Complete Care at Linwood, LLC

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 02/12/2025 from 09:12 AM until 10:20 AM, the surveyor observed the following in the kitchen in the presence of the Regional Food Service Director (RFSD):1. In the dry storage closet an open bag of gelatin mix wrapped in plastic wrap and an opened bag of potato chips had no labeled open or used by date. The RFSD acknowledged it should be dated, and the items were removed. 2. The high-temperature dishwasher is set to operate between 150 F and 180 F, the final rinse temperature should be 180 F. The surveyor observed the wash temperature at 134 F, the RFSD confirmed the temperature and indicated it should be 150 F. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a closed cover over the opening of 1 of 3 garbage containers. This deficient practice was evidenced by:On 02/12/2026 at 10:11 AM, the surveyor, accompanied by the Regional Food Service director (RFSD), observed the facility's outdoor trash disposal area. The surveyor observed three garbage containers (GC) situated at the rear of the property. One of the GCs had an open lid and contained trash which was exposed to the elements, and another GC observed overflowing with refuse. The area surrounding the three GCs was littered with debris, including but not limited to cardboard boxes and milk crates. [...]

Inspectors wroteBased on observation, interview, record review and facility provided documentation, the facility failed to ensure residents were treated with dignity and respect during A.) incontinence care for 1 of 2 (Resident # 10) and B.) 3 of 3 dining rooms observed during the Dining Task. This deficient practice was evidenced by the following:A) During initial tour on 02/12/2026 at 9:23 AM, the surveyor observed Resident #10 in bed wearing two incontinence briefs. During an interview at the same time with the surveyor, the certified nurse's assistant (CNA) #1 said that they are not supposed to be wearing two incontinence brief. CNA # 1 said that the overnight staff are responsible. She concluded saying when we come and find it, we report it to the nurses. [...]

Inspectors wroteBased on observation, interview, record review and facility provide documentation, the facility failed to ensure staff and vendors utilized appropriate personal protective equipment (PPE) during resident care in accordance with facility policy and accepted standards of infection control practice. This deficient practice was evidenced by the following:During initial tour on 02/12/2026 at 10:12 AM surveyor #1 observed an ultrasound technician (UT) performing an ultrasound on Resident # 152 while in their room. The door to room indicated that the resident was on enhanced barrier precautions (a set of rules where nursing home staff wear gowns and gloves during high-contact care for certain residents to stop the spread of dangerous germs). The ultrasound technician was observed not wearing a protective gown while performing an ultrasound. [...]

Inspectors wroteBased on observation, interview, and review of other facility-provided documentation, it was determined that the facility failed to maintain a clean and sanitary environment for 1 of 4 units (South). This deficient practice was evidenced by the following: On 02/12/2026 during the initial tour, Surveyor # 2 observed the following: At 10:56 AM, Surveyor # 2 observed the Sub-Acute soiled utility room. There was a filled garbage bag on the floor garbage overflowing from the receptacle bin. At 11:02 AM, Surveyor # 2 observed the soiled biohazard room across from room [ROOM NUMBER]. There were filled garbage bags left on floor. A 11:08 AM, Surveyor # 2 observed the biohazard room located in the secured unit. There were filled garbage bags on floor. Also at that time, the surveyor observed a broken hand sanitizer dispenser next to room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary facial care to maintain proper grooming and personal hygiene. The deficient practice was observed for 1 out of 3 residents reviewed for Activities of Daily Living, (Resident #153). The deficient practice was evidenced by the following:On 2/12/2026 at 10:37 AM, during the initial tour of the facility, the surveyor observed Resident #153 resting in bed wearing a hospital gown. The resident's face had thick and untrimmed beard and moustache about 2 inches long. Their hair appeared oily and unkempt. There was a malodorous smell in the room. On 2/13/2026 at 11:38 AM, the surveyor observed the resident in bed wearing a hospital gown. The resident's face was shaven. [...]

Inspectors wroteBased on observation, interview, review of medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 2 residents reviewed for position and mobility, (Resident #12) and was evidenced by the following: On 2/12/2026 at 9:43 AM, during the initial tour of the facility, the surveyor observed Resident #12 alert but non-verbal and resting in bed. The resident was mechanically ventilated via tracheostomy (a surgical opening in the neck created with a tube to keep the airway open for breathing). [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to accurately implement a physician prescribed fluid restriction order for 1 of 1 resident's (Resident #11) reviewed for dialysis. This deficient practice was evidenced by the following:On 02/13/2026 at 08:59 AM the surveyor observed and interviewed Resident #11 in his/her room. Resident #11 stated that he/she has been receiving dialysis for about 2 months. The surveyor observed a bottle of diet soda, a bottle of water, a carton of milk, a small juice cup, and two clear glasses of a pink colored beverage on the resident's bedside table tray. The surveyor questioned Resident #11 whether he/she was on a fluid restriction. Resident #11 replied that they were unsure if they were. [...]

