Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Linley Park Post Acute during CMS and state inspections, most recent first.
Failure to notify the Medical Director when a resident with severe cognitive impairment, dysphagia, a feeding tube, and an NPO order was found chewing gum. Surveyor observations confirmed gum in the resident's mouth on more than one occasion, and a progress note stated family had brought gum unannounced after a visit. The MD stated he was unaware of the gum use, and the NP said the resident should not have had gum because she was NPO.
A resident with NPO status, dysphagia, and severe cognitive impairment was observed with gum in her mouth on more than one occasion, despite no order for gum or pleasure feeds. Staff gave mixed reports about whether family could bring gum, and the family member admitted providing it as a comfort measure even after being told the resident could choke. The resident had a prior choking incident, and the record showed delayed care plan intervention related to gum.
A resident with NPO status, dysphagia, and a feeding tube was repeatedly found with chewing gum in her mouth despite no order allowing it. Staff and family members reported that the resident’s husband and other visitors brought gum in, and the resident was observed chewing it on more than one occasion. The resident also had a prior choking incident involving food, and staff interviews showed inconsistent understanding of whether she could have gum.
The facility failed to ensure two residents had a working means to summon staff when the call light system in the hallway serving their rooms was not functional. A resident with intact cognition demonstrated that the call bell did not work and no staff responded during observation, while another resident had no handbell within reach and said he had never been given one. The DON stated there was no written policy or plan for when the system was being worked on, and the Maintenance Director confirmed the call lights were under repair and bells had been moved to rooms.
A resident received blood pressure medication outside prescribed parameters, and insulin was improperly administered to three residents using flex pens. LPNs admitted to these errors, and the facility's policies on medication administration were not followed, indicating lapses in medication management practices.
A resident with diabetes repeatedly refused insulin and blood sugar checks, but the facility failed to notify the physician and responsible party as required by policy. Despite the resident's significant medical history, there was no documentation of communication regarding these refusals, highlighting a deficiency in the facility's notification procedures.
The facility experienced a 16% medication administration error rate due to improper insulin pen use and failure to shake Flonase before administration. LPNs did not follow correct procedures for priming insulin pens, leading to uncertainty about correct dosing. Additionally, a resident self-administered Flonase without proper preparation. The DON could not provide documentation of staff training on these procedures.
Expired medications and biologicals were found in multiple medication and treatment carts within the facility. Items such as UTI-Stat Cranberry, wound dressings, and other medical supplies were expired and confirmed by LPNs before removal. Additionally, some medications lacked open or expiration dates, indicating a failure to adhere to the facility's storage policy.
Failure to Notify Medical Director of NPO Resident Chewing Gum
Penalty
Summary
The facility failed to ensure that the Medical Director was notified when Resident 21 was found chewing gum, despite the resident having diagnoses including hemiplegia and hemiparesis, multiple sclerosis, intellectual disability, Alzheimer's disease, dementia, epilepsy, aphasia, and dysphagia. The resident's MDS showed a BIMS score of 1 out of 15 and indicated the resident was on a feeding tube. The resident's orders specified an NPO diet, NPO texture, and NPO consistency. A progress note documented that the resident was found chewing gum after a family visit and that the family had brought gum to the resident unannounced; the resident spit out the gum and the family was educated that the resident could not chew gum. Surveyor observations later found the resident with gum in the mouth while awake in bed and again while sitting in a geri-chair. During interview, the Medical Director stated he never knew anything about the resident chewing gum, and the Nurse Practitioner stated the resident should not have had gum because she was NPO and that it was an aspiration risk.
