Linden Place Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Linden Place Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600May 26, 2023

  Based on record review, observations, interviews with residents and staff, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 1 resident investigated for abuse (Resident #13). Resident #13 had reported to the facility Nurse Aide (NA)#1 needed to feed her roommate correctly. Resident #13 alleged later the same evening NA #1 grabbed Resident #13's face very hard, squeezed her face, in a manner which scared the resident and after the incident the resident was found to have bruising on her right jawline and right cheek. […]

• No harm, potential for more than minimal, patternF584Jan 10, 2026

  Based on observations and staff interviews, the facility failed to maintain in good repair a resident's room door and bathroom sink in 1 of 11 resident rooms and 1 of 11 resident bathrooms on 1 of 2 halls whose room and/or bathroom was observed to have environmental concerns (Resident #48).The findings included:1) An initial observation of Resident #48's room was conducted on 1/5/26 at 1:10 PM. This observation revealed the door latch on the door to the resident's room did not secure the door so that it would remain closed. Accompanied by the facility's Maintenance Director, an observation of the door to Resident #48's room was conducted on 1/8/26 at 4:00 PM. […]

• No harm, potential for more than minimal, patternF761Jan 10, 2026

  Based on observations and staff interviews, the facility failed to: 1) Label a medication with the minimum required information (including the resident's name) stored on 1 of 2 medication (med) carts (North Hall Med Cart #2); 2) Discard expired medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom) and on 1 of 2 medication carts observed (North Hall Med Cart #2); and 3) Date medications as to when they were opened to allow for the determination of the shortened expiration date for medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom).The findings included:1. An observation was conducted on 1/5/25 at 2:45 PM with Medication (Med) Aide #1 of the North Hall Medication Storeroom. […]

• No harm, potential for more than minimal, patternF565May 26, 2023

  Based on resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and/or respond to concerns voiced by residents during Resident Council meetings for 9 of 10 months (July 2022, August 2022, October through, December 2022, and January, February, March, and April 2023). Findings included: The Resident Council meeting minutes for July, August, October, November, and December 2022 revealed no concerns or grievances were documented from residents. The minutes indicated Resident #38, Resident #29, Resident #2, and Resident #55 attended these meetings. During an interview with the current Activities Director on 05/12/23 at 12:00pm, she stated she began working at the facility in April 2023. […]

• No harm, potential for more than minimal, patternF867May 26, 2023

  Based on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 5/12/23. This was for a deficiency that was cited in the area of Development/implement a Comprehensive Care plan on 5/28/21 and recited on the current recertification and complaint survey on 5/12/23. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 6/16/22. […]