Inspection Reports for Linden Court

The complaint investigation included allegations that the facility failed to protect residents from adverse behaviors, injury, abuse, and failed to provide clean bedding and required bed hold information. The investigation substantiated failure to protect residents from adverse behaviors and abuse by an employee with a felony conviction.

The facility failed to protect residents from residents with adverse behaviors, failed to protect residents from abuse by an employee with a felony abuse conviction, failed to assist a resident with dressing appropriately, failed to complete required admission MDS for a resident, failed to develop care plans addressing pain and oxygen use, failed to provide adequate assistance with eating for a resident, failed to maintain sanitary conditions preventing cross contamination during dining, failed to maintain exits free of obstructions, failed to maintain fire sprinkler system equipment, and failed to ensure corridor doors properly latch.

The complaint investigation included allegations that the facility failed to protect residents from adverse behaviors and abuse, failed to submit investigations within 5 working days, failed to provide appropriate positioning/transfers, and failed to ensure reports were complete and accurate. The facility was found compliant on all but the timely submission of abuse investigations, which was substantiated with a citation.

The investigation found the facility in compliance with regulatory requirements for most allegations except for one violation where the facility failed to submit an abuse investigation report within 5 working days to the state agency. The facility was cited for this violation and provided a plan of correction.

The complaint investigation was substantiated. The facility failed to submit investigations within 5 working days and failed to protect residents from abuse, specifically verbal abuse towards three residents (Residents 501, 502, and 510).

The facility was found to have failed to submit an investigation report within 5 working days and failed to protect three residents from abuse. The investigation revealed verbal abuse by a staff member towards residents, and the facility did not submit the investigation report timely to the State Agency.

The complaint allegations included failure to notify appropriate party of change in condition, failure to provide care according to practitioner's orders, failure to assist residents with glasses, failure to follow infection control guidelines, failure to provide ongoing activity program, failure to serve food at appropriate temperatures, failure to provide medications according to the Five Rights, and failure to ensure Minimum Data Set reflects residents' needs. Most allegations were not substantiated except for the Minimum Data Set coding deficiency.

The investigation found no violations for most allegations including notification of change in condition, care according to practitioner's orders, assistance with glasses, infection control, activity program, food temperature, and medication administration. However, a deficiency was found related to inaccurate coding of resident behavioral symptoms on the Minimum Data Set for three residents. Additional deficiencies included failure to include nursing assistants in care planning for five residents, failure to follow physician orders for TED Hose for one resident, failure to provide adequate encouragement to eat for one resident at risk for weight loss, failure to post accurate nurse staffing information, failure to ensure medications were obtained and available for one resident, failure to date and label open food items in the freezer, failure to prevent cross contamination by placing water glasses early, failure to maintain bathroom ventilation systems in working order in multiple rooms, failure to ensure corridor doors resist passage of smoke, and failure to prevent use of portable space heaters in resident rooms.

The complaint alleged the facility failed to follow care planned fall interventions and failed to change fall interventions after residents were identified at risk for falls. The investigation substantiated these allegations with findings of no documentation of revised care plans or interventions after falls for 4 sampled residents.

The facility failed to review and revise care plans for 4 sampled residents to prevent falls resulting in injury and failed to implement interventions to prevent falls and injuries. Residents continued to experience falls and injuries without documented interventions or increased monitoring.

The complaint alleged the facility failed to immediately notify the practitioner of change in condition and failed to provide prompt emergency services. The allegations were substantiated based on interviews and record reviews.

The facility failed to immediately notify the practitioner and responsible party after a resident fell and exhibited signs of potential injury, and also failed to provide prompt emergency services following the fall. These deficiencies were found to be violations of Federal tags F157 and F309 and corresponding state licensure regulations.

The complaint investigation was substantiated with findings that the facility did not report allegations of abuse timely, specifically incidents involving Residents 508 and 503B on 5/10/2017. The facility census was 112 at the time.

The investigation found the facility failed to report allegations of abuse within the required 2-hour timeframe, violating Federal tag F225 and State Licensure tag 175 NAC 12-006.02(8). The facility was found compliant regarding food form meeting residents' needs. Staff interactions were caring, but reporting delays were noted.

The facility was found deficient in multiple areas including resident dignity and respect, assessment accuracy, care plan development and implementation, food safety, ventilation, pest control, medical record completeness, fire safety systems, and electrical safety. Specific issues included failure to remove transfer slings and belts in dining rooms, inaccurate MDS coding, incomplete care plans, oxygen concentrators left running unattended, ice buildup in walk-in freezer, non-functioning bathroom ventilation, insect contamination in light fixtures, missing fire alarm notification devices, improperly installed sprinkler head, corridor door not latching, smoke barrier door not self-closing, incomplete fire drills, and uncovered electrical junction box.

