LYNWOOD MANOR HEALTHCARE CENTER

Nursing Home Inspector

730 KIMOLE LN
ADRIAN, MI 49221
Lenawee County
Phone: 517-263-6771
Provider Number: 235182
Last Inspection: 03/02/2017

About the Nursing Home

Number of Beds: 84
Number of Residents: 75
Beds Available: 9
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

85

Facility
58

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

85

2017
14

2016
19

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/2/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Pattern : Minimal 4 4/11/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 5/24/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/11/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/24/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/24/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/24/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 5/24/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 5/24/2017
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 4/11/2017
 
Failed To: Offer other nutritional food to each resident who will not eat the food served. Pattern : Minimal 4 4/11/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/11/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Potential 3 5/24/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 4/11/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/24/2017
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Widespread : Minimal 5 4/11/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 4/11/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 4/11/2017
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 4/11/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 4/11/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 4/11/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 4/11/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 5/24/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/11/2017
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Potential 3 4/11/2017
 

1/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 2/12/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 2/12/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 2/12/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 2/12/2016
 

3/27/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Isolated : Minimal 3 5/4/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/4/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/4/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 5/4/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/4/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/4/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/30/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/6/2017
 

6/8/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Potential 3 6/27/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Potential 3 6/27/2017
 

3/2/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Minimal 4 4/11/2017
 

11/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 1/6/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 1/6/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 1/6/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 1/6/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 1/6/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 1/6/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 1/6/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 75 91.75 85.64
Registered Nurses 0.69 0.67 0.89
Licensed Practical / Vocational Nurses 0.59 0.69 0.84
Certified Nursing Assistants 2.01 2.49 2.54
Total Staff Hours 3.30 3.86 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 6 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 97 98 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 99 92
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 0 2 2
of long-stay residents who lose too much weight 12 12 7
of long-stay residents who received an antianxiety or hypnotic medication 19 23 22
of long-stay residents who received an antipsychotic medication 9 6 12
of long-stay residents who self-report moderate to severe pain 3 3 6
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 27 21 17
of long-stay residents whose need for help with daily activities has increased 21 15 14
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 2 3 3
of low risk long-stay residents who lose control of their bowels or bladder 48 50 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 96 91 80
of short-stay residents who had an outpatient emergency department visit 15 9 11
of short-stay residents who made improvements in function 72 75 71
of short-stay residents who newly received an antipsychotic medication 3 1 1
of short-stay residents who self-report moderate to severe pain 14 9 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 60 81 79
of short-stay residents who were rehospitalized after a nursing home admission 18 17 21
of short-stay residents who were successfully discharged to the community 51 54 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0