Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Complete Care At Linwood, Llc during CMS and state inspections, most recent first.
Food storage and sanitation practices were not maintained consistently in the kitchen. Opened food items in dry storage were found without open or used-by dates, the high-temp dishwasher was observed operating below the temperatures required by policy, the dishwasher temp log had entries filled in before the lunch period, and boxes of food products, including uncooked meat, were stacked on the floor.
Improper Garbage Disposal Area Maintenance: The facility failed to keep the outdoor trash disposal area free of debris and failed to keep 1 of 3 garbage containers covered. Surveyors observed an open-lid GC with trash exposed, another GC overflowing with refuse, and debris such as cardboard boxes and milk crates scattered around the area. The EVSS and DOM stated the area was monitored by housekeeping and maintenance, but the facility could not produce a trash or refuse policy when requested.
Dignity and Respect Deficiencies in Incontinence Care and Dining: A resident was observed in bed wearing two incontinence briefs, and staff acknowledged residents are not supposed to be wearing two briefs. The resident had dementia and was always incontinent of bowel and bladder, but the care plan did not include interventions related to the issue until it was brought to the facility’s attention. In addition, residents in multiple dining areas were served meals on trays, with no tablecloths on the tables, and an LPN stated this was not conducive with a homelike environment.
Failure to Use PPE During Enhanced Barrier Precautions: A UT and a CNA were observed providing resident care without the required gown and gloves while room signs indicated Enhanced Barrier Precautions. The UT said she was not told the resident was on precautions and did not look at the sign, while the CNA acknowledged she should have been wearing PPE. Records showed one resident had a suprapubic catheter with EBP on the care plan and another had a physician order for EBP every shift.
Surveyors observed multiple sanitation and environmental issues on the South unit, including filled garbage bags on the floor in the Sub-Acute soiled utility room and biohazard rooms, overflowing trash, a broken hand sanitizer dispenser, an incontinence brief and used glove on the floor near a trash bin with no bag, a broken tile, and missing wall molding in a resident room. The DON stated that trash on the floor and missing molding should not be present because it is not a homelike environment and can cause germs to spread.
A resident who required max assistance with bathing and mod assistance with personal hygiene, including shaving, was observed with an untrimmed beard and moustache, oily unkempt hair, and a malodorous room. The resident stated they wanted a shave but had not been offered one until that day, and the EMR, PN, MAR/TAR, and 24-hour reports did not document any refusal of care. Staff and the DON stated that alternative care and documentation are used when showers are refused, and that shaving is part of care.
A resident with chronic respiratory failure, anoxic brain damage, and an unspecified contracture was observed with the right hand flexed into a fist on multiple occasions, with no splint, hand roll, or other positioning device present. The record showed no PT, OT, or restorative nursing services, no active order for a right-hand positioning device, and a care plan that did not address preventing worsening of the contracture. The DON stated the facility did not have a restorative services program, and the DOR said the resident had no positioning device because of wound risk.
A resident receiving dialysis had a physician-ordered 1500 mL fluid restriction, but multiple beverages were observed at the bedside and the resident was unsure about the restriction. Staff gave inconsistent accounts of how fluid intake should be monitored and documented, and no fluid intake documentation was found in the communication book or progress notes despite facility policy requiring nursing to document the amount of fluids the resident receives.
Medication labeling and storage were not maintained as required. An uncapped, unlabeled tube of zinc oxide and an uncapped, unlabeled tube of A&D ointment were found in a resident’s room, even though the resident was ventilator-dependent and fully dependent for care. In addition, the north wing medication room refrigerator had no visible internal thermometer while medications and vaccines were stored inside, and loose tablets were found in the drawers of two medication carts. The DON and CP stated that treatment tubes should be labeled and stored in treatment carts, medication refrigerators should have internal thermometers, and loose tablets should not be kept in the carts.
A facility failed to ensure infection control education was provided and documented for an agency CNA who entered a resident’s room requiring EBP without a gown or gloves while handling the bed remote. The CNA acknowledged she should have been wearing PPE, and the DON confirmed the agency orientation included verbal education on infection control, PPE, hand hygiene, isolation, and EBP, but there was no documentation of that training.
The facility was found to have multiple deficiencies in food labeling and storage, with numerous items in the refrigerator, spice rack, and meat freezer lacking proper labels or being exposed to air. The Dietary Director acknowledged the need for proper labeling to ensure freshness and prevent contamination, but the facility's practices did not align with its policies on food storage and labeling.
