Linda Manor Extended Care Facility

Inspectors wroteBased on observation and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in three out of three applicable facility unit kitchenettes. Specifically, the facility failed to implement safe food practices in three out of three facility unit kitchenettes relative to labeling, dating and guidelines for food storage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided care and services according to Physician orders for an indwelling urinary catheter (a thin, soft flexible tube that drains urine from the bladder) for one Resident (#88) out of four applicable residents, in a total sample size of 24 residents. Specifically, the facility staff failed to insert the correct indwelling urinary catheter size in accordance with Resident #88's Physician order, placing the Resident at risk for obstruction and pain.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), whose care plan interventions included the need for two staff members to provide assistance during care, which included incontinence care, bed mobility and repositioning, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions. On 05/04/25, Certified Nurse Aide (CNA #1) provided incontinence care to Resident #3 without another staff member present for assistance, CNA #1 positioned Resident #3 on his/her side, then turned away from the resident, he/she rolled off the bed and fell onto the floor. Resident #3 was transferred to the Hospital Emergency Department (ED) and diagnosed with a closed displaced fracture (broken pieces of bone that moved away from each other) of the right femoral neck (part of the thigh bone just below the hip joint).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), who required the assistance of two staff members for dressing, toileting care needs, bed mobility, and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident resulting in a serious injury. On 05/04/25, Certified Nurse Aide (CNA) #1 provided care to Resident #3 without having another staff member present for assistance, CNA #1 repositioned Resident #3 onto his/her side in bed, then turned away from Resident #3 to grab something, leaving him/her unattended and he/she rolled off the bed onto the floor. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had multiple wounds and required an appointment with an outside wound specialist, the Facility failed to ensure nursing staff clarified and/or followed up on his/her wound consult recommendations related to the need for an X-ray, in a timely manner, which resulted in a delay in treatment.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who sustained two unwitnessed falls and whose Comprehensive Care Plan indicated he/she was at risk for dehydration with the potential for slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease) the Facility failed to ensure they maintained a complete and accurate medical record when 1) nursing did not complete the 72 hour neurological checks following each of his/her unwitnessed falls, and 2) Certified Nurse Aides (CNAs) daily documentation related to Resident #1's fluid and food intake were not consistently recorded on his/her flow sheets.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed by nursing to be at risk for skin breakdown with actual pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful) the Facility failed to ensure nursing adequately assessed, measured and obtained Physician's orders related to wound care to his/her bilateral heels that included specifics related to treatments for offloading, in accordance with professional standards of practice in an effort to promote wound healing.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at risk for nutritional decline, dehydration, and with the potential slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease), the Facility failed to ensure Resident #1's nutritional status including body weight, meal percentage and fluid intakes, were accurately assessed and monitored appropriately by nursing and per facility policy.

Inspectors wroteBased on record review, and interview, the facility failed to notify the Physician of the unavailability of an ordered medication for one Resident (#1) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician when Resident #1's Fluoxetine (a psychotropic medication used to treat Depression) medication was unavailable to be administered in accordance with his/her Physician orders, resulting in the Resident not receiving five scheduled doses of Fluoxetine medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded for four Residents (#88, #12, #89, and #110) out of a total sample of 24 residents. Specifically, the facility failed to: 1. Accurately code that Resident #88 was receiving Hemodialysis (also known as dialysis: a procedure where a machine with a special filter called a dialyzer is used to remove waste products and fluids from the blood). 2. Accurately code an indwelling urinary catheter (a tube inserted into the bladder used to drain urine outside the body) usage for Resident #12 and Resident #89. 3. Accurately code the discharge disposition for Resident #110.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide nutrition care and services for one Resident (#264) out of a total sample of 24 residents, when the Resident was determined to be at risk for malnutrition. Specifically, the facility staff failed to perform monthly weight measurements for Resident #264 as ordered for June 2024, resulting in a significant weight loss being missed and a delay of nutritional interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental care and services as required for one Resident (#16) out of a total sample of 24 residents. Specifically, the facility staff failed to provide assistance with scheduling and maintaining dental services for Resident #16, when the Resident had consents for dental care and services.

Inspectors wroteBased on policy review, observation and interview, the facility failed to maintain sanitary conditions for two (Meadowview and Forestview) applicable unit kitchenettes out of a total of three unit kitchenettes. Specifically, the facility failed to maintain sanitary conditions for two of the two applicable unit kitchenette microwaves located on Meadowview and Forestview to prevent contamination and the spread of food-borne infections.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, was transferred to the Hospital Emergency Department (ED) for an evaluation when he/she became unresponsive, the Facility failed to ensure that nursing notified his/her Health Care Agent (HCA) of the transfer.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of Xarelto (anticoagulant medication) for treatment of atrial fibrillation (irregular heart rate) and history of bilateral pulmonary embolisms (blood clots in both lungs), the Facility failed to ensure they maintained a complete and accurate medical record when the Physician and Nurse Practitioner progress notes reference to Resident #1's anticoagulant dosage conflicted with the daily dosage being administered by nursing.

