Linden Place Center for Nursing and Rehabilitation

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain in good repair a resident's room door and bathroom sink in 1 of 11 resident rooms and 1 of 11 resident bathrooms on 1 of 2 halls whose room and/or bathroom was observed to have environmental concerns (Resident #48).

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1) Label a medication with the minimum required information (including the resident's name) stored on 1 of 2 medication (med) carts (North Hall Med Cart #2); 2) Discard expired medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom) and on 1 of 2 medication carts observed (North Hall Med Cart #2); and 3) Date medications as to when they were opened to allow for the determination of the shortened expiration date for medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom).

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to act upon group grievances, resolve repeat grievances, and/or communicate the facility's efforts to address grievances voiced during Resident Council meetings for 2 of 3 months reviewed (November 2025 and December 2025).

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to maintain accurate and consistent advance directive information throughout both the electronic medical record and paper record kept at the nursing station for 1 of 32 residents reviewed for advance directives (Resident #96).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR, a review to determine if the resident needs specialized services and nursing home care) Level II status (Resident #2) and Hospice services (Resident #17). This occurred for 2 of 32 residents whose MDS assessments were reviewed (Resident #2 and Resident #17).

Inspectors wroteBased on observations, record review, and resident interviews and staff interviews, the facility failed to develop a comprehensive care plan in the areas of use of a colostomy bag and urinary catheter (Resident #52), dialysis treatment (Resident #14), and discharge goal (Resident #65) for 3 of 32 residents whose care plans were reviewed.

Inspectors wroteBased on observations, record review, resident interview and staff interviews, the facility failed to shave facial hair for 1 of 4 residents reviewed for activities of daily living (ADL) (Resident #65).

Inspectors wroteBased on observation, record review, and staff and Nurse Practitioner interviews, the facility failed to obtain a physician order for the treatment of a stage 3 pressure ulcer and failed to set a pressure relieving air mattress to the correct setting for 1 of 3 residents reviewed for pressure ulcers (Resident #17).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen was in use for 1 of 1 resident reviewed for respiratory care (Resident #88).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 6 residents observed during the medication administration observations (Resident #11 and Resident #33).

Inspectors wroteBased on record review, and Ombudsman and staff interviews, the facility failed to notify the Ombudsman in writing of residents transfer to the hospital for 2 of 2 emergency hospitalization transfers reviewed for hospitalization (Resident #99 and Resident #88).

Inspectors wroteBased on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments within the regulated timeframe for 2 of 32 residents reviewed for MDS assessments (Resident # 1 and # 30).

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to honor a residents' request to have medications administered at a time that was desired for 1 of 4 residents (Resident #64) reviewed for choices.

Inspectors wroteBased on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to notify the on-call nurse practitioner when a resident had a change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization.

Inspectors wroteBased on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to identify a resident's change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain clean and sanitary floors, ensure baseboards were in good repair and ensure the toilet was clean and in good repair in 2 of 3 rooms (rooms [ROOM NUMBERS]), ensure the light fixture was clean and a sink was in good repair in 1 of 3 rooms (room [ROOM NUMBER]), and maintain cleanliness and sanitation in 1 of 2 linen closets and 1of 1 dining room observed for maintenance of a sanitary and orderly interior.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by pests observed in 1 of 3 hallways (the hallway leading into the dining room) and in 2 of 3 residents' rooms (rooms [ROOM NUMBERS]) reviewed for pest activity.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Findings Included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included multiple fractures and pressure ulcers. He was discharged to the hospital on [DATE] and did not return to the facility. [...]

Inspectors wroteBased on record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 5/28/21 and 5/26/23 and the current complaint investigation survey of 5/6/24. This failure occurred for a repeat deficiency originally cited in the area of comprehensive resident centered care plans that was subsequently recited on the current complaint investigation survey of 5/6/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI Program.

Inspectors wroteBased on record review, observations, interviews with residents and staff, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 1 resident investigated for abuse (Resident #13). Resident #13 had reported to the facility Nurse Aide (NA)#1 needed to feed her roommate correctly. Resident #13 alleged later the same evening NA #1 grabbed Resident #13's face very hard, squeezed her face, in a manner which scared the resident and after the incident the resident was found to have bruising on her right jawline and right cheek.

Inspectors wroteBased on resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and/or respond to concerns voiced by residents during Resident Council meetings for 9 of 10 months (July 2022, August 2022, October through, December 2022, and January, February, March, and April 2023).

Inspectors wroteBased on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 5/12/23. This was for a deficiency that was cited in the area of Development/implement a Comprehensive Care plan on 5/28/21 and recited on the current recertification and complaint survey on 5/12/23. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 6/16/22. [...]

Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 4 of 4 residents residing in the facility. (Resident #243, Resident #38, Resident #2, and Resident #18). Findings Included: a. During the facility tour on 5/8/23 at 10:00 AM, an observation was made of a roach crawling on the 100 hallway. b. During a Resident Council meeting on 5/10/23 at 10:00 AM, residents who attended the meeting (Residents #38, Resident #18, and Resident #2) reported that the facility had issues with pests in their room. There were roaches in their rooms and in the hallways. Resident #38 (President of Resident Council) was interviewed on 5/10/23, at 4:00 PM. The resident indicated that the facility had issues with pests. Resident #38 stated she saw a roach crawling on the wall beside the bathroom door in her room last night (on 5/9/23). [...]

Inspectors wroteBased on record review, resident and staff interviews the staff failed to report an allegation of employee to resident abuse to the Administrator immediately. This was evident for 1 of 3 residents reviewed for allegations of abuse. (Resident #13).

Inspectors wroteBased on record review and staff interview, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for 1 of 25 residents (Resident # 24).

Inspectors wroteBased on record reviews and resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 2).

Inspectors wroteBased on record review, staff, Nurse Practitioner, and Medical Director interview the facility failed to follow physician orders to obtain a hemoglobin A1c (HbA1c) every three months as ordered for Resident #33 for 1 of 24 residents reviewed.

Inspectors wroteBased on facility staff and record reviews, the facility failed to accurately document a sedative medication for a resident 1 of 6 nights during the stay in the facility. This occurred for 1 of 22 residents (Resident # 245) whose medications were reviewed.

Inspectors wroteBased on record review and staff interview the facility failed to provide written notice of discharge to the ombudsman for 1 of 1 resident (Resident #246) reviewed for discharge to the hospital. This practice had the potential to impact other residents.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the bed hold policy to 1 of 1 residents discharged to the hospital (Resident #246). This practice had the potential to impact other residents.