Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linda Manor Extended Care Facility during CMS and state inspections, most recent first.
Unsafe food storage and labeling were observed in three unit kitchenettes. The surveyor and FSD found open food and beverage items that were unlabeled, undated, or missing resident names, along with refrigerated items that were warm, melted, or stored in an out-of-order refrigerator and cooler. The FSD stated some items should have been discarded because they were older than three days, undated, or unlabeled.
A resident with obstructive and reflux uropathy had an indwelling Foley ordered as 16 Fr with a 10 mL retention bulb, but staff inserted an 18 Fr catheter with a 30 mL bulb instead. Nursing staff and the DON confirmed the catheter size did not match the physician order, and the nurse who changed it said she believed she had placed the correct size but did not.
A resident with severe cognitive impairment and total dependence on staff for ADLs was provided incontinence care by a CNA without the required second staff member present, contrary to the care plan and Kardex instructions. During care, the CNA turned away to retrieve supplies, resulting in the resident rolling off the bed and sustaining a head laceration and a displaced femoral neck fracture, requiring hospital admission. Staff interviews revealed confusion about the requirements for two-person assistance during bed mobility and care.
A resident with severe cognitive and physical impairments, care planned for two-person assistance with all bed mobility and positioning, was left unattended by a CNA during care. The CNA, working alone, turned away from the resident who was positioned on their side in a high bed, resulting in the resident rolling off the bed and sustaining a head laceration and a displaced femoral neck fracture. Staff interviews confirmed the care plan required two staff for such care, but this was not followed, leading to the resident's injury.
A resident with multiple wounds and complex medical conditions experienced a delay in treatment when nursing staff did not promptly clarify or follow up on a wound clinic's recommendation for a right foot X-ray to rule out osteomyelitis. Ambiguity in the wound clinic's notes led staff to believe the clinic would obtain the X-ray, resulting in a month-long delay before the facility secured the necessary imaging, which confirmed osteomyelitis.
A resident experienced two unwitnessed falls, and the facility failed to complete neurological checks as per policy. Additionally, the resident's food and fluid intake were not consistently documented, despite being at risk for dehydration and slow wound healing. Interviews confirmed that the required documentation was not completed accurately.
A resident at risk for skin breakdown with existing pressure injuries did not receive adequate care in a LTC facility. The facility failed to document and follow up on necessary wound care, including offloading pressure from the resident's heels. Weekly wound assessments were not conducted as required, and there was a lack of communication among staff regarding the resident's wound care needs. The wound care nurse was not informed in a timely manner, leading to a deficiency in providing necessary treatment and services.
A facility failed to accurately assess and monitor a resident's nutritional status, including body weight, meal percentage, and fluid intakes, as per policy. The resident, at risk for nutritional decline and slow wound healing, had a significant weight discrepancy that was not addressed. The resident's weight was recorded from hospital records, and weekly weight monitoring was not reinstated after hospitalization. The RD expected a re-weight due to the weight loss, and the resident was not started on a nutritional supplement until ten days after re-admission.
A resident with depression did not receive several doses of Fluoxetine due to unavailability, and the physician was not notified. The MAR indicated the medication was held, and interviews confirmed the lack of physician notification, as required.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in documenting their medical conditions and treatments. A resident with End Stage Renal Disease was not coded for dialysis treatments, two residents had incorrect urinary catheter status, and another resident's discharge status was inaccurately recorded. These issues were identified through record reviews and staff interviews.
A resident at risk for malnutrition was not weighed as ordered in June, leading to a significant weight loss going unnoticed until July. The resident, admitted with fractures and Diabetes Mellitus, reported dissatisfaction with food quality and a weight loss of about twenty pounds. The facility's policy required monthly weight monitoring, but this was not followed, resulting in a delay in nutritional interventions.
A resident with aphasia and hemiplegia, dependent on staff for oral hygiene, did not receive dental care despite having consents on file since 2015. Observations showed stained and debris-coated teeth, and interviews confirmed no dental visits since 2020, contrary to facility policy requiring staff to arrange such services.
The facility failed to maintain sanitary conditions in the microwaves of the Meadowview and Forestview unit kitchenettes. Despite a policy requiring daily checks and monthly deep cleaning, a surveyor observed significant food splatter and debris buildup. A housekeeper confirmed the microwaves had not been cleaned for some time, indicating non-compliance with the cleaning schedule.
