Lynwood Nursing And Rehabilitation

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not have the authority to refuse to take any resident out to smoke. She stated CNA D did take the residents out to smoke. She stated CNA D was in-serviced on customer service training and educated on not speaking to residents rudely. She stated CNA D was educated that she can not deny or revoke residents right to smoke and that if smoke break is going to run late, to let the ADON, or DON know, and they can notify the residents in a timely manner. She stated the potential negative outcome of residents not being treated with respect could be the residents having emotional distress and fearful of not being able to do things freely in the facility. Record review of facility document titled Employee Corrective Action form dated 8/7/2025 revealed; Type of action taken: Final WarningState subject of code of conduct rule violated: Conduct, attitude and behavior.Incident: A resident presented to both the DON and ADM that [CNA D] engaged in an unprofessional verbal exchange with a resident. In the exchange [CNA D] is speaking inappropriately to the resident and implying that smoking privileges could be taken away.Follow up review date: 9/7/2025.Consequences: Could lead to further disciplinary action up to or include termination. Signed by CNA D, DON and ADM on 8/7/2025.Record review of facility policy titled Conduct, attitude and behavior last revised December 2019, revealed; .Employees must maintain good attitude toward his/her job positions, co-workers, residents and visitors. All employees will treat residents, visitors and co-workers with respect kindness and dignity.6. Examples of conduct and behavior that are considered inappropriate and are therefore prohibited by this policy include, but are not limited to the following: a. Failure to treat all residents, visitors and fellow employees with kindness respect and dignity.Record review of facility policy titled Resident Rights implemented 7/2025 revealed; .Respect and Dignity: The resident has the right to be treated with respect and dignity.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lynwood Nursing and Rehabilitation

803 S Alamo Levelland, TX 79336

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an

interview on 09/02/25 at 2:22 PM, LVN B - night shift, stated he had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During an interview on 09/02/25 at 3:13 PM, RN A - day shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During an interview on 09/02/25 at 3:35 PM, CNA Fnight shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/02/25 at 4:25 PM, CNA E- night shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/03/25 at 9:42 AM, LVN C - day shift, stated she had been in-serviced on 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During interviews conducted on 09/03/25 between 11:45 AM - 3:00 PM, the following staff members - (PTA I, PTA J, PT, MA H, ADON, and CNA G) reported they had been in-serviced on 07/20/25 and 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. Record review of the facility's policy titled Wandering and Elopements, Revised April 2025 revealed: Policy StatementThe facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.Policy Interpretation and Implementation1. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wanderinga.

Residents will be assessed by the IDT for risk of elopement and unsafe wandering on admission, readmission, quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering).c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, and minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements- . The noncompliance was identified as PNC. The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the noncompliance before the survey began.

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