The complaint alleged the facility failed to have an effective infection control program to prevent spread of scabies and failed to have appropriate housekeeping/maintenance to reduce dust in the air. The investigation confirmed these allegations.

The facility failed to provide a dust barrier during deconstruction of a nursing station allowing dust particles to permeate into the 200 wing affecting one sampled resident and failed to increase housekeeping dust removal for three sampled residents in close proximity to the construction area. The facility also failed to monitor and assess the progress or symptoms of an identified skin condition on admission for one resident diagnosed with scabies following discharge.

The complaint investigation included allegations that the facility failed to submit investigations within 5 working days, failed to ensure residents are safe from residents with behaviors, failed to change fall interventions after residents were identified at risk, failed to ensure resident rights were not violated, and failed to ensure residents are free from abuse. The abuse allegation was substantiated with a citation for failure to report abuse immediately.

The investigation found no violations regarding timely submission of investigations, resident safety from behaviors, fall intervention changes, or resident rights. However, the facility failed to report an incident of staff to resident abuse immediately, resulting in a citation for not following abuse reporting policies.

The facility fails to complete investigations within five working days was investigated with an on-site visit on 11/19/2015. During the investigation, record reviews were completed of the facility incident reports. The facility had a process in place and the investigation had been completed within five working days, therefore, no violation was written for this allegation.

The complaint investigation found that the facility failed to complete investigations within five working days was not substantiated. The facility had a process in place and the investigation had been completed within five working days. Facility census was 111.

Complaint investigation focused on CMS Unannounced MDS 3.0 Staffing Focus Survey. The facility was cited for deficiencies related to MDS coding, comprehensive assessments, and document retrieval.

The facility was cited for failure to complete a comprehensive MDS assessment after significant change, failure to accurately code the MDS related to significant weight loss, and failure to provide timely requested documents for surveyor inspection.

The complaint alleged the facility failed to assess for change of condition due to medication administration. The investigation included review of resident records, observations, and interviews. The allegation was not substantiated, but related deficiencies were found.

The investigation found no violation regarding the allegation that the facility failed to assess and monitor resident condition changes due to medication administration. However, related deficiencies were cited for failure to document narcotic medications and responses to medications administered to four sampled residents, and failure to account for the disposition of narcotic medication for one deceased resident.

The complaint alleged failure to change fall interventions after residents were identified at risk for falls and failure to implement or follow the plan of care. The investigation found no violation regarding failure to change fall interventions or failure to implement the plan of care, except for one care plan not updated to reflect current interventions.

The investigation found that the facility implements a program to evaluate resident falls and identify fall interventions to prevent re-occurrence. However, one sampled resident's care plan was not updated to reflect current fall prevention interventions. A related deficiency was cited at Federal tag F280.

The facility was found deficient in providing resident privacy during medication administration, maintaining resident dignity by properly handling mechanical lift slings, storing assistive devices to prevent infection, and posting required no smoking signs in oxygen storage areas.

Complaint investigation revealed multiple deficiencies including abuse reporting, care planning, medication administration, infection control, and facility maintenance issues.

The facility was found deficient in multiple areas including failure to report abuse immediately, failure to document hiring decisions related to criminal background checks, inadequate resident bathing choice, poor housekeeping and maintenance, incomplete care plans, failure to monitor medication effects, unsecured medications, expired medications, infection control lapses including hand hygiene and linen handling, and unsafe storage of hazardous chemicals.

The facility failed to develop a discharge plan for a resident desiring discharge, did not revise care plans to prevent bruising for affected residents, failed to assess and monitor pressure sore treatment and nutrition, had medication errors exceeding 5%, did not follow preplanned menus or provide appropriate food substitutions, failed to maintain sanitary conditions in food storage areas, did not ensure proper hand hygiene during medication pass and dining service, and had obstructed exit corridors and improper oxygen concentrator storage.

The facility failed to provide pureed eggs as ordered by the medical practitioner and directed on the facility recipe, affecting three sampled residents with pureed diet orders. Observations and interviews confirmed that scrambled eggs were served instead of properly pureed eggs, which did not meet the definition of pureed foods.

The facility was found deficient in multiple areas including resident privacy during personal care, failure to report abuse allegations, incomplete care plans, lack of medical justification for catheter use, medication administration errors, improper food handling and storage, incomplete clinical records, fire safety door maintenance, improper smoke detector placement, and unauthorized use of power strips.

The complaint was substantiated as credible. Resident 2's fall risk was reviewed with the attending physician who ordered lab work, medication changes, and physical therapy. Safety monitoring devices were trialed to reduce falls, and the resident appeared safer with no further incidents.

The facility failed to implement adequate interventions to prevent falls for Resident 2, who had a history of falls and was assessed as high risk. Observations, record reviews, and interviews revealed insufficient supervision and lack of appropriate safety devices, although corrective actions were planned and discussed with the attending physician.