Unsafe Food Storage and Labeling in Unit Kitchenettes
Penalty
Summary
The facility failed to follow safe food practices in three of three applicable unit kitchenettes by not properly labeling, dating, storing, and discarding food and beverage items intended for resident use. The facility policy required food items to be labeled and use-by dated, refrigerated foods to be held at 40 degrees Fahrenheit or below, and foods brought in by visitors or family to be stored separately and discarded as appropriate. During observation in the Sunrise Unit kitchenette, the surveyor and Food Service Director found two open containers of peanut butter and one open jar of honey in the cabinet that were unlabeled and undated, along with a package of cotton candy grapes, a container of soup, and a container of macaroni in the refrigerator that lacked resident names and/or proper dating. In the Forestview kitchenette, the refrigerator had an out-of-order sign, and the Food Service Director stated it had been broken since 9/22/25. The surveyor observed opened prune juice, cranberry juice, and apple juice on the counter that were undated and warm to touch, as well as a cooler containing two milkshakes, a small ice cream container, and a bag of frozen berries that were melted, unlabeled, and undated, with melted ice and water inside the cooler. In the Meadowview Unit kitchenette refrigerator, the surveyor found three opened packages of deli meat, an opened package of pre-sliced cheddar cheese, two containers of pasta, opened cranberry juice, and opened grape jelly, with several items unlabeled, undated, or dated 9/19/25. The Food Service Director stated that the items in the Meadowview refrigerator should have been discarded because they were older than three days, undated, or unlabeled.
Incorrect Foley Catheter Size
Penalty
Summary
The facility failed to provide care and services according to physician orders for an indwelling urinary catheter for one resident with obstructive uropathy and reflux uropathy. The resident was cognitively intact with a BIMS score of 15 and had an indwelling catheter ordered as a 16 French Foley with a 10 mL retention bulb. The resident’s care plan also identified the catheter size as 16 French/10 cc retention bulb and directed catheter changes as needed to maintain patency. Record review showed the resident’s catheter was changed because of occlusion, and during observation the catheter in place was identified by nursing staff as an 18 French catheter with a 30 mL retention bulb. Nursing staff stated this was not the ordered size and that the larger catheter could cause obstruction or pain. The nurse who inserted the catheter said she attempted to irrigate it without success, changed it, and believed she had inserted the correct 16 French catheter with a 10 mL bulb, but did not. The DON stated the facility stocked the ordered catheter size and was unsure why the incorrect size had been inserted.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to consistently implement and follow a resident's care plan interventions, specifically regarding the required level of staff assistance during care. The resident, who had diagnoses including dementia and Parkinson's disease, was severely cognitively impaired and dependent on staff for all activities of daily living (ADLs), including bed mobility, dressing, toileting, and positioning. The care plan and Kardex clearly indicated that two staff members were required to assist with these tasks. On the evening of the incident, a certified nurse aide (CNA) provided incontinence care to the resident without another staff member present, despite the care plan's requirement for two-person assistance. The CNA positioned the resident on their side and briefly turned away to retrieve barrier cream, during which time the resident rolled off the bed and fell to the floor. The resident sustained a laceration to the head and a closed displaced fracture of the right femoral neck, requiring transfer to the hospital emergency department and subsequent admission. Interviews with staff revealed confusion and misunderstanding regarding the definition of bed mobility and the specific requirements for two-person assistance during care. The CNA involved believed that bed mobility only referred to boosting or small movements, not to positioning for personal care, and admitted to having provided care alone to the resident on previous occasions. Other staff confirmed that the care plan and Kardex specified two-person assistance for all care, and that this protocol was not followed at the time of the incident.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who was severely cognitively impaired and dependent on two staff members for dressing, toileting, bed mobility, and positioning was not provided with the required level of staff assistance during care. The resident, who had diagnoses including dementia and Parkinson's disease, was care planned to require two staff for all bed mobility and positioning tasks due to significant physical and cognitive limitations. On the evening of the incident, a CNA provided care to the resident alone, despite the care plan and Kardex specifying the need for two staff members for such activities. During the provision of care, the CNA positioned the resident on their side in bed and then turned away to retrieve a supply that was out of reach, leaving the resident unattended. The bed was in a high position, and the resident was left on their side, which was an unsafe position given their inability to assist with movement or maintain balance. While the CNA was away from the bedside, the resident rolled off the bed and fell to the floor, sustaining a laceration to the back of the head and a closed displaced fracture of the right femoral neck, requiring transfer to the hospital. Interviews with staff confirmed that the resident was totally dependent on staff for all care and that two caregivers should have been present during the incident. The CNA involved misunderstood the care plan instructions, believing that two-person assistance was only required for certain movements and not for all bed mobility or positioning. Other staff and management confirmed that the care plan was clear and that the required level of assistance was not provided at the time of the incident, directly leading to the resident's fall and injury.