The facility failed to timely address CP recommendations for three residents, including changes to medication administration and record-keeping. Recommendations made in August and September 2024 were not acted upon until October 2024, contrary to the facility's policy requiring completion within five days.
A resident experienced an unwitnessed fall, and the facility failed to maintain proper documentation and conduct a thorough investigation. The resident, who was cognitively intact, fell backward, and while initial assessments were performed, crucial documentation such as the RN's statement and neurological assessments were missing. Interviews revealed that required statements and post-fall documentation were not completed, and the DON confirmed the investigation was incomplete, highlighting the importance of such investigations to rule out abuse.
A facility failed to update a care plan for a resident with a surgical wound infection. Despite the resident's cognitive intactness and specific diagnoses, there were no physician's orders for wound care upon admission. Interviews with staff confirmed the oversight, and the facility's policy on care planning was not followed.
The facility failed to obtain admission orders and maintain proper documentation for a surgical wound, leading to delayed treatment for a resident. Another resident with a PICC line lacked necessary care orders, and a third resident's treatment records were incomplete, with multiple blanks in the TAR. Staff interviews confirmed the importance of proper documentation and adherence to care protocols.
A resident with cognitive impairment did not receive scheduled showers, and there was no documentation of refusals or family notifications. The LPN claimed to have contacted the family, but this was not recorded, violating the facility's policy.
The facility failed to properly store, label, and remove expired drugs, as observed in a medication room and cart. Expired cultures, vacutainers, and Pantoprazole were found, and lorazepam packaging was damaged. The LPN and acting-ADON acknowledged the issues, and the DON planned in-service education to address these deficiencies.
The facility failed to follow proper infection control practices, as an LPN did not perform hand hygiene before and between glove changes during medication administration, and an RN did not wear a gown while attending to a resident on contact precautions. These actions were contrary to the facility's policies on hand hygiene and transmission-based precautions.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner. During observation in the kitchen with the Regional Food Service Director present, an open bag of gelatin mix wrapped in plastic wrap and an opened bag of potato chips were found in the dry storage closet without a labeled open or used-by date. The Regional Food Service Director acknowledged the items should have been dated, and they were removed. The surveyor also observed the high-temperature dishwasher operating outside the temperatures reflected in the facility policy. The wash temperature was observed at 134 F and the final rinse temperature at 150 F, while the policy stated the wash temperature should be 150 F to 165 F and the rinse temperature should be 165 F to 180 F. In addition, the dishwasher temperature log had part of the lunch log entered before the lunch hour, and a Dietary aide stated this was a mistake and that they had gotten ahead of themselves. The surveyor also observed boxes containing food products stacked on the floor, including uncooked meat products stacked with boxes of food products, and the Regional Food Service Director stated the boxes were from a recent delivery and should not have been resting on the floor.
Improper Garbage Disposal Area Maintenance
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the garbage container area free of garbage and debris and by failing to keep a closed cover over the opening of 1 of 3 garbage containers. During an observation of the outdoor trash disposal area, three garbage containers were seen at the rear of the property, including one with an open lid and trash exposed to the elements and another overflowing with refuse. The area around the containers was littered with debris, including cardboard boxes and milk crates. During interviews, the EVSS stated the containers should remain free from debris and the lids should be closed, and the DOM stated housekeeping and maintenance were responsible for the area and that the containers were checked daily. The facility also failed to produce a trash or refuse policy when requested by the surveyor.
