Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
37 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Jan 2, 2025
Visit Reason
The inspection was conducted as a regulatory annual survey of Linden Woods Village nursing home to assess compliance with federal regulations regarding resident care, medication management, food safety, and other facility operations.
Findings
The facility was found deficient in several areas including failure to ensure residents' participation in care planning, failure to notify the Ombudsman of hospital transfers and discharges, inadequate documentation and monitoring of psychotropic medication use, improper labeling and storage of medications and biologicals, failure to accommodate resident dietary preferences, and unsafe food handling and sanitation practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to participate in the development and implementation of their person-centered care plans for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the Ombudsman of hospital transfers or discharges for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document indications for increase and attempt gradual dose reduction of antipsychotic medication for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one opened vial of Mantoux tuberculin purified protein derivative (PPD) was dated for residents' use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accommodate one resident's dietary preferences by serving bacon despite a 'no bacon' order. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure sanitizer used to sanitize food contact surfaces was at effective levels and failed to ensure food stored was labeled and discarded after use-by or expiration dates. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 37
BIMS score: 12
BIMS score: 15
BIMS score: 3
Sanitizer ppm: 0
Sanitizer ppm: 400
Medication incidents: 16
Medication dosage: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding care plan participation, psychotropic medication indications, and medication increase justification |
| Social Services Director | Social Services Director (SSD) | Confirmed failure to notify Ombudsman of resident transfers and discharges |
| MDS Coordinator | MDS Coordinator (MDSC) | Provided information on missed care plan conferences for residents |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Observed undated opened PPD vial and set it aside for discard |
| Culinary Director | Culinary Director (CD) | Verified sanitizer levels and food storage expiration dates |
| Restorative Aide | Restorative Aide (RA) | Admitted to writing incorrect breakfast order for Resident 11 |
| Dietary Aide | Dietary Aide (DA) | Served breakfast tray with bacon despite 'no bacon' order |
Inspection Report
Routine
Census: 35
Deficiencies: 2
Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding timely notification to residents, representatives, and the State Long-Term Care Ombudsman before transfer or discharge, and to evaluate medication administration practices.
Findings
The facility failed to send timely written transfer or discharge notices to the Ombudsman affecting some residents. Additionally, the facility had a 52% medication error rate, including crushing medications that should not be crushed, incorrect medication administration, and improper application of eye drops.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to send a written copy of transfer or discharge notice to a representative of the State Long-Term Care Ombudsman. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medications with less than 5% error rate; made 13 medication errors out of 25 opportunities (52% error rate). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication errors: 13
Medication error rate: 52
Residents affected: 2
Residents affected: 6
Facility census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed crushing medications incorrectly and improper medication administration. |
| RN B | Registered Nurse | Observed improperly administering eye drops, including touching eye with dropper and insufficient lacrimal pressure. |
| Director of Nursing | Director of Nursing (DON) | Provided information on medication crushing policies and proper eye drop administration. |
| Social Service Director | Social Service Director | Interviewed regarding failure to send transfer/discharge notifications to Ombudsman. |
| Administrator | Administrator | Interviewed about monthly discharge and transfer reports to Ombudsman. |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 4
Jan 9, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, and infection control at Linden Woods Village nursing home.
Findings
The facility was found deficient in providing adequate personal hygiene care, safe resident transfers, catheter care to prevent urinary tract infections, and proper administration and documentation of tuberculosis testing. Several residents were affected by incomplete perineal care, improper use of mechanical lifts and gait belts, and failure to clean catheter tubing and drainage equipment properly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure dependent residents received complete perineal care, affecting two of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff used proper techniques to reduce accidents or injuries during resident transfers using mechanical lifts and gait belts, affecting three of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide catheter care in a manner to prevent urinary tract infection, including improper cleaning of catheter tubing and placing drainage equipment on the floor, affecting one of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care to prevent infection by not administering, reading, and documenting Two-Step Tuberculin tests in a timely manner for three of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 3
Census: 35
Fluid volume: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in perineal care deficiency for improper hygiene technique |
| CNA B | Certified Nurse Aide | Named in perineal care deficiency and transfer technique deficiency |
| CNA F | Certified Nurse Aide | Named in perineal care deficiency and catheter care deficiency |
| CNA E | Certified Nurse Aide | Named in transfer technique deficiency and catheter care deficiency |
| Director of Nursing | Director of Nursing | Provided interview statements regarding proper care and transfer techniques |
| Administrator | Administrator | Provided interview regarding TB documentation system limitations |
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