Failure to Clarify and Timely Follow Up on Wound Care Recommendations
Penalty
Summary
Nursing staff failed to ensure timely clarification and follow-up on wound care recommendations for a resident with multiple wounds and complex medical conditions, including diabetes, multiple myeloma, chronic thrombocytopenia, anemia, and a recent right toe amputation. The resident was seen at an outside wound clinic, where recommendations for an X-ray of the right foot to rule out osteomyelitis were made on multiple occasions. Despite these recommendations, there was no documentation that nursing staff clarified the responsibility for obtaining the X-ray or followed up with the clinic after the appointments. The wound clinic's notes indicated that an X-ray order was placed in their system and could be completed at a hospital, but the clinic did not have X-ray capabilities. The facility staff, including the unit manager, reviewed the consultation notes but found them ambiguous and believed the wound clinic was responsible for obtaining the X-ray. It was not until a month after the initial recommendation that the unit manager contacted the wound clinic for clarification and learned that the facility was expected to obtain the X-ray. As a result, the X-ray was delayed and only completed after clarification was sought, ultimately confirming the presence of osteomyelitis in the resident's right third toe. The delay in obtaining the X-ray was due to a lack of timely communication and clarification between the facility nursing staff and the wound clinic regarding responsibility for carrying out the recommended diagnostic test.
Incomplete Neurological Checks and Meal Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who experienced two unwitnessed falls. The facility's policy required neurological checks to be conducted at specific intervals following an unwitnessed fall. However, the resident's neurological checks were not completed as per the policy. For the first fall, checks were missed at several intervals on the first day and were not documented for the required 72-hour period. Similarly, for the second fall, checks were not documented for the full 72-hour period. Interviews with the Assistant Director of Nurses and the Director of Nurses confirmed that the checks were not completed accurately according to the facility's protocol. Additionally, the facility did not consistently document the resident's food and fluid intake, which was crucial given the resident's risk for dehydration and slow wound healing due to low albumin levels. The resident's meal intake records showed multiple instances where the Certified Nurse Aides failed to document the percentage of meals consumed or the amount of fluids consumed over several days. Interviews with a CNA and a Unit Manager confirmed that CNAs were expected to document meal and fluid intake for every resident at every meal, but this was not consistently done for the resident in question.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was at risk for skin breakdown and had existing pressure injuries. The resident, who was readmitted to the facility with diagnoses including congestive heart failure and unspecified protein-calorie malnutrition, had documented pressure injuries on both heels upon discharge from the hospital. However, the facility's re-admission nursing assessment did not include these injuries, and the necessary physician's orders for wound care, including offloading, were not obtained or documented in the treatment administration record. The facility's policy required weekly wound assessments, including measurements and documentation, but these were not consistently performed for the resident. The resident's treatment administration record lacked orders for offloading pressure from the heels, and there was no evidence of weekly wound measurements or assessments being conducted as per the facility's policy. Interviews with nursing staff revealed a lack of communication and follow-up regarding the resident's wound care needs, with responsibilities for wound care not being clearly assigned or executed. The wound care nurse was not notified of the resident's wounds upon admission, and by the time she was informed, the situation had worsened. The director of nurses expected all wounds to be measured weekly and interventions to be documented, but this was not adhered to in practice. The facility's failure to follow its own policies and procedures for wound care and prevention led to the deficiency in providing necessary treatment and services to promote healing and prevent further skin breakdown.
Failure to Monitor Resident's Nutritional Status and Weight
Penalty
Summary
The facility failed to ensure the accurate assessment and monitoring of a resident's nutritional status, which included body weight, meal percentage, and fluid intakes, as per facility policy. The resident, who was at risk for nutritional decline, dehydration, and slow wound healing due to low albumin levels, was readmitted to the facility with a significant weight discrepancy that was not addressed. The facility's policy required re-weighing if there was a weight change of more than three pounds, but despite a 25-pound difference in weight readings over approximately two weeks, no re-weight was obtained. The resident's weight was recorded from the hospital discharge summary rather than being measured upon re-admission, and the order for weekly weights was discontinued during a brief hospitalization and not reinstated upon return. The Registered Dietician (RD) expected a re-weight due to the documented weight loss and noted that the resident was not started on a nutritional supplement until ten days after re-admission, despite having been on Ensure Plus at the hospital. The RD also highlighted the lack of a Unit Manager, which made follow-through difficult. Interviews with facility staff, including the Nurse Practitioner (NP) and the Assistant Director of Nurses (ADON), revealed that they were unaware of the weight discrepancies and that the order for weekly weights was not re-entered into the Electronic Medical Record System (EMRS). The Director of Nurses (DON) stated that staff should have obtained a re-weight due to the significant weight discrepancy. The failure to monitor and document the resident's nutritional status and weight accurately led to the deficiency identified by the surveyors.