone and telling them she did not have to take them out to smoke. Both residents, who had cognitive deficits and complex medical histories, felt disrespected by the interaction, which was confirmed by video evidence and interviews. The DON acknowledged that the CNA's actions violated resident rights and facility policy.
A resident with anxiety and depression was denied the right to call her family member at night by a CNA, despite her care plan emphasizing the importance of family involvement. The family member was willing to receive calls at any time, and the facility's policy mandates respect for residents' communication rights. This incident violated the resident's rights and could have impacted her emotional well-being.
A resident in a LTC facility was left in a soiled brief for about two hours due to delayed response to call lights. Despite being cognitively intact, the resident required substantial assistance for personal hygiene. The resident's family member activated the call light multiple times, but staff were busy with other duties, including taking residents for a smoke break, leading to a delay in care. This failure to follow the facility's call light response policy placed the resident at risk for skin breakdown and infections.
The facility failed to maintain RN coverage for eight hours a day, seven days a week, on ten specific days due to unreported hours for a salaried RN. Despite being scheduled, the RN's hours were not recorded, leading to a deficiency in staffing. Interviews revealed that staff turnover and miscommunication contributed to this oversight, with the ADM working on a new tracking system for salaried RNs.
The facility failed to replace oxygen tubing weekly for two residents, as required by physician orders. One resident with COPD and severe cognitive impairment and another with congestive heart failure were observed with undated oxygen tubing. Interviews with the DON and ADM confirmed the oversight, acknowledging the potential for infection control issues due to non-compliance with the facility's policy on respiratory care.
A LTC facility experienced a 20% medication error rate involving two residents. Errors included missed doses, incorrect dosages, and unauthorized medication administration. Med Aide C failed to verify orders, leading to incorrect administration of Lactulose, Magnesium, Thiamine, and Ferrous Sulfate. The facility's administration acknowledged training responsibilities but was unaware of some unauthorized actions.
The facility failed to store and date foods in the refrigerator and did not store pans correctly, as observed during a survey. Uncovered desserts, a bowl of pureed food, and sandwiches were found without dates, and pans were stored right side up. Interviews with the ADM and DM confirmed that staff were trained on proper procedures, but these were not followed, violating the facility's food storage policy.
Two LVNs at a facility failed to adhere to infection control protocols during wound care for two residents. One LVN did not wash hands between glove changes, while the other contaminated wound dressing materials by reaching into his pocket with gloves on. Both incidents highlight lapses in hand hygiene practices, despite staff training on infection control.
The facility failed to inform residents about their rights to file grievances, with 7 residents unaware of the process, lacking access to forms, and unable to file anonymously. The grievance procedure was not posted, and forms were not readily available, contributing to unresolved grievances.
The facility failed to properly store wound cleaners, leaving two bottles unattended on a treatment cart. An LVN left the bottles exposed while attending to a resident, despite warnings on the bottles and training on secure storage. Interviews with the LVN, DON, and ADM confirmed the oversight and the importance of storing medications in locked compartments.
The facility failed to implement comprehensive care plans for two residents, one with wound care needs and another requiring oxygen therapy. Despite having physician's orders, the care plans did not include these critical interventions. Staff interviews and observations confirmed the oversight, which was acknowledged by the DON and Clinical Resource RN.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with respect, dignity, and privacy during care when CNAs used personal cell phones while providing resident care, including peri-care. During interviews, 10 confidential residents stated that cell phone use by CNAs made them feel ignored, not a priority, embarrassed, and concerned that staff could make mistakes because of distraction. They also stated their privacy was violated and that this occurred on every shift, primarily on the night shift, and that they did not know the names of the CNAs involved because the behavior was so frequent they believed every CNA in the facility used a cell phone while performing care. The DON stated staff should provide privacy any time they were performing resident care and that cell phones should only be used in the break room and outside the facility, never in resident rooms, hallways, or at nurses' stations. The ADM gave the same account regarding privacy and cell phone use. The facility policy on Promoting/Maintaining Resident Dignity stated staff should pay attention to the resident as an individual, not talk to each other while performing a task as if the resident is not there, maintain resident privacy, and that random observations and/or verifications are conducted by the DNS or designee to ensure compliance.
