The Lingenfelter Center

In the surveyor’s words

From the most serious findings on record at The Lingenfelter Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF732Jun 6, 2024

  Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure all of the correct information was on the daily staff posting. Findings include: Review of the daily staff posting dated April 14, 2024 revealed the date, census, total number of licensed staff, the total number of non-licensed staff, total hours for licensed staff and total hours for non-licensed staff, but did not reveal the actual hours worked for each category of licensed and non-licensed staff. The daily staff posting dated January 1, 2024 was not provided by the facility. An interview was conducted on June 6, 2024 at 8:28 a.m. […]

• No harm, potential for more than minimal, isolatedF583Jul 9, 2026

  Based on observation, clinical record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure that privacy was maintained during medication administration for 3 residents (#203, #200, and #206) out of 11 sampled residents. The universe was 87. This deficient practice could result in unauthorized access to residents' private medical records.Findings include:-Resident #203Resident #203 was admitted on [DATE] with diagnosis including vascular dementia with anxiety, type 2 diabetes mellitus, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF689Jul 9, 2026

  Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure one of six sampled residents (#210) received a timely, monitoring, and treatment following a fall. The deficient practice delayed recognition of the resident's injury and delayed medical treatment resulting in prolonged pain, hospitalization and surgical hip repair of a right hip fracture. Findings include:Resident #210 was admitted on [DATE] with diagnoses including dementia, osteoporosis, paranoid schizophrenia, cognitive communication deficit, epilepsy, history of falling, and generalized muscle weakness.The fall risk assessment dated [DATE] revealed a score of 6.0, indicating a low fall risk. […]

• No harm, potential for more than minimal, isolatedF757Jul 9, 2026

  Based on observation, clinical record review, interviews, facility documentation and policy, the facility failed to ensure necessary blood sugar medications were administered according to provider orders for one resident (#200) out of five sampled residents. The universe was 87. This deficient practice could put residents at the risk for not receiving medications as per the parameter.Finding include: Resident #200 was admitted on [DATE], with diagnosis including unspecified dementia with anxiety, post-traumatic stress disorder, type 2 diabetes mellitus (DM), and sleep apnea.A review of the care plan dated [DATE], revealed that the resident was at risk of fluctuating blood sugar related to DM. […]

• No harm, potential for more than minimal, isolatedF600Apr 8, 2026

  Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights for two of three sampled residents (#3, #5) to be free from physical abuse by another resident. The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment. The sample was 3. The universe was 3.Findings include:A facility-reported 5-day investigation, submitted to the State Agency on April 3, 2026, revealed that a resident-to-resident altercation occurred on March 31, 2026, at approximately 7:11 PM, involving Resident #3 and Resident #5. […]