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to notify the physician about the unavailability of a prescribed medication for a resident diagnosed with depression. The resident was supposed to receive Fluoxetine, a psychotropic medication, twice daily as per the physician's orders. However, the medication was not administered on several occasions due to its unavailability from the pharmacy. Specifically, the medication was not given on four separate occasions, and there was no documentation indicating that the physician was informed about these missed doses. The resident, who was moderately cognitively impaired, did not receive the scheduled doses of Fluoxetine on specific dates, as indicated by the Medication Administration Record (MAR). The MAR showed that the medication was marked as held and not administered. During interviews, both a nurse and the unit manager confirmed that the medication was not administered due to its unavailability and that the physician was not notified, as required. The clinical record progress notes also lacked any evidence of physician notification regarding the missed doses.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #88, who was diagnosed with End Stage Renal Disease and dependent on Hemodialysis, was not accurately coded in the MDS assessments to reflect the dialysis treatments he/she was receiving. Despite being cognitively intact and attending dialysis sessions regularly, the MDS assessments did not indicate this treatment, as confirmed by the Clinical Reimbursement Coordinator upon review. Similarly, Resident #12, who had a diagnosis of urinary retention and an indwelling urinary catheter, was inaccurately coded in the MDS assessment as not having a catheter, despite physician orders and care plans indicating otherwise. Additionally, Resident #89 was inaccurately coded as having an indwelling urinary catheter in the MDS assessment, even though the catheter had been discontinued a year prior, as confirmed by the Unit Manager and MDS Nurse. Furthermore, Resident #110's discharge status was incorrectly coded in the MDS assessment as a discharge to a short-term general hospital, whereas the resident was actually discharged home with instructions and belongings. These inaccuracies in MDS coding were identified through record reviews and staff interviews, highlighting a failure in maintaining accurate resident assessments.
Failure to Monitor Resident's Weight Leads to Missed Malnutrition Risk
Penalty
Summary
The facility failed to provide adequate nutrition care and services for a resident at risk for malnutrition. The resident, who was admitted with a displaced fracture of the left humerus, a left maxillary fracture, and Diabetes Mellitus, was not weighed monthly as ordered in June 2024. This oversight resulted in a significant weight loss of 18 pounds going unnoticed until July 2024. The facility's policy required monthly weight monitoring, especially for residents at risk of malnutrition, but this was not adhered to in the case of the resident. The resident expressed dissatisfaction with the food quality and reported a weight loss of about twenty pounds since admission. The facility's Director of Nursing acknowledged that the resident should have been weighed in June but was not, and the weight loss was only identified in July. The dietician, who reviews weekly weight reports, confirmed that the resident was not weighed as ordered in June and was only informed of the significant weight loss in July. This delay in identifying the weight loss led to a delay in implementing necessary nutritional interventions.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental care and services for a resident, identified as Resident #16, who had been admitted with diagnoses including aphasia and hemiplegia. The resident was dependent on staff for oral hygiene and had consent forms on file requesting dental services dating back to 2015, 2018, and 2020. Despite these consents, the facility did not ensure that the resident received dental care, as evidenced by the absence of documentation in the medical record indicating any dental visits since 2020. Observations by a surveyor noted that the resident's teeth were stained and coated with debris, and the resident's daughter expressed concerns about the lack of dental care. Interviews with facility staff, including a Unit Manager and the Corporate Quality Improvement Nurse, confirmed that the resident had not been seen by a dentist since 2020, despite the facility's policy requiring staff to arrange appointments and transportation for dental services.
Failure to Maintain Sanitary Conditions in Unit Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in two of its unit kitchenettes, specifically in the microwaves located in the Meadowview and Forestview units. The facility's policy on sanitary conditions, revised on September 21, 2022, requires that removable parts of fixed equipment be washed and sanitized, while non-removable parts should be cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution. Additionally, housekeeping responsibilities for these units include ensuring that all areas, including kitchenettes, are clean and maintained. On July 9, 2024, a surveyor observed splattered food and built-up debris on the interior top and sides of the microwaves in both the Meadowview and Forestview unit kitchenettes. During an interview, a housekeeper confirmed that the microwaves should be checked daily and cleaned if necessary, and deep cleaned monthly. The housekeeper acknowledged that the microwaves appeared not to have been cleaned for a significant period, as evidenced by the amount of built-up debris and food splatter, indicating a failure to adhere to the facility's cleaning schedule.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 108 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Leeds
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highview Of Northampton | 0.5 mi | — | 0 | 0 |
| Care One At Northampton | 2.9 mi | ★★★★★ | 4 | 0 |
| Hadley Pointe Nursing Rehab & Care | 7.3 mi | ★★★★★ | 9 | 0 |
| Center For Extended Care At Amherst | 8.2 mi | ★★★★★ | 2 | 0 |
| Care One At Holyoke | 9.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.