Food Not Palatable or Served at Proper Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for residents receiving Regular, Mechanical Soft, and Pureed diets during a lunch meal observation. During the meal, surveyors observed pureed seasoned chicken thighs and pureed mac-n-cheese served to residents on a pureed diet with a very coarse appearance, and pureed chicken gravy was also present. Temperatures were not taken during that observation, but pictures were documented by the surveyor. During a kitchen tour the next day, surveyors requested a test tray and observed food on the steam table and on the test tray. Steam table temperatures included sausage at 181 F, red beans at 192 F, turnip green at 200 F, pureed sausage at 168 F with a coarse appearance, pureed red beans at 195 F with a coarse appearance, pureed turnip green at 183 F with poor flavor, and mechanical sausage at 135 F. When the test tray arrived, temperatures were sausage at 152 F, red beans at 162 F, turnip green at 170 F, pureed sausage at 168 F with a coarse appearance, pureed red beans at 195 F with a coarse appearance, pureed turnip green at 183 F with poor flavor, and mechanical sausage at 131 F and described as lukewarm. Four of seven foods tested had flavor, texture, and temperature issues. During interviews, 10 of 10 residents voiced concerns about food palatability, stating the rolls were raw and difficult to chew and the vegetables were unrecognizable because they were cooked too long. The RD, DM, ADM, and a cook all acknowledged that the pureed foods shown in the pictures did not look smooth or appropriate for a pureed diet and stated that such food would not be palatable. The family member of a resident on a pureed diet stated the resident had been placed on puree after choking incidents with turkey and sliced peaches, and that he did not like how the food looked or tasted. The facility policy titled Food Preparation Guidelines stated that food and drinks shall be palatable, attractive, and at a safe and appetizing temperature.
Unlabeled Food and Dirty Kitchen Equipment
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During a kitchen tour, surveyors observed an iced tea machine inside the beverage station with dirt and stains. They also observed greasy stains on both the right and left doors of reach-in refrigerator #1, reach-in refrigerator #2, walk-in freezer #1, and walk-in freezer #2. Surveyors found multiple food items in the refrigerators and freezers that were not labeled and did not have use-by dates. In reach-in refrigerator #1, items included covered sausages in a sheet pan, tomato paste in a transparent container, sandwiches, and turkey bologna in two clear plastic bags. In reach-in refrigerator #2, items included cheese, liquid eggs, lettuce, and turkey breast in different clear plastic bags. In walk-in freezer #1, items included ham, diced chicken, chicken thighs, fish sticks, and beef burrito in different clear plastic bags. In walk-in freezer #2, items included waffles, frozen vegetables, cookies, and carrots in different clear plastic bags. During interviews, the RD, DM, an aide, and the ADM stated that kitchen staff were responsible for dating and labeling food items and cleaning the equipment, and that the food items should have had use-by dates. The RD stated that staff were not aware that use-by dates should have been indicated on those food items. The DM and ADM stated that the dirty machines and unlabeled or undated food items could cause residents to get sick, and the ADM stated that food without a use-by date could result in serving something that was no longer good.
Menu Not Followed and Residents Not Notified of Meal Substitution
Penalty
Summary
The facility failed to follow the lunch menu for 1/11/2026 during a dining observation from 12:22 p.m. to 12:51 p.m. The weekly menu for week five’s Sunday lunch listed braised beef tips with gravy, steamed rice, roasted brussels sprouts, dinner rolls, and frosted cake, but a handwritten message on a whiteboard near the kitchen entrance listed a substitute lunch of seasoned chicken thighs, chicken gravy, mac and cheese, dinner roll, and frosted cake. During the observation, only the dinner rolls and frosted cake were seen as part of the lunch meal served. During a confidential meeting, ten of ten confidential residents stated the menu was rarely followed, menus were not posted for their review, and menus were not posted on common bulletin boards. They also stated they were given choices at breakfast for lunch and dinner, but at times were still not served what they chose, and they were not notified that the lunch menu had been changed. The RD stated she was not aware the lunch menu was not followed and was not sure the residents were informed. The DM stated she was responsible for making sure the menu was followed and that if food was not in stock, she had to replace it with items available; she also stated she informed residents verbally that the menu was being substituted. The ADM stated the residents were informed verbally. The facility policy stated standardized cycle menus are planned in advance and utilized, menus should be approved and signed by the RD, and the current week-at-a-glance menu should be posted in designated common areas.
Failure to Change Gloves During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after RN A failed to change gloves and perform hand hygiene during wound care for Resident #27. Resident #27 was a cognitively intact male with a history of pulmonary embolism, respiratory failure, and heart failure. His care plan identified refusal or resistance to repositioning as contributing to pressure injuries on the heels and buttocks/sacrum, and physician orders directed wound treatment for the coccyx, left heel, and right ankle. During wound care observation, RN A cleaned the resident’s left heel wound, applied a dressing, then cleaned the right ankle and applied betadine, and then cleaned the coccyx wound and applied Triad. RN A did not change gloves or perform hand hygiene after cleaning each wound area. RN A stated she had been trained to change gloves when going from dirty to clean and to use hand hygiene in between, and the DON stated staff were expected to change gloves and use hand hygiene when moving from a dirty area to a clean area. The facility policy for clean dressing changes also directed staff to remove gloves, wash hands, and put on clean gloves after cleansing the wound.
Failure to Ensure Resident Swallowed Oral Medications During Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure that a resident with severe cognitive impairment and a history of medication refusal and pocketing actually swallowed her prescribed oral medications. The aide placed the medications in the resident's mouth during breakfast and left the area without verifying ingestion. The medications were later found in a cup beside the resident's breakfast tray by a family member, who then assisted the resident in taking them. The resident involved had diagnoses including Alzheimer's disease, coronary artery disease, hypertension, and major depressive disorder, and was assessed as having severe cognitive impairment. She was prescribed multiple medications, including antidepressants, anticoagulants, diuretics, antiplatelets, and anticonvulsants. The medication administration record indicated that the medications were documented as given, but direct observation and interviews revealed that the aide did not remain with the resident to confirm that the medications were swallowed, despite knowing the resident's history of holding or refusing medications. Interviews with facility staff confirmed that the standard procedure for medication administration requires the staff member to remain with the resident until all medications are taken and to check the resident's mouth if there is a history of pocketing. The aide admitted to not following this procedure and acknowledged awareness of the correct protocol. The incident was reported by the resident's family member, and staff interviews corroborated that the medications were left unsupervised, leading to the deficiency in pharmaceutical services.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a newly admitted resident with dementia and anxiety disorder. The resident was admitted for a respite stay and, although initially assessed as not at risk for elopement, began to exhibit confusion, wandering, and exit-seeking behaviors shortly after admission. Staff observed the resident ambulating in hallways, attempting to exit through alarmed doors, and expressing a desire to leave, but the initial elopement risk assessment was not updated to reflect these behaviors. On the evening following admission, the resident eloped from the facility without staff knowledge. Door alarms sounded around the time of the elopement, but staff attributed the alarms to a visitor and to other residents being taken outside for a smoking break. Staff did not check the exterior of the building or conduct a head count when the alarms sounded, resulting in a delay in discovering the resident's absence. The facility was notified of the elopement by a community member who found the resident at a nearby apartment complex, appearing confused. Interviews and record reviews revealed that staff had observed the resident's wandering and exit-seeking behaviors but did not implement increased supervision or update the care plan in a timely manner. The lack of immediate response to door alarms and failure to account for all residents contributed to the resident's unsupervised exit from the facility. The deficiency was identified as having placed the resident at risk for harm, serious injury, or death.