NPO Resident Allowed to Chew Gum Without Clear Care Planning
Penalty
Summary
The facility failed to ensure that a resident with physician-ordered NPO status and documented aspiration risk had a care plan meeting and implemented measures to protect her from choking related to chewing gum. The resident’s diagnoses included hemiplegia and hemiparesis, multiple sclerosis, intellectual disability, Alzheimer’s disease, dementia, epilepsy, aphasia, and dysphagia. Her MDS showed a BIMS score of 1 out of 15 and that she was on a feeding tube. Her orders were for NPO diet, NPO texture, and NPO consistency, and no orders were found for pleasure feeds or chewing gum. The resident had a choking incident in June when a nurse witnessed food in her mouth and the resident was choking. A care plan intervention related to chewing gum was not implemented until later in December, and the record showed an intervention dated after the choking incident that called for frequent monitoring during mealtimes to ensure she did not have by-mouth foods. On observation, surveyors found the resident with a lump of chewing gum moving in her mouth while she talked. On another observation, she was again found with gum in her mouth while alone in her room, and the gum was removed by the ADON after the resident indicated how she would take it out. Staff interviews showed inconsistent understanding of whether the resident could have gum. Multiple staff stated they were not allowed to give her gum, but also reported that family members, especially her husband, brought it in and gave it to her. The medical director stated that if she was NPO, she should not be chewing gum and that there was a risk of aspiration. The family member acknowledged giving her gum as a comfort measure and said staff had previously told him she could choke from it, but he continued to bring it in until told otherwise. The resident was unable to answer questions about the gum during interview attempts and later stated that her husband gave it to her.
NPO Resident Allowed to Keep and Chew Gum
Penalty
Summary
The facility failed to ensure that a resident with physician-ordered NPO status and documented aspiration risk was protected from avoidable accident hazards related to choking. The resident had multiple diagnoses including hemiplegia and hemiparesis, multiple sclerosis, intellectual disability, Alzheimer’s disease, dementia, epilepsy, aphasia, and dysphagia. Her MDS showed a BIMS score of 1 out of 15 and that she was on a feeding tube. Her care plan included frequent monitoring during mealtimes after a choking incident, and her orders specified an NPO diet with no orders for pleasure feeds or chewing gum. Despite those orders, the resident was observed with chewing gum in her mouth on multiple occasions. She was seen smiling and talking with a lump of gum moving in her mouth, and later was again found alone with gum in her mouth while sitting in a geri-chair. When asked, she indicated the gum was kept in her window and demonstrated how she would remove it and throw it away. At another point, staff found her chewing gum and removed it. The resident also had a prior progress note documenting that a nurse witnessed her with a sandwich in her mouth and choking. Staff interviews showed inconsistent understanding and enforcement of the resident’s NPO status. Several staff stated they were not allowed to give her gum, but family members, especially her husband, brought it in and gave it to her. One family member acknowledged giving her gum as a comfort measure and said she forgot she had been told the resident could choke from it. The medical director and nurse practitioner both stated that because she was NPO, she should not have gum and that it was an aspiration risk. The resident was unable to answer questions reliably about the gum, and staff reported that she frequently asked for it.
Call Light System Not Functional and No Reliable Means for Residents to Summon Staff
Penalty
Summary
The facility failed to ensure residents had a means to call for staff when the call bell system was not functional in the hallway serving rooms 20 through 34, affecting 2 of 2 residents reviewed. The surveyor requested a copy of the call bell policy or a written plan for when the system was being worked on, and the DON stated that no policy or plan existed. During observation, R7, who was cognitively intact with a BIMS score of 15 and dependent for toileting hygiene, transfers, and wheelchair mobility, demonstrated that her call bell was not functioning when she pushed it and the red light above the cord did not flash. No staff member came to her room during the 20-minute observation period, and no handbell was observed within her reach. R7 stated the call bell had not worked since the previous day and that she did not know how she would get help if it was not working. R86, who also had a BIMS score of 15 and was dependent for all ADLs except eating and bed mobility, was observed lying in bed with no handbell on his bedside table or within reach. He stated that he had never been given a bell to ring. An LPN stated the call light system had been replaced and that everyone should have a bell they could use, and later found a bell in R7's room behind the TV. The DON stated bells were given to everyone when the call lights were being worked on but was unsure whether there was a written plan or policy. The Maintenance Director confirmed the call lights were being worked on on that side of the building and that bells had been brought to the rooms, with final testing still pending.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that Resident 125 was free from significant medication errors, as the resident received a blood pressure medication, Midodrine, outside the ordered parameters. The physician's order specified that the medication should not be administered if the systolic blood pressure was greater than 120. Despite this, the medication was given multiple times when the resident's systolic blood pressure exceeded this limit. This error was acknowledged by the involved LPNs during interviews, who admitted to administering the medication despite the blood pressure readings being outside the prescribed parameters. Additionally, the facility failed to properly administer insulin using a flex pen for three residents observed during medication administration. The LPNs involved did not follow the correct procedure for priming the insulin pen, which is necessary to ensure the correct dose is delivered. Observations revealed that the insulin pens were not held upright, and the presence of insulin at the needle tip was not confirmed before administration. This improper technique was confirmed by the LPNs during interviews, who acknowledged their mistakes in the administration process. The facility's policies on medication administration were not adhered to, as evidenced by the failure to follow prescriber orders and the incorrect administration of insulin. The Director of Nursing was unable to provide documentation of nurse check-off sheets for insulin administration, indicating a lack of oversight and training in medication administration procedures. These deficiencies highlight significant lapses in the facility's medication management practices, affecting the safety and well-being of the residents involved.
