Lynwood Manor Healthcare Center
Lynwood Manor Healthcare Center in Adrian, MI — inspection on February 20, 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 an interview on 02/20/2026 at 11:10 a.m. R1 was observed lying down in bed and it was observed that her left leg was elevated and covered by bedding. R1 explained that on 01/20/2026 that she had gone to an appointment outside of the building. R1 explained that once the appointment was completed her sister had called the facility requesting transportation to return. R1 explained that when the facility van arrived, she was assisted into the van by the driver. R1 explained that the van driver secured the wheelchair to the floor of the van but did not place a seat belt around her. R1 explained as the van was returning to the facility the van driver stopped suddenly at which time she was thrown out of her wheelchair and landed onto the floor. R1 explained that she was then transported to the hospital by an ambulance. R1 explained that she had broken her left leg and broken her left ankle. R1 explained that both fractures required surgery. R1 explained that her pain had not increased due to the fractures and her level of function for activities of daily living had not changed due to the new fractures. R1 explained that she was originally admitted after a fractured pelvis so the pain was no different and that her level of function for activities of daily living had not changed because of the new fractures to her left leg and ankle.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:A new form entitled Transport Driver Checklist for Wheelchair transport was developed and initiated.
The new checklist included- wheelchair properly placed, wheelchair secured/brakes locked, 4-point anchors, seatbelt secured properly.
Check list was to be completed on each transport.All Van Drivers were re-educated by 02/03/2026 for safety training and use of the new Transportation Driver Checklist for Wheelchair transport.An Ad Hoc Quality Improvement Council Meeting was conducted on 02/02/2026.Visual Audits will be completed no less than 2x per week for 4 weeks of driver securing passenger in van, and then weekly x 4 weeks.
Audits will be done by NHA or designee.
Audit reviews of the document Transport Driver Checklist for Wheelchair transport will be completed weekly for 4 weeks.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.