Failure to Treat Residents with Respect and Dignity During Smoke Break Incident
Penalty
Summary
Certified Nursing Assistant (CNA) D failed to treat two residents with respect and dignity during an interaction related to scheduled smoke breaks. One resident, who had severe cognitive deficits due to conditions such as COPD and alcohol-induced dementia, and another resident with moderate cognitive deficits and a history of schizophrenia, HIV, insomnia, and alcoholic cirrhosis, were involved in the incident. CNA D told the residents that she did not have to take them out to smoke, which was perceived as disrespectful and argumentative by the residents. This exchange was recorded by one of the residents, who felt that their rights were being violated. The incident occurred when the facility was running behind on scheduled smoke breaks. CNA D, reportedly irritated by the delay, told the residents that she would not take them out to smoke and that they could not always expect to go at the same time. During the interaction, CNA D used a stern and argumentative tone, telling the residents that she could take away their smoking privileges and questioning one resident about recording the conversation. The video evidence and resident interviews confirmed that CNA D's manner was not consistent with treating residents with respect and dignity, as required by facility policy and resident rights regulations. Both residents expressed that they felt disrespected by the way CNA D spoke to them, with one resident specifically stating that he felt he was not treated with respect. The Director of Nursing (DON) acknowledged that CNA D did not have the authority to deny residents their smoke break and that her behavior violated the residents' right to be treated with respect. The facility's policies require all employees to treat residents with kindness, respect, and dignity, which was not upheld in this instance.
Resident's Right to Communication Denied
Penalty
Summary
The facility failed to uphold the resident's rights to dignity and self-determination by not allowing a resident to communicate with her family member when requested. The incident involved a resident with a history of anxiety, depression, and cognitive communication deficit, who was cognitively intact as per her MDS assessment. On the night of the incident, the resident requested to call her family member at approximately 2:30 AM, but the request was denied by CNA B, who believed the family member would be asleep. The resident's care plan emphasized the importance of family involvement in her care and highlighted her need for reassurance due to her anxiety and fear of separation from her family. Despite this, CNA B did not facilitate the call, which could have provided the resident with the needed reassurance and potentially reduced her anxiety. Interviews with the family member and other staff confirmed that the family member was willing to receive calls at any time and that the resident's anxiety could have been alleviated by allowing the call. The facility's policy on resident rights mandates that residents be treated with respect, dignity, and have access to communication with people outside the facility. The failure to allow the resident to call her family member was a violation of these rights, as confirmed by interviews with the facility's administration and nursing staff. The incident highlights a lapse in adhering to the facility's policy and the resident's care plan, which could have negatively impacted the resident's quality of life and emotional well-being.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary incontinence care for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact but required substantial assistance for personal hygiene and toileting, was left in a soiled brief for approximately two hours. This incident occurred despite multiple call light activations by the resident's family member, who reported the issue to the facility. The resident's family member initially activated the call light when the resident needed to use the restroom. A CNA responded but turned off the call light without providing assistance, stating they would return shortly. The family member activated the call light two more times, but the resident was not attended to until much later, after the CNA had taken other residents for a smoke break. During this time, the resident had a bowel movement and remained in a soiled brief until the CNA returned with assistance. Interviews with facility staff revealed that the CNAs were busy with other duties and did not prioritize the resident's immediate needs. The facility's policy on call light response was not followed, as the call light was turned off without the resident's needs being met. The delay in care placed the resident at risk for skin breakdown and infections, as noted by the facility's Family Nurse Practitioner.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, on ten specific days within a 91-day period. This deficiency was identified through interviews and record reviews, which revealed that the facility did not report RN hours for the specified dates. Although RN A was scheduled to work on these days, the hours were not recorded in the CMS PBJ Staffing Data Report. Interviews with the HR representative and the Director of Nursing (DON) indicated that the previous DON, who was salaried, did not clock in or out, leading to uncertainty about how her time was reported. The corporate resource nurse and the Administrator (ADM) were also unaware of the lack of RN coverage on these days. The facility's policy requires RN coverage for eight hours a day, seven days a week, to ensure resident safety and well-being. However, due to staff turnover and miscommunication at the corporate level, the facility failed to maintain this coverage. The ADM acknowledged the policy requirement and was working on a new system to track RN hours for salaried staff who do not clock in. The absence of RN coverage could potentially lead to missed assessments and a lack of leadership for the Licensed Vocational Nurse (LVN) staff, as noted by the DON.
