Lynwood Post Acute Care Center
LYNWOOD POST ACUTE CARE CENTER in LYNWOOD, CA — inspection on March 31, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 1 had severely impaired cognition (a significant decline in memory, thinking, and reasoning that renders individuals unable to live independently).
The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed.
During a review of Resident 1's physician order, dated 3/27/2026, the order indicated Resident 1 was to receive supplemental oxygen at two (2) liters per minute (L/min, a unit of measuring oxygen flow rate), continuously.
The order did not indicate staff were able to adjust the rate as needed.
During a review of Resident 1's care plan titled The resident has altered respiratory status/difficulty breathing [related to] COPD., dated 11/10/2025, the care plan indicated staff were to administer oxygen as ordered.
During an observation on 3/31/2026 at 8:45 a.m., and 3/31/2026 at 9:40 a.m., at Resident 1's bedside, Resident 1 was observed receiving supplemental oxygen at a flow rate of 3 L/min.
During an interview on 3/31/2026 at 9:47 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was receiving 3 L/min of supplemental oxygen when he checked her vitals that morning (3/31/2026). LVN 1 stated 3 L/min was not the ordered flow rate and stated he reported it to the previous shift's Registered Nurse Supervisor (RNS) 1. LVN 1 stated he was unsure what RNS 1 did after he reported the flow rate.
During an interview on 3/31/2026 at 9:49 a.m., with RNS 2, RNS 2 stated there was no documentation in Resident 1's record to indicate a need to increase Resident 1's oxygen flow rate, or to indicate RNS 1 informed the physician of the increase from 2 L/min to 3 L/min. RNS 2 stated Resident 1's physician order was to administer supplemental oxygen at a fixed rate of 2 L/min. RNS 1 stated the expectation is that the RNS was to follow the order as written.
During a concurrent observation and interview, on 3/31/2026 at 9:56 a.m., at Resident 1's bedside, with RNS 1, RNS stated Resident 1 was on 3 L/min of supplemental oxygen and stated the flow rate needed to be corrected to match the physician order.
During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, revised 10/2010, the P&P indicated staff were to verify there was a physician order for oxygen administration.
The P&P indicated that staff were to document the flow rate and rationale for the flow rate.
The P&P indicated staff were to report any information in accordance with professional standards of practice.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE