A list of the most recent deficiencies for Linda Manor Extended Care Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-11-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-01 | 2023-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-24 | 2023-05-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-24 | 2023-05-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-24 | 2023-05-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-24 | 2023-05-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-24 | 2023-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-24 | 2023-05-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-05-03 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-24 | 2023-05-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-24 | 2023-05-03 | N |
| Keep all essential equipment working safely. | Health | 2023-03-24 | 2023-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-05-01 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-03-29 | 2023-05-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-29 | 2023-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-03 | 2022-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-03 | 2022-06-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-09-17 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-22 | 2021-08-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-09 | 2021-07-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-09 | 2021-07-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-09 | 2021-07-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-09 | 2021-07-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-09 | 2021-07-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-09 | 2021-07-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-07-09 | 2021-07-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-09 | 2021-07-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-27 | 2019-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-27 | 2019-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-12 | 2019-03-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-12 | 2019-03-28 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-02-12 | 2019-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-12 | 2019-03-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-12 | 2019-03-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-12 | 2019-03-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-12 | 2019-03-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-12 | 2019-03-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-02-12 | 2019-03-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-12 | 2019-03-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-02-12 | 2019-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-27 | 2019-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-27 | 2019-03-14 | N |