Failure to Replace Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the failure to replace oxygen tubing weekly as per physician orders. Resident #40, a female with chronic obstructive pulmonary disease and severe cognitive impairment, was observed receiving oxygen therapy with undated tubing, and the last recorded change was over a week prior. Similarly, Resident #114, a female with congestive heart failure and no cognitive impairment, was also observed with undated oxygen tubing, contrary to the physician's directive for weekly changes. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's protocol required weekly changes of oxygen tubing, which was not adhered to. The DON acknowledged that agency nurses were responsible for the oversight on Sundays, the designated day for tubing changes, and admitted that the failure to comply with this protocol could lead to infection control issues. The facility's policy on infection prevention in respiratory therapy tasks also stipulated a seven-day change interval for oxygen cannulae and tubing, which was not followed in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate during a survey. This was based on 6 out of 30 medication administration opportunities involving two residents. The errors included a missed dose of Xifaxan for one resident due to unavailability, and incorrect dosages of Lactulose, Magnesium, and Thiamine for another resident. Additionally, an incorrect multivitamin was administered, and Ferrous Sulfate was given without a physician's order. Resident #55, a male with a history of toxic encephalopathy, hypertension, and alcoholic cirrhosis, did not receive his prescribed Xifaxan due to its unavailability. During a medication administration observation, Med Aide C administered only 15mL of Lactulose instead of the prescribed 30mL. Resident #58, with a history of disorders of phosphorus metabolism, schizophreniform disorder, and hypomagnesemia, received incorrect dosages of Magnesium and Thiamine, and was given a multivitamin and Ferrous Sulfate without proper orders. Interviews revealed that Med Aide C was aware of the errors but lacked understanding of the potential negative outcomes of administering medications without orders. The facility's administration acknowledged the responsibility of the DON and ADON for training staff on medication administration, but there was a lack of awareness regarding the unauthorized administration of Ferrous Sulfate. The facility's policy emphasized the importance of adhering to the five rights of medication administration and avoiding tablet splitting unless necessary.
Improper Food Storage and Handling in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed during a survey. Specifically, the facility did not properly store and date foods in the refrigerator, which included uncovered trays of desserts, a bowl of pureed food, and sandwiches, all without dates. Additionally, the facility did not store pans correctly, with some being placed right side up on shelves instead of upside down. These practices were identified during an initial observation of the kitchen. Interviews with the Administrator (ADM) and Dietary Manager (DM) revealed that both acknowledged the importance of storing food covered and dated, and storing pots and pans upside down to prevent contamination. The ADM and DM confirmed that all kitchen staff had been trained on these procedures, and the DM was responsible for monitoring compliance. The facility's policy on food storage, which aligns with state, federal, and US Food Codes and HACCP guidelines, was not followed, as evidenced by the lack of dating and improper storage of food and kitchenware.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of two licensed vocational nurses (LVNs) during wound care procedures for two residents. LVN A did not wash hands between glove changes while providing wound care to a resident with a right buttock wound. Despite being trained on infection control and handwashing, LVN A admitted to not using soap and water or alcohol-based hand rub (ABHR) between glove changes, which could potentially spread infection. LVN B also demonstrated a lapse in infection control practices while attending to a resident with a pressure ulcer on the right heel. During the wound care procedure, LVN B reached into his pocket with gloves on, removed alcohol packets, and placed them on a clean surface, potentially contaminating the wound dressing materials. LVN B acknowledged the mistake and noted that he had not received specific wound care training from the facility, as he was an agency nurse. The facility's interim Director of Nursing (DON) confirmed that hand hygiene should be performed between glove changes and that staff had been trained on infection control. However, the observed deficiencies in hand hygiene practices by LVN A and LVN B during wound care procedures indicate a failure in implementing the facility's infection control policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections.
