The Lingenfelter Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Environmental Deficiencies

Keep all essential equipment working safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on observation and interview, the facility failed to provide corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6, 19.3.6.3, and 19.3.6.3.10. This deficient practice could affect all residents and staff in the affected area.Â

Based on interviews, record review, observations, and facility policy, the facility failed to protect the rights of 10 residents to be free from abuse by another resident, and failed to protect the rights of 3 residents to be free from abuse by staff. The deficient practice could result in residents being abused by other residents or staff.Â

Violation cited

Violation cited

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#3 and #4) were provided adequate supervision to prevent resident abuse. Findings include: -Resident # 3 (alleged perpetrator) was admitted to the facility on October 29, 2024 which include diagnoses of Hypertension, Diabetes Mellitus, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder (PTSD). Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has confusion-poor decision making related to cognitive impairment, limited mental function and disease process. The interventions include reorient to situations as needed, anticipate needs, observe for signs and symptoms of disease, administer medications as ordered, observe for side effects and effectiveness, and note changes and notify medical doctor as needed. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has unsafe wandering. The interventions include monitor for any needed interventions such as alarms; monitor closely, 30 minutes safety checks as needed; notify for increased restlessness; anticipate needs such as thirst, hunger, and need to toilet; monitor for patterns and redirect to safe areas. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident exhibits negative physical behavior manifested by hitting, kicking, spitting, pinching or biting towards others-strikes/hits/pinches/attempts to bite/scratch staff when they assist with activities of daily living or administer medications. The interventions include remove person from situation if begins to show signs of agitation in public place, remind calmly about the necessity to refrain from physical acting out. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident require supervision and redirection from staff related to behaviors such as delusional thoughts, paranoia, verbal and physical aggression, accusatory statements, wandering, rejection of cares, agitation, and anxiousness. Review of plan of care document titled, Standard Care Plans, dated October 30, 2024 at 23:30, resident #3 was in a resident to resident altercation, resident #3 was the aggressor. The interventions included one on one conversation, reapproach, watching television, assess for injuries, and psych consult. Review of record, Medication Administration Record (MAR) dated October 31, 2024 at 01:35 revealed resident was administered Haldol and Ativan for signs and symptoms of clinical distress related to anxiety-pacing, unprovoked physical aggression-punching, short tempered and irritable, paranoia and delusions of believing resident is at home and others are intruders. Review of records from progress note titled physician's order note dated October 31, 2024 at 02:57 revealed resident-resident altercation, psych eval. Review of records from progress no

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#3 and #4) were provided adequate supervision to prevent resident abuse. Findings include: -Resident # 3 (alleged perpetrator) was admitted to the facility on October 29, 2024 which include diagnoses of Hypertension, Diabetes Mellitus, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder (PTSD). Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has confusion-poor decision making related to cognitive impairment, limited mental function and disease process. The interventions include reorient to situations as needed, anticipate needs, observe for signs and symptoms of disease, administer medications as ordered, observe for side effects and effectiveness, and note changes and notify medical doctor as needed. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has unsafe wandering. The interventions include monitor for any needed interventions such as alarms; monitor closely, 30 minutes safety checks as needed; notify for increased restlessness; anticipate needs such as thirst, hunger, and need to toilet; monitor for patterns and redirect to safe areas. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident exhibits negative physical behavior manifested by hitting, kicking, spitting, pinching or biting towards others-strikes/hits/pinches/attempts to bite/scratch staff when they assist with activities of daily living or administer medications. The interventions include remove person from situation if begins to show signs of agitation in public place, remind calmly about the necessity to refrain from physical acting out. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident require supervision and redirection from staff related to behaviors such as delusional thoughts, paranoia, verbal and physical aggression, accusatory statements, wandering, rejection of cares, agitation, and anxiousness. Review of plan of care document titled, Standard Care Plans, dated October 30, 2024 at 23:30, resident #3 was in a resident to resident altercation, resident #3 was the aggressor. The interventions included one on one conversation, reapproach, watching television, assess for injuries, and psych consult. Review of record, Medication Administration Record (MAR) dated October 31, 2024 at 01:35 revealed resident was administered Haldol and Ativan for signs and symptoms of clinical distress related to anxiety-pacing, unprovoked physical aggression-punching, short tempered and irritable, paranoia and delusions of believing resident is at home and others are intruders. Review of records from progress note titled physician's order note dated October 31, 2024 at 02:57 revealed resident-resident altercation, psych eval. Review of records from progress no