Linwood Village Nursing & Retirement Apts

In the surveyor’s words

From the most serious findings on record at Linwood Village Nursing & Retirement Apts, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 21, 2021

  Based on record review and interview, it was determined the facility failed to provide supervision to ensure a resident's safety while outside on the facility's patio, resulting in heat exhaustion for one (#1) of three residents who were reviewed for supervision. It resulted in the resident being treated for heat exhaustion at a local emergency room . This had the potential to affect 29 residents which required supervision outside of the facility. Findings: Resident #1 had diagnoses which included COVID-19, [CONDITION(S)], hypertension, cardiomegaly, major depressive disorder, [CONDITION(S)] disorder and [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF655May 23, 2025

  Based on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 3 (#47, 54, and #161) of 15 sampled residents reviewed for baseline care plans. The administrator identified 55 residents resided in the facility. Findings: A Care Plans- Baseline policy, revised March 2022, read in part, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. […]

• No harm, potential for more than minimal, patternF851May 23, 2025

  Based on record review and interview, the facility failed to ensure the direct care staffing hours on the Quality of Care report were accurately reported. The administrator identified 55 residents resided in the facility. Findings: A policy titled Quality of Care (QOC) Reporting policy, read in part, This policy establishes a structured approach to tracking, reporting, and improving Quality of Care in SNF's, (Skilled nursing facility) ensuring compliance with CMS (Centers for Medicaid/Medicare) regulations, PDPM (payment driven patient module) documentation standards, and Quality Reporting Programs (QRP). Review of the Quality of Care Report for February, March, and April 2025, showed the following days were below the state required minimum of 2.9%: a. […]

• No harm, potential for more than minimal, patternF565Feb 23, 2024

  Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Administrator identified 49 residents resided in the facility. Findings: A Resident Council Meeting policy, dated 01/02/24, documented the facility shall act upon concerns, make attempts to accommodate, and communicate their decisions to the council. Resident Council minutes, dated 11/30/23, documented concerns with nurses yelling down the hall, medications were administrated late, call lights in the morning not being answered while food was being delivered, residents not being assisted timely, hamburgers were dry, not enough vegetables, and resident items were missing. […]

• No harm, potential for more than minimal, patternF657Feb 23, 2024

  Based on record review and interview, the facility failed to ensure care plans were revised for three (#34, 40, and #32) of 13 sampled residents reviewed for care plans. The Administrator identified 49 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 01/02/24, documented the plan of care would be revised as needed. 1. Resident #34 had diagnoses which included dementia. A Care Plan for falls, was last updated 01/09/24. Progress Notes, dated 02/07/24 and 02/10/24, documented the resident fell . It documented on 02/07/24 Resident #34 sustained a right clavicle fracture. […]