Inspectors wroteBased on interview and record review the facility failed to implement a COVID-19 monitoring plan to prevent the spread of infection for two Residents (#1 and #2) out of a total sample of three residents. Specifically, the facility's staff failed to screen for signs and symptoms of COVID-19 every shift (Q-shift) while outbreak testing was being conducted within the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Immunizations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#4) out of a total sample of five residents.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure its staff provided a copy of the transfer and/or discharge notices to a Representative of the Office of the State Long-Term Care Ombudsman for four Residents (#113, #35, #55 and #61), out of a sample of 22 residents.

Inspectors wroteBased on observations, interview, record and policy reviews, the facility failed to ensure its staff developed and implemented the plan of care for seven Residents (#40, #55, #61, #22, #16, #35 and #104), out of total sample of 22 residents. Specifically, the facility staff failed to: 1. ensure the plan of care relative to falls/activities of daily living (ADLs) was implemented for two Residents (#40 and #55), 2. implement the Physician's Orders for three Residents (#61, #22 and #16) relative to utilization of bed rails, and 3. obtain weights as ordered by the Physician for two Residents (#35 and #104).

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff treated each resident with respect and dignity, impacting one Resident (#35), out of a sample of 22 residents. Specifically, staff repeatedly did not address Resident #35 by his/her preferred name.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff consulted the attending provider relative to an alteration in treatment for one Resident (#76), out of a sample of 22 residents. Specifically, facility staff failed to inform the Resident's attending Physician and/or the Physician designee that the Resident did not wear his/her right hand splint, as ordered.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean environment was maintained on one Unit (Sunrise), out of three units observed. Specifically, the facility's staff failed to ensure the privacy curtains for Resident #41's room were clean. Findings Include: Review of the facility policy titled Environmental Services Guidelines, dated September 2011, indicated the following: -Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. Resident #41 was admitted to the facility in November 2021 and resided on the Sunrise Unit. On 3/21/23 at 10:15 A.M., the surveyor observed in Resident #41's room a large brown stain and multiple small brown stains on the privacy curtain. During a subsequent interview following the observation Resident #41 said he/she would like a clean curtain in his/her room. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff provided assistance for one Resident (#89), out of a total sample of 22 residents. Specifically, facility staff failed to provide grooming/ maintaining facial hair for the resident who was unable to carry out activities of daily living (ADLs).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that its staff provided care and services consistent with professional standards relative to the identification, monitoring, and documentation of a facility acquired pressure injury (also called pressure ulcer or bed sore: are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for one sampled Resident (#105), out of five applicable residents with facility acquired pressure injuries, out of a total sample of 22 residents. Specifically, the facility failed to: 1) implement their policy relative to performing an initial and weekly assessment of a newly identified wound, 2) accurately document the location of the wound(s) throughout the clinical record, and 3)document whether turning and repositioning of the Resident occurred per the care plan.

Inspectors wroteBased on observations, interviews, record and policy reviews, the facility failed to ensure its staff reduced the risk of falls for two Residents (#40 and #55), out of a total sample of 22 residents. Specifically, facility staff failed to implement the plan of care and provide effective interventions for Residents #40 and #55 who had numerous falls while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed a Trauma-Informed Care Assessment at the time of admission or after it was identified for one Resident (#102), out of a sample of 22 residents. Specifically, the facility failed to complete a Trauma-Informed Care Assessment for a diagnosis of Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) per facility policy. Findings Include: Review of the facility policy titled Trauma-Informed Care, revised 11/18/22 indicated the following: -A Trauma-Informed Care Assessment will be completed by Social Services upon admission, as well as for all resident's residing in the facility with a diagnosis of PTSD. Resident #102 was admitted to the facility in November 2022 with a diagnosis of PTSD. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff maintained accurate medical records for two Residents (#105 and #102), out of a sample of 22 residents. Specifically, 1. for Resident #105, failure to accurately document: a) the location of a pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure), and b) turning and positioning information on a Certified Nursing Assistant (CNA) flowsheet. 2. for Resident #102, failure to accurately complete the Preadmission Screening and Resident Review (PASRR- a federal and state required process that is designed to identify evidence of severe mental illness and/or intellectual or developmental disabilities for those seeking admission to a Medicaid and/or Medicare certified nursing facility).

Inspectors wroteBased on observation and interviews, the facility failed to ensure its staff maintained electrical equipment in safe operating condition for one Resident (#76), out of a sample of 22 residents. Specifically, the resident's electronic bed control contained exposed wires creating potential for electrocution and/or burns.