Linden Village

Resident #1 hit Resident #2 in the face, resulting in a cut on the upper lip and a lost tooth.

A discrepancy was found between the actual morphine count and the narcotic count sheet, and a dose administration was not recorded on the count sheet.

Staff documented the administration of Albuterol and Acetaminophen prior to actually administering the medications to the resident.

No carbon monoxide alarm was installed near the gas stove in the main kitchen.

Poisonous materials, including mouthwash and toothpaste, were left unlocked and accessible to a resident in the secured dementia care unit.

A pungent odor of urine was detected in the family room near bedrooms 1-8 of the Mt. Hope cottage.

Bathrooms in the Quentin and Stoy buildings lacked proper air circulation through the ceiling vents.

The facility failed to conduct an annual fire safety inspection and fire drill by a fire safety expert within the required timeframe.

Annual medical evaluations for two residents were not conducted for the year 2022.

Blood glucose readings on a glucometer did not match the numbers transcribed on the Medication Administration Record (MAR).

The Act 13 Mandatory Abuse form for an alleged incident of abuse reported on 7/14/2022 was not completed and submitted to AAA within 48 hours.

The home failed to immediately notify the resident's designated person of a report of suspected abuse, delaying notification until the following day.

Contracts for Resident 2 and Resident 3 were not signed by the residents.

Direct care staff left the building for breaks or to assist in other buildings, leaving the building without staff present while residents were in the home.

Staff were pouring medications into cups for multiple residents to be taken later and leaving medication cups with residents without supervision.

Physician orders for daily blood glucose testing were not completed for Resident 1 and Resident 2 on 5/20/2021 and 5/31/2021.

A resident did not receive required stand-by assistance for transfers as indicated in their assessment and support plan, resulting in multiple falls.

A resident's medical evaluation failed to include information regarding the placement of a deep brain simulator.