Dignity and Respect Deficiencies in Incontinence Care and Dining
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during incontinence care. During an initial tour, a surveyor observed the resident in bed wearing two incontinence briefs. A CNA stated that residents are not supposed to be wearing two incontinence briefs and said overnight staff were responsible, adding that when day staff find it, they report it to the nurses. The resident’s admission record showed diagnoses including dementia and type 2 diabetes, and the MDS indicated the resident was always incontinent of bowel and bladder. The resident’s care plan did not include any interventions related to wearing two incontinence briefs until after the issue was brought to the facility’s attention by the surveyor. The facility also failed to provide a dignified dining experience in 3 of 3 dining rooms observed during the Dining Task. During breakfast and lunch observations, residents were served meals on trays in the south wing day room and south wing dining room, and there were no tablecloths on the tables during lunch. Meals were left on the trays for the meal, including when residents were seated at one table eating lunch off trays. An LPN stated that meals are usually served on trays in the dining room and acknowledged that this was not conducive with a homelike environment. The facility’s dignity policy stated that residents are to be cared for in a manner that promotes well-being, self-worth, self-esteem, and a dignified dining experience.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff and vendors used appropriate PPE during resident care in accordance with facility policy and accepted infection control practice. During an initial tour, an ultrasound technician was observed performing an ultrasound on a resident whose door indicated Enhanced Barrier Precautions were in place, but the technician was not wearing a protective gown. The resident’s EMR showed diagnoses including prostate cancer and obstructive and reflux uropathy, and the care plan identified a focus for Enhanced Barrier Precautions related to a suprapubic catheter. In interview, the ultrasound technician stated the nurses did not tell her the resident was on precautions and said she did not look at the sign on the door. A separate observation found a CNA employed by a staffing agency inside another resident’s room, where a sign outside the doorway indicated Enhanced Barrier Precautions were required. The CNA was operating the resident’s bed remote control while the resident was in bed, and the CNA was not wearing a protective gown or disposable gloves. The CNA acknowledged she should have been wearing gown and gloves. The resident’s EMR showed a physician’s order for Enhanced Barrier Precautions every shift, started on 09/20/2025. The facility’s policy identified high-contact resident care activities requiring Enhanced Barrier Precautions, including dressing, bathing, transferring, hygiene, changing linens, and changing briefs or assisting with toileting.
Unsafe and Unclean Environment on South Unit
Penalty
Summary
The facility failed to maintain a clean and sanitary environment on the South unit, with surveyors observing multiple housekeeping and environmental issues during the initial tour. In the Sub-Acute soiled utility room, a filled garbage bag was on the floor and garbage was overflowing from the receptacle bin. In the soiled biohazard room across from a room, filled garbage bags were left on the floor, and in the biohazard room located in the secured unit, filled garbage bags were also on the floor. Surveyors additionally observed a broken hand sanitizer dispenser next to a room, an incontinence brief and used disposable glove on the floor near a trash bin with no trash bag, more filled trash bags on the floor, and a broken tile in the biohazard room. In one resident room, the molding was missing from the middle of the wall. The DON stated that missing molding and trash on the floor should not be present because it is not a homelike environment and can cause germs to spread in the facility.
Failure to Provide Needed Facial Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure Resident #153, who required assistance with activities of daily living, received necessary facial care to maintain proper grooming and personal hygiene. On 2/12/2026, the resident was observed in bed wearing a hospital gown with a thick, untrimmed beard and moustache about 2 inches long, oily and unkempt hair, and a malodorous smell in the room. On 2/13/2026, the resident was again observed in bed wearing a hospital gown, and the face was then shaven, but the hair still appeared oily and unkempt. The resident stated they did not want a shower but wanted their face shaved, and said they had been in the facility for two weeks and had not been offered shaving until that day. Record review showed the resident was admitted with diagnoses including legal blindness, cellulitis of both lower limbs, and abnormalities of gait and mobility. The MDS dated 2/10/2026 indicated intact cognition, maximum assistance with bathing, and moderate assistance with personal hygiene including shaving. The care plan initiated on 2/5/2026 stated the resident required assistance with ADLs such as showering and shaving. Progress notes, MAR/TAR notes, and the 24-hour reports did not document any refusal of care from admission through the surveyor inquiry. Staff interviews indicated that when residents refuse showers, alternatives such as a bed bath or hair wash in bed are offered and refusals are documented, and the DON stated shaving is part of care on shower days and as needed.
Failure to Provide Services for Resident Contracture and Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with an unspecified contracture received services to prevent further decreased ROM after therapy was discontinued. Resident #12 was admitted with chronic respiratory failure, dependence on a respirator, anoxic brain damage, and unspecified contracture. During observations on 2/12/2026, 2/13/2026, and 2/17/2026, the resident was alert but non-verbal, mechanically ventilated via tracheostomy, and resting in bed with the right hand flexed at the wrist and the right fingers flexed into a fist. No hand splint, hand roll, or other positioning device was observed on the resident, the bed, or in the room, and the UM/RN confirmed the right hand was contracted. The medical record showed severely impaired cognitive skills, unspecified contracture, no PT, OT, or restorative nursing participation, and no splint or brace assistance on the MDS. The active order summary did not include any current or discontinued order for a right-hand positioning device, and the OT order had been discontinued in 10/2022. The comprehensive care plan for limited mobility did not include an intervention to prevent worsening of the right-hand contracture. The DON stated the facility did not have a restorative services program, and the DOR stated the resident did not have a positioning device because of wound risk. No PT or OT service reports were initially provided to the surveyor, and the OT evaluation and plan of treatment showing bilateral palm rolls was provided only after the survey inquiry.
Failure to Document and Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to accurately implement a physician-ordered 1500 mL fluid restriction for a resident with chronic kidney disease stage 4 and dependence on renal dialysis. During observation, the resident had multiple fluids at the bedside, including diet soda, water, milk, a juice cup, and two glasses of a pink beverage, and stated they were unsure whether they were on a fluid restriction. The resident’s record showed dialysis scheduled three times weekly and a care plan focused on dialysis with monitoring of intake and output. The nutrition evaluation and dietitian note both reflected a diabetic/renal diet with a 1500 cc fluid restriction prescribed by the MD. The facility did not have an active diet slip available when requested, and one was written in the surveyor’s presence. Staff interviews showed inconsistent understanding of how the fluid restriction was to be monitored and documented: an LPN stated they were unaware of the restriction and believed documentation would only occur if intake and output were specifically ordered, while the DON stated fluid observations should be documented in the MAR and/or TAR. Review of the 24-hour communication book and progress notes revealed no documentation of the resident’s fluid intake, despite the facility policy stating that the nursing department will document the amount of fluids the resident receives.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Medications and biologicals were not consistently labeled and stored in accordance with facility policy and accepted professional principles. During the initial tour, an uncapped, unlabeled, and unbagged 4-ounce tube of zinc oxide ointment was observed on the overbed table at the foot of Resident #25’s bed, and an uncapped, unlabeled, and unbagged 4-ounce tube of Vitamin A&D ointment was observed on the windowsill beside the bed. Resident #25 was in bed connected to a mechanical ventilator, was fully dependent on staff for all activities of daily living including transfers, and had diagnoses including cerebral palsy, dependence on respirator status, and persistent vegetative state. The resident’s record showed a prior order for zinc oxide that had been discontinued, and there was no active or discontinued order found for Vitamin A&D ointment. The north wing medication room refrigerator was also found without a visible internal thermometer. When the refrigerator was opened, warm air was observed inside, and medications and biologicals were stored within it, including daptomycin, intravenous saline with vancomycin vials, Aplisol solution, and Fluarix influenza vaccines. RN/UM #2 could not locate the thermometer and stated that there should have been one inside the refrigerator. The DON stated that medication refrigerators need an internal thermometer and that the facility process was to keep internal temperatures at 38 to 40 degrees Fahrenheit. The CP also stated that medication refrigerators should have internal thermometers to ensure temperatures remained within manufacturer recommendations. Loose tablets were also observed inside medication cart drawers in two separate carts on the north wing. Five loose tablets were found in the drawer of the north wing front cart, and three loose tablets were found in the drawer of the east wing even cart. RN/UM #2 and RN/UM #1 each stated that loose tablets should not be in the carts and should be disposed of in the drug disposal bottle located in the medication cart. The DON and CP both stated that loose tablets should not be in the medication cart and should be removed and disposed of by nursing staff. Facility policy stated that medications and biologicals are to be stored in their received packaging or containers and kept in locked compartments under proper storage conditions.
