Linden Woods Village

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to ensure the kitchen was clean and in good repair. The facility census was 32. Review of the facility policy titled, Food Storage Policy, dated October 2018, showed:-Foods shall be stored in a manner that complies with safe food handling practices;-Staff will maintain clean food storage areas at all times;-Food in dry storage will be kept off the floor;-All foods stored in the refrigerator or the freezer will covered, labeled and dated with a use by date;-Open container must be dated and sealed. The facility did not provide a policy for cleaning and repair of the kitchen. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and home like environment when the facility did not ensure vents in the hallways and the vents outside resident rooms were clean and free of debris, the ceiling in the dining room was clean and in good repair and when the facility failed to ensure the handrail by the dining room was clean. This had the potential to affect all residents who had the right live in a clean environment that was free from dirt, dust and in good repair. The facility census was 32. The facility did not provide the requested policy on clean and home like environment. Observation on 05/04/2026 at 08:35 A.M., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide proper peri-care for three of 12 sampled residents (Resident #6, #11, and #30). The facility census was 32. Review of the facility training and competency, titled, Combined Perineal Care Female and Male, undated, showed:- Once a gloved hand has touched something soiled (old depends, garbage can, used trash bags, etc), it cannot be used to touch something clean without removing gloves and performing hand hygiene;- Having a second clean person can assist with this procedure;- Do not place soiled items on the clean surface or bed;- One wipe, one swipe: no scrubbing or re-using wipes or cloths;- Always wipe away from the peri-area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents received the appropriate care and services to prevent urinary tract infections to the extent possible and when the facility staff failed to ensure proper urinary catheter care was performed for one resident (Resident #6), and additionally when the facility failed to collect a physician ordered urine sample for eight days causing delay in start of treatment for one resident (Resident #30) of the 12 sampled. The facility census was 32. Review of the facility training and competency titled, Combined Catheter Care, undated, showed:- Once care is completed, ensure tubing is strapped to inner thigh;- One wipe, one swipe: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent with an error rate of 24% out of 29 opportunities, when the staff crushed medications for administration that were not supposed to be crushed, additionally when the facility staff failed to administer medication with sufficient water and with, or after food as ordered by the physician. This affected one of 12 sampled residents (Resident #16). The facility census was 32. Review of the facility undated policy titled, Medication Administration Competency: General Guideline, showed staff were supposed to compare the order in the Medication Administration Record (MAR) three times prior to medication administration. Review of the facility undated policy titled, Medication Administration Competency: Oral Medications, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage and labeling of medications and biologicals when the facility had an open bottle of lorazepam (an anti-anxiety medication) with no open date for one resident (Resident #8) and three open bottles of stock medications used for multiple residents with no open date. Additionally, when the facility had three opened bottles of glucose control solution (solutions used for daily calibration/testing of bedside blood glucose machines) with no open date. This had the potential to affect all residents with orders for these medications. The facility census was 32. The facility did not provide a policy regarding storage and labeling of medications and biologicals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program when the facility staff did not wear proper Personal Protective Equipment (PPE) when providing high contact cares for one resident (Resident #3), when the facility staff did not change gloves and perform hand hygiene between dirty and clean tasks (Resident #11) and additionally when the staff failed to sanitize vital sign equipment (blood pressure cuff, thermometer, etc.) between uses on residents (Resident #3 and #11). This affected two of 12 sampled residents. The facility census was 32. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility) was completed before admission for one resident (Resident #6). The affected one of 12 sampled residents. The facility census was 32. The facility did not provide a PASARR policy. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services that meet professional standards when the facility failed to properly document pain and urinary continence status on weekly assessments for one of 12 sampled residents (Resident #30). The facility census was 32. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 04/08/26, showed:-No cognitive impairment;-Reported frequent pain;-Always incontinent of urine;-Dependent on nursing staff for all hygiene cares, toileting and transfers;-Diagnoses included: Heart failure, high blood pressure and chronic pain. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the sanitizer used to sanitize food contact surfaces was at a level effective to sanitize the surfaces and failed to ensure food stored in the walk-in refrigerator and the refrigerator on the unit was labeled and discarded after the use-by date and/or expiration date for 38 census residents residing in and receiving food from the dietary department. This had the potential to result in food borne illness and cross contamination. The facility census was 37.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents' right to participate in the care planning process was honored for two of two residents (Resident (R) 11 and R32) reviewed for care plans out of 16 sampled residents. This failure placed the residents at risk for the provision of care not being person-centered.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the Ombudsman was notified two of two residents (Resident (R) 31 and R35) reviewed for emergent hospital transfer out of 16 sample residents. As a result of this failure, the residents would not have the added protection and/or advocacy of the Ombudsman's office to monitor the potential possibility of an inappropriate facility-initiated transfer or discharge.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of six residents (Resident (R) 5) had documented indications for an increase of an antipsychotic medication and failed to attempt a gradual dose reduction of the antipsychotic medication without clinical rationale of 16 sample residents. This failure had the potential for R5 to not receive the lowest effective dose of atypical antipsychotic medication. The facility census was 37.

Inspectors wroteBased on observation, interview, facility policy review, and Centers for Disease Control and Prevention (CDC) reference, the facility failed to ensure one undated opened vial of Mantoux tuberculin purified protein derivative (PPD) of three vials in the refrigerator was dated for residents' use. This failure could lead to inaccurate tuberculosis testing by the potential for a false positive (or false negative) result due to the components of the PPD solution being degraded. The facility census was 37.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to accommodate one of one resident's (Resident (R) 11) dietary preferences reviewed for food choices of 16 sampled residents. This failure had the potential to result in reduced meal consumption and may potentially affect the residents' nutritional or health status. The facility census was 37.

Inspectors wroteBased on interviews and record review, the facility failed to send a written copy of transfer or discharge notice to a representative of the office of the State Long-Term Care Ombudsman. This affected two of 12 sampled residents, (Resident #22 and #39). The facility census was 35. Review of the facility's policy for transfers and discharges, notice to the Ombudsman, reviewed January 2018, showed: - The facility will send resident transfer and discharge list to the Ombudsman Office monthly; - The facility will print a monthly transfer/discharge list for the previous month from their electronic medical record (EMR); - Transfer/discharge list will be electronically (email) mailed to the Ombudsman office; - The facility will keep a copy of the sent email to show it was completed. 1. Review of Resident #39's baseline care plan, dated 12/14/22, showed: - The resident was a full code; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications with a less than 5% medications error rate. Facility staff made 13 medication errors out of 25 opportunities for error resulting in a 52% medication error rate. Facility failed to ensure staff did not crush medications that are recommended by the manufacturer to not be crushed. Facility staff failed to stay with a resident until all of his/her polyethylene glycol had been finished. Facility staff failed to give a resident his/her calcium pill instead gave a Vitamin C pill. Facility staff failed to administer the correct dose of Voltaren gel to a resident's bilateral shoulders. Facility staff failed to apply lacrimal pressure to the eyes per policy after instilling eye drops. Facility staff to apply the correct amount of eye drops per eye per physician's orders. [...]