Linda Mar Care Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Certified Dietary Manager (CDM), the position responsible for supervision of daily food service operations, was fully qualified when he did not have a dietetics manager's certification prior to assuming his full-time duty at the facility. This failure was likely to result in inadequate supervision of the dietary department for 42 residents who ate food from the kitchen out of a census of 42.

Inspectors wroteBased on interview and record review, facility failed to ensure that the resident or the resident representative was provided education about the benefits, risks, and potential side effects associated with the COVID-19 (an infectious virus) vaccine in 4 out of 5 sampled residents (Resident 16, 12, 142 and 92) This failure has the potential for residents to accept vaccination without fully informed consent or decline vaccination due to a lack of knowledge about the COVID-19 vaccine.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for one of 12 sampled residents (Resident 143) when a care plan was not developed to address Resident 143's right-sided hearing loss. This failure was likely to fail to meet Resident 143's nursing needs and goals to attain the resident's highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there was one pack of expired frankfurters (a seasoned smoked sausage made of beef and pork) in the freezer. This failure was likely to result in putting a resident at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one out of two sampled resident's (Resident 32) primary language. This failure has the potential for a resident to not meet their highest practicable physical, functional, mental, and psychosocial well-being due to a language barrier.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents in multiple resident bedrooms had at least 80 square feet of living space per resident (sq ft/resident) for 14 of 21 bedrooms (Rooms 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 and 122). This failure has the potential for residents to not to have enough appropriate space for the provision of care or daily living.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and interventions for one of three residents ( Resident 1) when: Resident 1, extensive assist with bed mobility per MDS section G, rolled out of bed during incontinent care. This failure resulted in Resident 1 hitting the side of the table and sustained laceration on the forehead.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 21 shared resident bedrooms (room [ROOM NUMBER]) measured at least 80 square feet (sq ft) per resident, was included on the facility's approved waiver. This failure had the potential for an inadequate space for provision of resident cares.

Inspectors wroteBased on interviews and facility policy review, the facility failed to implement the Legionella (a bacteria found naturally in [NAME] environments that could cause health concerns when it grew and spread in a building water systems) Water Management Program to prevent, detect, and control the spread of Legionnaire's disease (a form of atypical pneumonia caused by the bacteria Legionella; signs and symptoms usually include cough, shortness of breath, high fever, muscle pain, and headaches). This had the potential to affect 44 of 44 residents who resided in the facility.

Inspectors wroteBased on observation, record review, interviews, and review of facility policies, the facility failed to ensure staff maintained 1 (Resident #196) of 2 sampled residents' dignity when staff did not ensure the resident's unclothed body was not partially exposed to staff and other residents in the hallway during transport to the shower room.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for 1 (Resident #96) of 12 sampled residents. Specifically, Resident #96's MDS did not indicate the resident received hospice care.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to maintain records of ongoing communication with a dialysis clinic for 1 (Resident #39) of 1 sampled resident reviewed for dialysis.

Inspectors wroteBased on observations, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when: Two (2) of five(5) dietary staff did not wear appropriate hair restraints e.g. hairnet, hat and/or beard restraint to prevent hair from contacting food. This failure had the potential to cause food borne illness to 42 residents who received food from the kitchen out of the facility census of 42.

Inspectors wroteBased on interview and record review, the facility failed to implement their Quality Performance Improvement(QAPI)program when: 1. There is no evidence the QAPI committee regularly review and analyze data collected under the QAPI program. 2. There is no evidence of established measures to track effectivity, corrective actions and monitoring of events to assure that programs improvements were sustained. This failure had the potential to cause systemic failures affecting outcomes of care and quality of life for all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive their medication according to manufacturer's specification when one resident (Resident 137 ) of 13 sample residents, did not rinse mouth after taking Symbicort Aerosol 2 puffs (corticosteroid medication inhaled through the mouth used to open airway for easy breathing). Reference: https://online.[NAME].com/lco/action/home ( a nationally recognized drug reference) accessed 5/10/21, indicated .after use of the inhaler, patient should rinse mouth/oropharynx with water and spit out rinse solution .localized infections with Candida albicans or Aspergillus niger have occurred frequently in the mouth and pharynx with repetitive use of oral inhaler of corticosteroids . This failure had the potential for residents receiving inhaler, unnecessary discomfort caused by mouth infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection control program for 2 (Resident 137 and Resident 88) of 13 sampled residents when: 1. Registered Nurse 1 (RN1) did not wash hands after removing gloves during and after medication administration administration of Resident 88 and Resident 137. 2. Intravenous (IV- administer medications through a vein) tubing intended to be used for Resident88's next IV antibiotic dose did not have a sterile cap on the end of the tubing which was opened and exposed. This failure had the potential for contamination to spread infection and communicable diseases in the facility. Findings. During a med pass observation on 5/4/21, at 8:33 am, RN1, removed gloves after preparing medications for Resident 88. RN1, then put on a new pair of gloves, proceeded inside Resident 88's room and gave meds. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents in multiple resident bedrooms had adequate useable living space for 13 of 21 bedrooms (Rooms 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 and 122). This failure had the potential for residents not to have enough space for the provision of care.