Agency CNA Lacked Documented Infection Control Orientation
Penalty
Summary
The facility failed to ensure that infection control education was provided and documented for 1 of 1 agency staff members, a CNA who was providing care to a resident in a room requiring Enhanced Barrier Precautions (EBP). During a tour of the unit, a surveyor observed the CNA inside the resident’s room while the resident was in bed, with bed sheets on the floor and the privacy curtain half drawn. Although a sign outside the doorway indicated that the room required EBP, the CNA was operating the resident’s bed remote control without wearing a protective gown or disposable gloves. When asked, the CNA acknowledged that she should have been wearing a gown and gloves and confirmed that she worked for a staffing agency. Record review showed that the resident had a physician’s order for EBP every shift, started on 09/20/2025. The CNA’s facility orientation and competency record contained only a welcome document addressing abuse reporting and reporting protocols, with no infection control education, procedures, or policies documented. The DON stated that agency CNAs receive a facility tour and verbal education on infection control, PPE, hand hygiene, isolation, and EBP, but confirmed that this education was not documented and was provided only verbally. The facility’s policy for orienting agency staff stated that agency staff should receive onboarding to ensure resident safety and wellbeing and should be provided a census for the side they are assigned to.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as observed by a surveyor in the presence of the Dietary Director (DD) and the Regional Dietary Director (RDD). During the inspection, various food items in the refrigerator, spice rack, and meat freezer were found improperly labeled or not labeled at all with open and use-by dates. Specific items included breadcrumbs mislabeled as flour, an opened stick of butter, tomatoes, cooked puree pork, salad dressings, and various cheeses and condiments without appropriate labeling. Additionally, spices and dry goods were found exposed to air and not properly sealed or labeled, including granulated garlic powder, ground ginger, and pancake waffle mixes. The DD acknowledged that items should be labeled to ensure freshness and prevent contamination. The facility's policies on dating and labeling, dry food storage, and opened food storage were reviewed and found to be inconsistent with the observed practices. These policies require all food items to be labeled with the name, received date, and use-by date, and to be stored in airtight containers to prevent exposure to air and contaminants. The surveyor noted that the facility did not comply with these policies, as evidenced by the numerous unlabeled and improperly stored food items, which could potentially lead to contamination and health risks.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for three residents reviewed for medication management. For Resident #70, the CP had recommended changes to the administration of Carvedilol, correction of a duplicate Tylenol order, and adjustment of MiraLAX dosage. These recommendations, made in August and September 2024, were not acted upon until October 3, 2024. Resident #92's CP recommendations included writing separate orders for Morphine sulfate, sequencing the indication for Tylenol, and verifying Morphine Sulfate liquid dosage. These recommendations, initially made in August 2024, were not addressed until October 3, 2024. The delay in addressing these recommendations indicates a lapse in the facility's medication management process. For Resident #50, the CP's recommendations included changes to the administration records for Ammonium Lactate, Omeprazole, and Guaifenesin ER, as well as clarifications for several other medications. These recommendations, made in August and September 2024, were not completed until early October 2024. Interviews with the North Unit Manager and the Director of Nursing revealed that the facility's policy required CP recommendations to be completed within five days, a standard that was not met in these cases.
Failure to Document and Investigate Unwitnessed Fall
Penalty
Summary
The facility failed to maintain proper documentation and conduct a thorough investigation following an unwitnessed fall involving Resident #278. The resident, who was cognitively intact with a BIMS score of 13 out of 15, experienced a fall on 07/22/2023. The nursing progress notes indicated that the resident lost balance and fell backward, after which vital signs were taken, and a body assessment was performed. However, the surveyor found that the Registered Nurse's statement and neurological assessments were missing from the Accident/Incident Report Checklist provided by the facility. Interviews with facility staff revealed that the Licensed Practical Nurse was responsible for obtaining vital signs, while the Registered Nurse was to complete the full assessment. It was confirmed that statements from all staff involved, including the RN, were not obtained, and there was a lack of post-fall documentation, including neurological checks. The Director of Nursing acknowledged that a thorough investigation was not completed, emphasizing the importance of such investigations to rule out abuse. The facility's policies on accidents, incidents, and documentation were not adhered to, as evidenced by the missing witness accounts, follow-up information, and the signature of the person completing the report.
Failure to Revise Care Plan for Surgical Wound Infection
Penalty
Summary
The facility failed to revise a comprehensive care plan to address the nursing interventions required for a surgical wound infection in one of the residents. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had diagnoses including surgical aftercare following surgery on the digestive system and a retroperitoneal abscess. Despite these conditions, the resident's Order Summary Report, Medication Administration Record, and Treatment Administration Record did not include physician's orders for surgical wound care or maintenance upon admission. The individualized comprehensive care plan noted enhanced barrier precautions related to a surgical incision but lacked specific interventions for surgical wound care. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the oversight. The LPN described the care plan as a guideline that should be continuously updated to reflect the resident's needs, including any surgical wounds and necessary nursing interventions. The Director of Nursing acknowledged the absence of an updated care plan regarding the surgical wound infection. The facility's policy on care planning emphasized the need for measurable objectives, timeframes, and ongoing assessments to ensure care plans are revised as residents' conditions change, which was not adhered to in this case.