Inspectors wroteBased on observation, interview, and review of medical record and pertinent facility documents, it was determined that the facility failed to a.) label and store treatment medications securely inside the treatment cart for 1 unsampled resident (Resident #25), b.) monitor the temperature of refrigerated drugs and biologicals in 1 out of 5 medication rooms (north wing) inspected , and c.) store medications securely in their packaging inside the medication carts for 2 out of 5 medications carts (north wing front cart and east wing even cart) inspected during the medication storage and labeling task. The deficient practice was evidenced by the following: 1.) On 2/12/2026 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #25 in bed connected to a mechanical ventilator (a life-support machine that assists a person to breathe). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that infection control education was provided and documented for 1 of 1 agency staff members (CNA; Certified Nurse Aide) # 1 providing care to a resident in a room requiring Enhance Barrier Precautions (EBP). The deficient practice was evidenced by the following: On 02/13/2026 at 11:34 AM during a tour of the [NAME] Unit, Surveyor # 2 observed Certified Nurses Aide (CNA) # 1 inside Resident # 102's room. Outside of the doorway of the room was a sign indicating the room required Enhanced Barrier Precautions (EBP; a set of rules where nursing home staff wear gowns and gloves during high-contact care for certain residents to stop the spread of dangerous germs). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date food products stored in a refrigerator, spice rack, and meat freezer; b) properly discard food products on or before the expiration date; and c) properly store food products in a manner without covers. The deficient practice was evidenced by the following: On 10/02/2024 from 9:47 AM to 10:48 AM, the surveyor, accompanied by the Dietary Director (DD) and later at 10:47 AM joined by the Regional Dietary Director (RDD), observed the following: 1.) Next to the preparation table near the sink, the surveyor observed breadcrumbs inside a clear container labeled flour and not labeled with an open and use by date. The surveyor then observed a refrigerator referred to as the everything refrigerator. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 3 of 5 residents reviewed for medication management (Resident #70, Resident #92, and Resident #50). The deficient practice was evidenced by the following: On 10/03/2024 at 08:48 AM the surveyor requested from the Director of Nursing (DON) the CP's recommendations for Resident #70, Resident#92, and Resident # 50, from the last 6 months. 1. A review of the admission Record for Resident#70 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Heart Failure, and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). [...]

Inspectors wroteComplaint #NJ167309 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed fall. This deficient practice was identified for 1 of 4 residents (Resident #278) reviewed for accidents and was evidenced by the following: The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). [...]

Inspectors wroteComplaint: NJ00167309 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to revise a comprehensive care plan to identify the nursing intervention required to care of a surgical wound infection. This deficient practice was identified for 1 of 26 residents (Resident #278) reviewed for care planning. The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). [...]

Inspectors wrote3.) A review of Resident # 70's admission Record indicated Resident #70 was admitted to the facility with diagnoses which include but were not limited to Heart Failure, Type 2 Diabetes Mellitus (a condition that occurs when the body doesn't respond properly to insulin, causing high blood sugar levels), and Morbid Obesity Due to Excess Calories ( a complex disease that occurs when the body stores to much fat due to an imbalance between calories consumed and calories used). A review of Resident #70's Treatment Administration Record (TAR) for March 2024 revealed a physician's order (PO) with an order date of 03/14/2024, for negative pressure therapy wound vac with Y connect to B/L [bilateral] hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed a blank on the TAR, there were no nurse's initials indicating the treatment was administered on 03/15/2024. [...]

Inspectors wroteComplaint # NJ00177156, 00176805 Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received showers as scheduled for 1 of 2 sampled residents (Resident #21), reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: On 10/03/2024 at 10:39 AM, the surveyor observed Resident #21 in the room. He/She stated they would rather be home, but had no issues with this facility. According to the admission Record Resident #21 was admitted to the facility with diagnosis that included but were not limited to intellectual disabilities and depression. The Minimum Data Set (MDS), an assessment tool, dated 08/28/2024 reflected that Resident # 21 was moderately cognitively impaired and that resident required substantial assistance with showering. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store, label, and remove expired drugs from the facility inventory. The deficient practice was observed in 1 of 3 medication rooms and 1 of 9 medication carts reviewed under the Medication Storage Task. On 10/04/2024 at 9:26 AM, the surveyor observed the [NAME] Wing Medication Storage room in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) #1. At that time, the surveyor observed the following concerns: Three cultures that expired on 09/23/2024. Three cultures that expired on 08/08/2024. Two urine vacutainers that expired on 06/30/2024. One 1000 milliliter (mL) bag of Dextrose solution that expired in July of 2024. Two bottles of Pantoprazole 2 milligram(mg)/mL with a use-by date of 08/30/2024. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to A.) perform hand hygiene before applying gloves and between changing gloves and B.) failed to follow transmission-based precautions, specifically by not using a gown within a resident's room who was on transmission-based precautions. The deficient practice was observed for 1 of 2 nurses observed for Medication Administration task and 1 of 1 Resident (Resident # 425) reviewed for Transmission Based Precautions. This deficient practice was evidenced by the following: A.) On 10/03/2024 at 08:18 AM during the Medication Administration task, surveyor #1 observed Licensed Practical Nurse (LPN) # 1 putting on personal protective equipment (PPE) prior to administering medications to Resident #100. [...]

