A list of the most recent deficiencies for Lynwood Manor Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-14 | 2023-10-27 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-14 | 2023-10-27 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-14 | 2023-10-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-31 | 2023-06-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-05-31 | 2023-06-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-17 | 2023-05-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-17 | 2023-05-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-17 | 2023-05-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-17 | 2023-05-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-17 | 2023-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-17 | 2023-05-26 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-04-17 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-17 | 2023-05-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-17 | 2023-05-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-08 | 2023-04-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-08 | 2023-04-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-04-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-08 | 2023-04-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-08 | 2023-04-10 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-24 | 2022-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-24 | 2022-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-24 | 2022-08-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-24 | 2022-07-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-25 | 2022-07-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-25 | 2022-07-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-25 | 2022-07-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-05-25 | 2022-07-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-25 | 2022-07-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-25 | 2022-07-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-25 | 2022-07-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-25 | 2022-07-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-25 | 2022-07-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-07-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-07-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-25 | 2022-07-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-25 | 2022-07-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-25 | 2022-07-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-25 | 2022-07-04 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-05-25 | 2022-07-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-25 | 2022-07-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-09 | 2021-11-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-18 | 2021-04-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-18 | 2021-04-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-18 | 2021-04-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-08-28 | 2020-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-28 | 2020-10-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-08-28 | 2020-10-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-08-28 | 2020-09-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-08-28 | 2020-09-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-08-28 | 2020-09-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-08-28 | 2020-09-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-08-28 | 2020-09-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-27 | 2020-09-11 | N |
