Lindan Park Care Center

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (medication cart #1) of 6 medication carts reviewed for storage of medications. The facility failed to ensure medication cart #1 was locked while unattended on 06/04/26. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for 22 (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #9, Resident #11, Resident #19, Resident # 24, Resident #26, Resident #27, Resident #32, Resident #35, Resident #36, Resident #37, Resident #42, Resident #45, Resident #44, and Resident #47, Resident #49, and Resident #54) of 22 residents reviewed for privacy and confidentiality of records. The facility failed to ensure that the Thickened Liquid List was not accessible to visitors in the Dining Room on 05/04/26 and 05/05/26. The facility failed to ensure that the Red Napkin List was not accessible to visitors in the Dining room [ROOM NUMBER]/04/26 and 05/05/26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage area and refrigerator areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags, containers, and boxes in the dry storage pantry, refrigerator, and freezer areas.3. The facility failed to ensure that expired items in the dry storage area were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area and were separated from the other canned food.5. The facility failed to ensure that the A/C vents in the kitchen's food preparation area were cleaned. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with a PASRR Level 2 evaluation for 1 of 5 residents (Resident #3), reviewed for resident assessment. Resident #3's PASRR Level 1 screening did not reflect mental illness, and the resident did not have a PASRR Level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #3) of three residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse when CNA A force fed her on 03/03/25. The resident suffered psychosocial harm. On 03/20/25 at 1:00 PM, an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 1:15 PM. While the IJ was removed on 03/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of choking, aspiration, serious injury, harm, and death.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner for three (Residents #5, #11, #46, #37, #30, and #59) of three residents reviewed for knowledge of how to file a grievance. The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. These failures could affect 6 of 60 resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance. Observation on 03/05/25 at 2:45 PM Surveyor attempted to open the frame with many attempts were required. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry and the refrigerator areas. 3. The facility failed to ensure that expired items in the dry storage pantry and the refrigerator areas were removed. 4. The facility failed to ensure that 1 dented can was removed from the shelf in the dry pantry area. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. [...]

Inspectors wroteBased on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #29) of five residents reviewed for PASARR services. The facility failed to ensure Resident #29 was properly screened for PASARR services This failure could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for two (Resident #58, Resident #59) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #58 for his planned discharge home on [DATE]. 2. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to post required postings with the required contact information for the public, residents and family. The facility failed to post required notification to residents or their representatives through prominent postings throughout the facility on how to contact someone to file a complaint. This failure could place 60 of 60 residents at risk for physical and verbal abuse, which could result in decreased self-esteem, reduced quality of life, injury, or decline in condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify the resident's physician consistent with his or her authority, when there was a change in condition for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in condition was discovered by RN A (Registered Nurse) on Resident #1 on 1/26/2025 at 5:16 AM. The physician was not notified of the change in condition by RN A (Registered Nurse). This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify the resident's physician and responsible party consistent with his or her authority, when there was an injury of unknown origin for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician, and Resident #1's responsible party when an injury of unknown origin was discovered on Resident #1. The physician and responsible party were not made aware of the injury of unknown origin until Resident #1 was admitted to the hospital for unrelated treatment. This deficient practice could place residents at risk of not having their physician or responsible party informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on interviews and record review the facility failed to report abuse, neglect, exploitation, or critical incidents for 1 of 1 resident (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin in a timely manner, that was discovered on 12/31/2024, to HHSC. The facility reported the injury of unknown origin on 1/02/2025. This failure could place clients at risk for abuse, neglect, and incidents.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 6 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #1's Care Plan did not include an inaccurate diagnosis of Parkinsonism. This failure could place residents at risk for medication and /or treatment errors and omissions in care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 6 of 6 residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure nonfood-contact surfaces were kept free of dust and other debris. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #21) of three residents reviewed for dignity. The facility failed promote Resident #21's dignity by not covering his catheter's urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Residents #53 and #58) of seventeen residents reviewed for call lights. The facility failed to ensure Residents #53's and #58's call light were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #52) of 7 residents reviewed for comprehensive care plans. The facility failed to accurately define the quantity and type of alcohol the doctor's order authorized Resident #52 to safely consume daily on his care plan. The failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident (Resident #64) of 4 residents reviewed for enteral nutrition. 1. LVN A failed to check for residual volume prior to medication administration for Resident #64 These failures could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for one (Resident #36) of three residents on psychoactive medication in that: The facility failed to ensure that Residents #36 had orders for psychotropic medications lorazepam (brand name Ativan) that did not contain PRN orders beyond 14 days without an end date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #27 and Resident #52) of 7 residents reviewed for resident medical records. The facility failed to accurately define the quantity of alcohol (beer or wine) authorized for 2 residents (Resident #27 and Resident #52) to safely consume daily per their physician orders. This failure could place residents at risk for the inappropriate care due to inaccurate or incomplete medical and clinial records as ordered by their physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #26) of 3 residents reviewed for infection control. The facility failed to ensure Resident #26's catheter bag was kept off the floor while in the dining room. This failure could place residents at risk of contracting or spreading an infection.