Linwood Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF919Sep 5, 2024

  Based on observations, a review of facility documentation, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure the call bell system was fully functional in three (100, 200 and 300) out of the four areas of the facility. The facility failed to identify the risks and safety of the residents who need to utilize their call bell for staff assistance placing the residents in an Immediate Jeopardy situation. […]

• Actual harm, isolatedF600Jul 1, 2026

  Based on a review of facility policies, clinical records, facility investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure one of 10 residents reviewed (Resident 1) remained free from emotional and psychosocial abuse, exploitation, and invasion of privacy when a staff member intentionally recorded the resident on a personal cellular telephone during toileting care and while the resident was using the toilet without the resident's knowledge or consent. This deficient practice resulted in actual psychosocial harm through humiliation, loss of dignity, and violation of the resident's privacy. […]

• Actual harm, isolatedF689May 21, 2025

  Based on observation, review of clinical records and select facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that staff implemented a physician-ordered adaptive device (lidded cup) to mitigate the risk of injury from hot liquids for one of 21 sampled residents (Resident 60) resulting in actual harm, a burn injury to the upper thigh area and failed to ensure nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for one of 21 residents reviewed (Resident 195). These failures resulted in actual harm to both residents. […]

• Actual harm, isolatedF600Jun 28, 2024

  Based on a review of clinical records, select facility reports and the facility's abuse prohibition policy, and resident and staff interviews, it was determined that the facility failed to ensure that one resident was free from sexual abuse (Resident 48) and the facility neglected to provide the necessary care and services to prevent psychosocial and/or physical harm and physical discomfort for two residents out of 21 sampled (Residents 21 and 80). Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on May 10, 2024, indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the regulation. […]

• No harm, potential for more than minimal, widespreadF943Jun 28, 2024

  Based on staff interviews and a review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received training on the facility's abuse prohibition policy and facility specific-procedures. Findings include: During an interview with the Nurse Educator on June 28, 2024, at 10:00 a.m., revealed that the facility utilizes an on-line education platform for staff to complete mandatory education and additional education topics were provided as needed on paper and offered a variety of educational methods present topics. The Nurse Educator provided the educational content on which staff received for their annual abuse prevention education program. […]