Linwood Meadows Care Center

In the surveyor’s words

From the most serious findings on record at Linwood Meadows Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 3, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant (CNA) 1 was allowed to continue to care for Resident 1. This failure resulted in Resident 1 sustaining skin discoloration to hands, wrists, and abrasions (injury to the skin caused by force) to the left forearm and right shoulder which caused Resident 1 pain and emotional distress. Findings: During a review of Resident 1's Progress Notes, dated 9/8/21, at 10 PM, the Progress Notes indicated, At this time resident sitting at nursing station in geri chair [reclining chair on wheels]. Resident is sitting with legs hanging over the side of geri chair. […]

• No harm, potential for more than minimal, widespreadF880Oct 26, 2023

  Based on interview and record review, the facility failed to follow its policy and procedure on: 1. Surveillance for Infections when the monthly reports did not contain the complete information required. 2. Monitoring Compliance with Infection Control when the facility did not complete the hand hygiene monitoring. These failures had the potential to result in a facility-wide infection outbreak affecting all residents, staff, and visitors. Findings: 1. During a concurrent interview and record review on 10/24/23 at 9:28 a.m. with Infection Preventionist (IP) 1 and IP 2. The facility's Infection Surveillance Monthly Report (ISMR) dated August and September 2023, were reviewed. IP 1 stated the infection surveillance were incomplete. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2021

  Based on observation, interview, and record review, the dietary staff failed to follow proper sanitation and safe food handling practices when: 1. Ensuring the inside of two clean plate covers were not touching DS uniform while waiting to cover the lunch plates. 2. Performing handwashing and changing gloves prior to preparing a grilled cheese sandwich during tray line. These failures had the potential to result in foodborne illnesses for residents in the facility. Findings: 1. During a concurrent observation and interview on 7/20/21, at 12:16 PM, with Registered Dietitian (RD), Dietary Aide (DA) was observed holding the inside of two clean plate covers against his uniform while waiting to cover lunch plates with food prepared in the tray line. RD validated the findings. 2. […]

• No harm, potential for more than minimal, widespreadF814Jul 23, 2021

  Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly collected and disposed in a safe and efficient manner. This failure had the potential to result in harboring, feeding, and attracting pests and vermin. Findings: During an observation on 7/19/21, at 12:32 PM, in the area just outside of the kitchen, with Dietary Supervisor (DS) and Registered Dietitian (RD), one of two garbage dumpster's had the cover left opened . During an interview on 7/23/21, at 11:00 AM, with RD, RD stated, the two garbage dumpster's should always be closed to prevent harborage and feeding of pests, and pest infestation.

• No harm, potential for more than minimal, widespreadF880Jul 23, 2021

  Based on observation, interview, and record review, the facility failed to: 1. Handle, store, process linens in a safe and sanitary method to prevent the spread of infection. 2. Store clean briefs appropriately. 3. Maintain a safe and sanitary environment in resident bathroom. 4. Two housekeeping staff failed to follow manufactures contact times for disinfectant. These failures had the potential to spread communicable diseases and infection to the facility's residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 7/20/21, at 8:56 AM, with the Laundry Aide (LA), in the Laundry Dirty Area, seven yellow barrels with soiled linens inside and three big gray barrels with clean pillows inside were observed stored side by side. […]