Linden Grove Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Aug 20, 2025

  Based on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significant medication error that resulted in opioid overdose and hospitalization in an intensive care unit, requiring administration of Narcan (a life-saving opioid-reversing medication). In addition, the facility failed to ensure correct medication administration documentation for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for medication errors. On 08/14/2025 at 2:37 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.45(f)(2), F760, Free of any significant medication errors, related to the facility's failure to ensure that a resident (Resident 1) was not subject to significant medication errors. […]

• Actual harm, isolatedF686Oct 9, 2025

  Based on interview and record review, the facility failed to provide necessary care and monitoring of a Foley catheter (a medical device inserted into the bladder) to prevent the occurrence of an avoidable pressure injury (PI - localized damage to skin and/or underlying soft tissue related to an inserted medical device) for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when they developed an avoidable PI to the skin around the urinary catheter insertion site, with unrelieved pain evidenced by anxiousness, rolling in bed, restlessness, verbalizing pain and discomfort that required transfer to the hospital for evaluation, treatment, and pain management. […]

• Actual harm, isolatedF689May 22, 2025

  Based on interview and record review, the facility failed to accurately assess, identify, monitor, and adequately supervise residents at risk of elopement for 1 of 3 sample resident (Resident 1) reviewed for accident hazards. Resident 1, who had a cognitive impairment and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently observed by a bystander to fall on a freeway ramp, hit their head, and was transported by Emergency Services (EMS) personnel to a hospital for evaluation. […]

• Actual harm, isolatedF688Jan 26, 2024

  Based on observation, interview and record review, the facility failed to ensure two of four residents (Resident 68 and 85) reviewed for range of motion/mobility, consistently received restorative services (movement of joints to maintain range of motion) to maintain or prevent declines in mobility. This failure resulted in harm to Resident 68 who experienced a decrease in left hip extension and worsening of the left knee contracture (a permanent shortening of muscle and loss of joint mobility). This failure placed residents at risk of decreased motion, mobility and a decreased quality of life. […]

• Actual harm, isolatedF689Dec 6, 2023

  Based on observation, interview, and record review, the facility failed to address safety risk factors and provide the necessary supervision to ensure safety from avoidable accident and injuries for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure resulted in harm when Resident 1 was hit by a moving vehicle while in their wheelchair unsupervised out in the parking lot of the facility. Resident 1 required emergency medical services to transfer to the hospital, sustained a fracture to the left ankle, and experienced severe pain and discomfort. Findings included . […]