Linden Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 6, 2022

  Based on observation, interview and record review the facility failed to ensure one of three residents (1) was assessed for and interventions developed for exit seeking behaviors and elopement (leaving the premises unaccompanied, when assessed not to be safe to do so) in a timely manner. Failure to ensure assessment for elopement risk and adequate supervision, placed residents at risk for elopement and associated injuries. This failure caused actual harm to Resident 1, who walked away from the facility and fell , resulting in injuries that required medical treatment. […]

• No harm, potential for more than minimal, patternF880Nov 21, 2025

  Based on observation, interview and record review the facility failed to ensure staff followed infection control standards of practice regarding implementation of personal protective equipment (PPE, protective equipment designed to safeguard individuals and reduce the risk of contracting or spreading infectious diseases) with residents on Transmission Base Precautions (TBP, safeguards within a room or facility that are put in place to help prevent the spread of diseases) to mitigate the spread of COVID-19 for 5 of 5 staff (Staff I, P, Q, J and K), reviewed for infection control practices. This failure placed residents, staff, and visitors at an increased risk of exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases during a COVID-19 outbreak. […]

• No harm, potential for more than minimal, patternF689Oct 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident/hazards with: A) a resident that required a smoking apron for safety when smoking for 1 of 2 residents (Resident 29) reviewed for accident/hazard of smoking, B) the securement of compressed oxygen cylinder storage for 1 of 2 storage rooms (East/West storage room) reviewed for accident/hazards of oxygen cylinder storage, and C) that toxic cleaning chemicals were safely stored away from residents for 2 of 3 hallways (East/West and Central Hall) reviewed for accidents/hazards of chemicals. This failure placed residents at an increased risk for avoidable accidents, significate injury, and unmet care needs. […]

• No harm, potential for more than minimal, patternF804Oct 30, 2024

  Based on observation, interview, and record review, the facility failed to consistently provide appetizing and palatable food for 4 of 7 residents (Residents 44, 34, 21, and 57) reviewed for food quality. Additionally, observations in the kitchen showed a delay in meal service which resulted in cold food served to the residents. These failures placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals. Findings included . <Resident 44> Review of the resident's record showed they were admitted to the facility with diagnoses including diabetes (high levels of sugar in the blood), and chronic obstructive pulmonary disease (COPD, a chronic lung disease). […]

• No harm, potential for more than minimal, patternF812Oct 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure periodic testing of sanitizing agents used for proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, appropriate labeling of open foods, and that food delivery carts were clean, for 1 of 1 kitchen reviewed for safe food service. This failure placed residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases. Findings included . Review of the policy titled, Food Preparation and Service, dated ,d+[DATE], showed food and nutrition services staff would prepare, distribute, and serve food in a manner that complied with safe food handling processes. […]