Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Linwood, Llc during CMS and state inspections, most recent first.
The facility was found to have multiple deficiencies in food labeling and storage, with numerous items in the refrigerator, spice rack, and meat freezer lacking proper labels or being exposed to air. The Dietary Director acknowledged the need for proper labeling to ensure freshness and prevent contamination, but the facility's practices did not align with its policies on food storage and labeling.
The facility failed to timely address CP recommendations for three residents, including changes to medication administration and record-keeping. Recommendations made in August and September 2024 were not acted upon until October 2024, contrary to the facility's policy requiring completion within five days.
A resident experienced an unwitnessed fall, and the facility failed to maintain proper documentation and conduct a thorough investigation. The resident, who was cognitively intact, fell backward, and while initial assessments were performed, crucial documentation such as the RN's statement and neurological assessments were missing. Interviews revealed that required statements and post-fall documentation were not completed, and the DON confirmed the investigation was incomplete, highlighting the importance of such investigations to rule out abuse.
A facility failed to update a care plan for a resident with a surgical wound infection. Despite the resident's cognitive intactness and specific diagnoses, there were no physician's orders for wound care upon admission. Interviews with staff confirmed the oversight, and the facility's policy on care planning was not followed.
The facility failed to obtain admission orders and maintain proper documentation for a surgical wound, leading to delayed treatment for a resident. Another resident with a PICC line lacked necessary care orders, and a third resident's treatment records were incomplete, with multiple blanks in the TAR. Staff interviews confirmed the importance of proper documentation and adherence to care protocols.
A resident with cognitive impairment did not receive scheduled showers, and there was no documentation of refusals or family notifications. The LPN claimed to have contacted the family, but this was not recorded, violating the facility's policy.
The facility failed to properly store, label, and remove expired drugs, as observed in a medication room and cart. Expired cultures, vacutainers, and Pantoprazole were found, and lorazepam packaging was damaged. The LPN and acting-ADON acknowledged the issues, and the DON planned in-service education to address these deficiencies.
The facility failed to follow proper infection control practices, as an LPN did not perform hand hygiene before and between glove changes during medication administration, and an RN did not wear a gown while attending to a resident on contact precautions. These actions were contrary to the facility's policies on hand hygiene and transmission-based precautions.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as observed by a surveyor in the presence of the Dietary Director (DD) and the Regional Dietary Director (RDD). During the inspection, various food items in the refrigerator, spice rack, and meat freezer were found improperly labeled or not labeled at all with open and use-by dates. Specific items included breadcrumbs mislabeled as flour, an opened stick of butter, tomatoes, cooked puree pork, salad dressings, and various cheeses and condiments without appropriate labeling. Additionally, spices and dry goods were found exposed to air and not properly sealed or labeled, including granulated garlic powder, ground ginger, and pancake waffle mixes. The DD acknowledged that items should be labeled to ensure freshness and prevent contamination. The facility's policies on dating and labeling, dry food storage, and opened food storage were reviewed and found to be inconsistent with the observed practices. These policies require all food items to be labeled with the name, received date, and use-by date, and to be stored in airtight containers to prevent exposure to air and contaminants. The surveyor noted that the facility did not comply with these policies, as evidenced by the numerous unlabeled and improperly stored food items, which could potentially lead to contamination and health risks.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for three residents reviewed for medication management. For Resident #70, the CP had recommended changes to the administration of Carvedilol, correction of a duplicate Tylenol order, and adjustment of MiraLAX dosage. These recommendations, made in August and September 2024, were not acted upon until October 3, 2024. Resident #92's CP recommendations included writing separate orders for Morphine sulfate, sequencing the indication for Tylenol, and verifying Morphine Sulfate liquid dosage. These recommendations, initially made in August 2024, were not addressed until October 3, 2024. The delay in addressing these recommendations indicates a lapse in the facility's medication management process. For Resident #50, the CP's recommendations included changes to the administration records for Ammonium Lactate, Omeprazole, and Guaifenesin ER, as well as clarifications for several other medications. These recommendations, made in August and September 2024, were not completed until early October 2024. Interviews with the North Unit Manager and the Director of Nursing revealed that the facility's policy required CP recommendations to be completed within five days, a standard that was not met in these cases.
Failure to Document and Investigate Unwitnessed Fall
Penalty
Summary
The facility failed to maintain proper documentation and conduct a thorough investigation following an unwitnessed fall involving Resident #278. The resident, who was cognitively intact with a BIMS score of 13 out of 15, experienced a fall on 07/22/2023. The nursing progress notes indicated that the resident lost balance and fell backward, after which vital signs were taken, and a body assessment was performed. However, the surveyor found that the Registered Nurse's statement and neurological assessments were missing from the Accident/Incident Report Checklist provided by the facility. Interviews with facility staff revealed that the Licensed Practical Nurse was responsible for obtaining vital signs, while the Registered Nurse was to complete the full assessment. It was confirmed that statements from all staff involved, including the RN, were not obtained, and there was a lack of post-fall documentation, including neurological checks. The Director of Nursing acknowledged that a thorough investigation was not completed, emphasizing the importance of such investigations to rule out abuse. The facility's policies on accidents, incidents, and documentation were not adhered to, as evidenced by the missing witness accounts, follow-up information, and the signature of the person completing the report.