Failure to Provide Grievance Information and Access
Penalty
Summary
The facility failed to provide residents and their representatives with information on their rights related to filing grievances or concerns. This deficiency was identified for 7 out of 15 confidential residents during a Resident Council meeting. These residents were unaware of the grievance process, did not know where to obtain or submit a grievance form, and were not informed that they could file grievances anonymously. Additionally, the grievance procedure had not been discussed in Resident Council meetings, and there were no postings of the grievance procedure in prominent locations within the facility. Upon review of the facility's grievance policy, it was noted that a copy of the grievance/complaint procedure should be prominently posted in the facility. However, observations revealed that the facility did not include instructions regarding the grievance procedure in any of the prominent postings. Grievance forms were not readily available to residents, and there was no means for residents to submit grievances anonymously. Interviews with the Administrator (ADM) and Social Worker (SW) confirmed these findings. The ADM, who had been employed for only six days, acknowledged that the grievance procedure was not posted and that residents could not file grievances anonymously. The Social Worker stated that grievance forms were available at the nurses' station, the SW's office, and the ADM's office, but residents had to ask for them. The SW also confirmed that there was no confidential manner for submitting grievances anonymously. The facility's grievance policy indicated that all grievances should be investigated and resolved within three working days, with residents or their representatives informed of the findings and any corrective actions taken. However, the lack of accessible grievance procedures and forms, as well as the absence of anonymous submission options, contributed to the deficiency in addressing residents' grievances effectively.
Improper Storage of Wound Cleaners on Treatment Cart
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as observed during a survey. Specifically, two bottles of wound cleaners were left unattended on top of a treatment cart by an LVN. This occurred while the LVN was preparing wound care supplies outside a resident's room and subsequently entered the room, leaving the bottles exposed. The wound cleaner bottles had warnings indicating they should be kept out of reach of children and that ingestion could require medical attention. Interviews with the LVN, DON, and ADM confirmed that the wound cleaner is considered a medication and should be stored securely in a locked cart. The LVN admitted to forgetting to store the bottles properly, despite being trained on medication and supply storage. The DON and ADM reiterated the importance of secure storage to prevent potential negative outcomes, such as ingestion or tampering with the solution. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, which included measurable objectives and timeframes to meet their needs. For the first resident, who was cognitively intact and had multiple diagnoses including stroke, traumatic brain dysfunction, and non-Alzheimer's dementia, the care plan did not address her wound care needs. Despite having physician's orders for wound care, the care plan lacked any mention of this critical aspect of her treatment. Interviews with staff revealed that the resident's wounds were being managed through a wound care clinic and facility care, but the care plan was not updated to reflect these interventions. The second resident, who had dementia, chronic obstructive pulmonary disease, and other health issues, also lacked a comprehensive care plan addressing her oxygen use. Although there was a physician's order for continuous oxygen therapy via nasal cannula, this was not included in her care plan. Observations showed that the resident often removed her nasal cannula, and staff interviews confirmed this behavior. However, the care plan did not incorporate strategies to manage or address this issue, leaving a gap in her care management. The facility's policy required that care plans be updated to reflect any changes in a resident's condition, but this was not adhered to in these cases. The Director of Nursing and the Clinical Resource RN acknowledged the oversight, indicating that the care plans should have been updated to include the necessary interventions for both residents. This failure to update care plans could potentially impact the residents' ability to receive individualized care tailored to their specific needs.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Levelland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Levelland Nursing & Rehabilitation Center | 13 mi | ★★★★★ | 10 | 1 |
| Apex Secure Care Brownfield | 16.3 mi | ★★★★★ | 18 | 1 |
| Brownfield Rehabilitation And Care Center | 16.6 mi | ★★★★★ | 10 | 0 |
| Crown Point Health Suites | 24.7 mi | ★★★★★ | 7 | 0 |
| Hansford County Hospital District Dba Lakeridge Nu | 26.7 mi | ★★★★★ | 12 | 0 |
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