Linda Manor Extended Care Facility

In the surveyor’s words

From the most serious findings on record at Linda Manor Extended Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF656Jun 6, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose care plan interventions included the need for two staff members to provide assistance during care, which included incontinence care, bed mobility and repositioning, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions. On 05/04/25, Certified Nurse Aide (CNA #1) provided incontinence care to Resident #3 without another staff member present for assistance, CNA #1 positioned Resident #3 on his/her side, then turned away from the resident, he/she rolled off the bed and fell onto the floor. […]

• Actual harm, isolatedF689Jun 6, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who required the assistance of two staff members for dressing, toileting care needs, bed mobility, and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident resulting in a serious injury. On 05/04/25, Certified Nurse Aide (CNA) #1 provided care to Resident #3 without having another staff member present for assistance, CNA #1 repositioned Resident #3 onto his/her side in bed, then turned away from Resident #3 to grab something, leaving him/her unattended and he/she rolled off the bed onto the floor. […]

• Actual harm, isolatedF686May 3, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing upon admission to have no open areas (pressure injuries), had limited mobility due to a right distal femur (thigh bone) fracture and left distal humerus (long bone in the arm that runs from the shoulder to elbow) fracture, and was also assessed by nursing to be at high risk for skin breakdown, the Facility failed to ensure Resident #1 received adequate care to prevent the development of pressure injury, when nursing failed to consistently implement preventative skin care measure interventions including turning and repositioning, and application of foam boots. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2025

  Based on observation and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in three out of three applicable facility unit kitchenettes. Specifically, the facility failed to implement safe food practices in three out of three facility unit kitchenettes relative to labeling, dating and guidelines for food storage. Findings include: Review of the facility policy titled Dietary Department Guidelines, last updated 5/2018, indicated: >Food Preparation and Handling-Food items should be labeled and use by dated to allow for rotation of supplies.-All items stored in the refrigerator will be covered and use by date labeled.-Refrigerated foods and cold foods will be stored and held at refrigerator… […]

• No harm, potential for more than minimal, patternF842Aug 29, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who sustained two unwitnessed falls and whose Comprehensive Care Plan indicated he/she was at risk for dehydration with the potential for slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease) the Facility failed to ensure they maintained a complete and accurate medical record when 1) nursing did not complete the 72 hour neurological checks following each of his/her unwitnessed falls, and 2) Certified Nurse Aides (CNAs) daily documentation related to Resident #1's fluid and food intake were not consistently recorded on his/her flow sheets. […]