Focused Care at Linden

In the surveyor’s words

From the most serious findings on record at Focused Care at Linden, in the surveyor’s own words.

• Immediate jeopardy, patternF635Feb 12, 2025

  Based on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 7 residents reviewed for admission physician orders. (Resident #93) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. […]

• Immediate jeopardy, patternF686Feb 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. […]

• Immediate jeopardy, patternF580Mar 13, 2024

  Based on interview and record review the facility failed to immediately consult the physician when a resident had a significant change in physical and mental condition for 1 of 7 residents reviewed for physician notification (Resident #1.) LVN A noted Resident #1 had a change in condition on [DATE] around 2:00 p.m. but LVN A did not consult the physician until 8:00 p.m. Facility staff failed to consult the physician when Resident #1's oxygen level was 87 percent and had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. […]

• Immediate jeopardy, patternF684Mar 13, 2024

  Based on interview and record review the facility failed to ensure treatment and care was provided to meet professional standards of practice for 1 of 7 residents reviewed for quality of care. (Resident #1) The facility failed to ensure Resident #1 was provided a timely assessment when she experienced a change of condition. LVN A noted Resident #1 had a change in condition on [DATE] around 2:00 p.m. but LVN A did not assess the resident at that time. At 8:00 p.m., Resident #1's oxygen level was 87 percent and she had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. […]

• Immediate jeopardy, patternF760Mar 13, 2024

  Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents reviewed for medications. (Resident #1 and Resident #2) The facility failed to ensure: *Resident #1 (deceased ) was given medications as prescribed. She was given Venlafaxine 75mg two times daily for a total of 6 times over a period of 5 days when the medication was supposed to be on hold. *Resident #1 was given Lisinopril and Metoprolol Succinate ER 12 times in [DATE] and 3 times in February 2024 when the medications were supposed to be held because her blood pressure was below the parameters. […]