Deficiencies in Wound and PICC Line Care Documentation
Penalty
Summary
The facility failed to obtain admission orders and maintain proper documentation for a surgical wound for a resident who had undergone surgery on the digestive system and had a retroperitoneal abscess. Upon review, it was found that there were no physician's orders for surgical wound care upon admission, and the documentation of the wound was inconsistent, with missing entries on certain dates. The resident experienced sero-sanguinous and purulent drainage from the wound, indicating a possible infection, yet there was a delay in obtaining appropriate treatment orders. Interviews with staff confirmed that admission orders for surgical wounds are crucial to prevent infection and ensure proper care. Another resident was admitted with a PICC line but lacked physician orders for its care and maintenance, including dressing changes and flushes to keep the line patent. The facility's policy required such orders to ensure the PICC line remained free from infection and functional. Despite the absence of orders, a nurse documented flushing the PICC line, which was not authorized, raising concerns about the accuracy of the documentation and the potential for errors in patient care. Additionally, the facility failed to maintain complete treatment records for a third resident, as evidenced by multiple blanks in the Treatment Administration Record (TAR) for various treatments, including wound vac changes, offloading heels, and pain assessments. Interviews with the Unit Manager and DON confirmed that there should be no blanks in the TAR, indicating a lapse in documentation and potentially in the administration of necessary treatments.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, which was identified during a survey. The resident, who was moderately cognitively impaired and required substantial assistance with showering, was scheduled to receive showers every Sunday and Thursday. However, the Treatment Administration Record (TAR) for September showed multiple instances where the showers were not documented, and there was no record of the resident refusing showers or the family being notified of such refusals. Interviews with the Regional Clinical Director and a Licensed Practical Nurse (LPN) revealed that although the LPN claimed to have contacted the resident's family regarding the refusals, this was not documented in the progress notes. The facility's policy required documentation of any refusals and the reasons, along with any interventions taken, but this was not adhered to. The lack of documentation led to the conclusion that the showers were not provided as scheduled.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to properly store, label, and remove expired drugs from its inventory, as observed in one of the medication rooms and one of the medication carts. During an inspection, the surveyor found expired cultures, urine vacutainers, and a bag of Dextrose solution in the medication storage room. Additionally, bottles of Pantoprazole with past use-by dates were also found. The LPN/Unit Manager present during the inspection acknowledged the expired items and admitted to not knowing the expiration details of the Pantoprazole, confirming the need to discard the expired items. In a separate observation, the surveyor noted that the packaging of lorazepam tablets on a medication cart was opened and torn, which was not noticed by the LPN responsible for counting the medication. The LPN admitted to not checking the back of the package during the count. The acting-Assistant Director of Nursing confirmed that both sides of medication packages should be checked for integrity during counts, and any damaged packages should be discarded with supervisors notified. The Director of Nursing stated that in-service education would be provided to ensure proper handling of damaged medication packages.
Infection Control Deficiencies in Hand Hygiene and Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and while following transmission-based precautions. During a medication administration task, an LPN was observed not performing hand hygiene before applying gloves and between changing gloves. The LPN admitted to not performing hand hygiene despite acknowledging its necessity. The facility's policy on administering medications and hand hygiene clearly outlines the requirement for hand hygiene before and after glove use, which was not followed in this instance. Additionally, a separate incident involved an RN failing to wear a gown while inside a resident's room who was on contact precautions due to Group B Streptococcus and Methicillin Resistant Staphylococcus Aureus in a wound. The RN acknowledged the need for a gown to protect both herself and the resident but did not comply with the precautionary measures. The facility's policy on transmission-based precautions mandates the use of gowns and gloves for interactions involving contact with the resident or potentially contaminated areas, which was not adhered to in this case.
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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.
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Nursing homes near Linwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowview Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Our Ladys Center For Rehabilitation & Healthcare | 3.7 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At The Shores | 5.3 mi | ★★★★★ | 9 | 0 |
| Excel Care At Egg Harbor | 5.5 mi | ★★★★★ | 1 | 0 |
| Preferred Care At Absecon | 8.2 mi | ★★★★★ | 0 | 0 |
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