Inspectors wroteComplaint #: NJ00160150, NJ00169450, NJ00159215 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to, a.) provide sufficient staffing numbers to meet minimum staffing requirements and b.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: Refer F677(D) a.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. [...]

Inspectors wroteComplaint #: NJ00160150 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to dependent residents. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2, and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. At that time, the resident granted permission for the surveyors to observe his/her incontinence brief. [...]

Inspectors wroteCompliant Number: NJ00159616 Based on observation, interview, and record review, it was determined that the facility failed to provide indwelling urinary catheter (a tube that is placed inside the bladder to facilitate the flow of urine) care in a manner to prevent urinary tract infections (UTI). This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for catheter care and urinary tract infection and was evidenced by the following: According to the admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to: neuromuscular dysfunction of bladder (person who lacks bladder control due to brain, spinal cord, or nerve problems), chronic kidney disease (gradual loss of kidney function over time), and Type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose). [...]

Inspectors wroteComplaint # NJ00160024, NJ00160394, NJ00160202 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident nurse call system to operate as designed for 3 of 5 call bells observed. This deficient practice was evidenced by the following: On 12/29/23 at 8:00 AM, the surveyor observed North Wing Unit, no resident rooms had a call bell light illuminated above room doors. On 12/29/23 at 8:12 AM, the surveyor entered the Star Spa Bathroom (shower room) on North Wing and observed three call systems. The call bell located next to the toilet was activated by the surveyor at 8:12 am. The surveyor waited three minutes and exited the Star Spa Bathroom and notice no light was illuminated above the door. On 12/29/23 at 8:15 AM, the surveyor interviewed the Unit Clerk (UC). [...]

Inspectors wroteBased on interview and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service since March 2023. This failure had the potential to affect 115 residents who received food from the kitchen.

Inspectors wroteBased on observation, resident, staff, and Ombudsman interviews, the facility failed to provide access to the resident identified telephone, for three of four units (West, East, and North), where calls can be made without being overheard. This failure created the potential for residents to be without private telephone communication.

Inspectors wroteBased on observation, resident, staff, and Ombudsman interviews, the facility failed to provide a functioning ice/water machine on one (West) of four wings. This deficient practice had the potential to affect the proper hydration status of 38 residents who resided on the [NAME] unit.

Inspectors wroteBased on observation, interview, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to have sufficient dietary staff to assure resident meals were served as scheduled. The failure had the potential to affect 115 residents who consumed meals prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, tasting of foods on a requested test tray, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to serve food that was palatable and hot to eleven of eleven residents (Resident (R) 33, R34, R67, R111, R31, R36, R39, R72, R84, R89, and R91) reviewed for food palatability. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's meal schedule, the facility failed to have no more than 14 hours between the resident evening meal and breakfast meal the following day. This failure had the potential to affect 115 residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's milk refrigerator, electric slicer, three kitchen drawers, and canned food storage racks clean and sanitized and failed to date opened bread products and discard creamed soup and hot dog buns with expired use by dates. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy to one of 43 residents (Resident (R)101) on the South unit during care. The failure created the potential for R101 to be exposed to other residents, staff, and visitors.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 43 facility residents on one of four wings (South). For seven of 43 residents (Resident (R) 76, R17, R60, R122, R35, R30, R82) the environment was not maintained. Throughout the South unit the temperature was not controlled in a comfortable range creating a warm environment for residents, staff, and visitors.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure one of two medication carts on the secured unit was locked while unattended. This had the potential to affect 10 (Resident (R) 80, R93, R30, R57, R240, R115, R13, R95, R17 and R10) of 43 residents who were at risk for wandering on the secured unit. Findings Include: Review of R80's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 03/10/23, revealed R80 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R80 was severely cognitively impaired. The MDS recorded R80 had diagnoses which included dementia, anxiety, and major depressive disorder, and self-propelled per wheelchair. [...]