Failure to Notify Physician and Responsible Party of Insulin Refusal
Penalty
Summary
The facility failed to notify the physician and the responsible party for a resident who refused insulin on multiple occasions. The facility's policy requires that the resident's attending physician and responsible party be notified of significant changes in the resident's condition, including refusal of treatment or medications two or more consecutive times. Despite this policy, there was no documentation indicating that the physician or the responsible party was informed of the resident's repeated refusals of insulin and blood sugar checks. The resident, who was admitted with diagnoses including cerebrovascular accident, diabetes mellitus type 2, and other conditions, refused scheduled doses of insulin and blood sugar checks on several occasions in June and July 2024. Interviews with the responsible party and facility staff confirmed that the responsible party was not informed of these refusals, and the Director of Nursing acknowledged that the nurse should have notified the physician and the responsible party. The lack of documentation and communication regarding the resident's refusal of insulin represents a deficiency in the facility's adherence to its notification policy.
Medication Administration Errors in Insulin and Flonase
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5 percent, resulting in a 16 percent error rate during the survey. The errors were primarily related to the improper administration of insulin using insulin pens. On multiple occasions, LPNs did not follow the correct procedure for priming the insulin pens, which involves holding the pen upright and ensuring insulin is visible at the needle tip before administration. Instead, the pens were held horizontally, and the presence of insulin at the needle tip was not confirmed, leading to uncertainty about whether the correct dose was administered to the residents. Additionally, there was an incident involving the administration of Flonase, where the LPN failed to shake the medication before giving it to the resident, who then self-administered it without proper preparation. The LPN could not confirm that the resident received the medication correctly. The Director of Nursing was unable to provide nurse check-off sheets for the demonstration of proper insulin pen use, indicating a lack of documented training or competency verification for the staff involved in these medication errors.
Expired Medications and Biologicals Found in Facility Carts
Penalty
Summary
The facility failed to ensure that outdated medications and biologicals were removed from storage, as observed in multiple medication and treatment carts. Specifically, expired items were found in 3 out of 4 medication carts and 2 out of 2 treatment carts. These included a bottle of UTI-Stat Cranberry, various wound dressings, and other medical supplies such as cleansing body lotion and hydrogel impregnated gauze. The expired items were confirmed by different LPNs and subsequently removed from the carts. Additionally, several medications in use were found without open or expiration dates, including Aspart Flex Pen, Lantus Flex Pen, and Lispro Flex Pen. Other expired items included Goodsense Hemorrhoidal Suppositories and Guardian Fiber Powder. These findings indicate a lapse in the facility's adherence to its policy on the storage of medications, which mandates the return or destruction of outdated or improperly labeled drugs and biologicals.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare - Anderson | 1.4 mi | ★★★★★ | 0 | 0 |
| Achieve Rehabilitation And Nursing Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Richard M Campbell Veterans Nursing Home | 5.8 mi | ★★★★★ | 0 | 0 |
| Iva Post-acute | 15 mi | ★★★★★ | 5 | 0 |
| Piedmont Post-acute | 16.1 mi | ★★★★★ | 7 | 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.