Failure to Revise Care Plan for Surgical Wound Infection
Penalty
Summary
The facility failed to revise a comprehensive care plan to address the nursing interventions required for a surgical wound infection in one of the residents. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had diagnoses including surgical aftercare following surgery on the digestive system and a retroperitoneal abscess. Despite these conditions, the resident's Order Summary Report, Medication Administration Record, and Treatment Administration Record did not include physician's orders for surgical wound care or maintenance upon admission. The individualized comprehensive care plan noted enhanced barrier precautions related to a surgical incision but lacked specific interventions for surgical wound care. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the oversight. The LPN described the care plan as a guideline that should be continuously updated to reflect the resident's needs, including any surgical wounds and necessary nursing interventions. The Director of Nursing acknowledged the absence of an updated care plan regarding the surgical wound infection. The facility's policy on care planning emphasized the need for measurable objectives, timeframes, and ongoing assessments to ensure care plans are revised as residents' conditions change, which was not adhered to in this case.
Deficiencies in Wound and PICC Line Care Documentation
Penalty
Summary
The facility failed to obtain admission orders and maintain proper documentation for a surgical wound for a resident who had undergone surgery on the digestive system and had a retroperitoneal abscess. Upon review, it was found that there were no physician's orders for surgical wound care upon admission, and the documentation of the wound was inconsistent, with missing entries on certain dates. The resident experienced sero-sanguinous and purulent drainage from the wound, indicating a possible infection, yet there was a delay in obtaining appropriate treatment orders. Interviews with staff confirmed that admission orders for surgical wounds are crucial to prevent infection and ensure proper care. Another resident was admitted with a PICC line but lacked physician orders for its care and maintenance, including dressing changes and flushes to keep the line patent. The facility's policy required such orders to ensure the PICC line remained free from infection and functional. Despite the absence of orders, a nurse documented flushing the PICC line, which was not authorized, raising concerns about the accuracy of the documentation and the potential for errors in patient care. Additionally, the facility failed to maintain complete treatment records for a third resident, as evidenced by multiple blanks in the Treatment Administration Record (TAR) for various treatments, including wound vac changes, offloading heels, and pain assessments. Interviews with the Unit Manager and DON confirmed that there should be no blanks in the TAR, indicating a lapse in documentation and potentially in the administration of necessary treatments.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, which was identified during a survey. The resident, who was moderately cognitively impaired and required substantial assistance with showering, was scheduled to receive showers every Sunday and Thursday. However, the Treatment Administration Record (TAR) for September showed multiple instances where the showers were not documented, and there was no record of the resident refusing showers or the family being notified of such refusals. Interviews with the Regional Clinical Director and a Licensed Practical Nurse (LPN) revealed that although the LPN claimed to have contacted the resident's family regarding the refusals, this was not documented in the progress notes. The facility's policy required documentation of any refusals and the reasons, along with any interventions taken, but this was not adhered to. The lack of documentation led to the conclusion that the showers were not provided as scheduled.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to properly store, label, and remove expired drugs from its inventory, as observed in one of the medication rooms and one of the medication carts. During an inspection, the surveyor found expired cultures, urine vacutainers, and a bag of Dextrose solution in the medication storage room. Additionally, bottles of Pantoprazole with past use-by dates were also found. The LPN/Unit Manager present during the inspection acknowledged the expired items and admitted to not knowing the expiration details of the Pantoprazole, confirming the need to discard the expired items. In a separate observation, the surveyor noted that the packaging of lorazepam tablets on a medication cart was opened and torn, which was not noticed by the LPN responsible for counting the medication. The LPN admitted to not checking the back of the package during the count. The acting-Assistant Director of Nursing confirmed that both sides of medication packages should be checked for integrity during counts, and any damaged packages should be discarded with supervisors notified. The Director of Nursing stated that in-service education would be provided to ensure proper handling of damaged medication packages.
Infection Control Deficiencies in Hand Hygiene and Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and while following transmission-based precautions. During a medication administration task, an LPN was observed not performing hand hygiene before applying gloves and between changing gloves. The LPN admitted to not performing hand hygiene despite acknowledging its necessity. The facility's policy on administering medications and hand hygiene clearly outlines the requirement for hand hygiene before and after glove use, which was not followed in this instance. Additionally, a separate incident involved an RN failing to wear a gown while inside a resident's room who was on contact precautions due to Group B Streptococcus and Methicillin Resistant Staphylococcus Aureus in a wound. The RN acknowledged the need for a gown to protect both herself and the resident but did not comply with the precautionary measures. The facility's policy on transmission-based precautions mandates the use of gowns and gloves for interactions involving contact with the resident or potentially contaminated areas, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Linwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowview Nursing And Rehabilitation Center | 3.2 mi | — | 0 | 0 |
| Our Ladys Center For Rehabilitation & Healthcare | 3.7 mi | — | 0 | 0 |
| United Methodist Communities At The Shores | 5.3 mi | — | 0 | 0 |
| Excel Care At Egg Harbor | 5.5 mi | — | 1 | 0 |
| Preferred Care At Absecon | 8.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.