Linn Manor Care Center

In the surveyor’s words

From the most serious findings on record at Linn Manor Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF741Aug 31, 2022

  Based on record review, staff and resident's responsible party (RP) interviews, the facility failed to have sufficient staff with appropriate competencies and skills sets that included caring for residents with mental and psychosocial disorders, to provide nursing and related services to assure resident safety, and attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident, for 2 of 4 residents reviewed. This failure resulted in a resident's attempted suicide that required transfer to the hospital for a higher level of care (Resident #1), and a resident's continued inappropriate and unsolicited sexual behaviors of touching female residents in a sexual manner (Resident #2). […]

• Actual harm, isolatedF689Oct 16, 2025

  Based on clinical record review, staff interviews, and facility policy review the facility failed to provide adequate supervision to prevent a fall, resulting in a hip fracture for one out of three residents reviewed (Resident#1). The facility reported a census of 35 residents. Findings include:The Minimum Data Set assessment dated [DATE] for Resident #1 listed diagnoses of dementia, heart failure, Atrial fibrillation (irregular heart beat), malnutrition, adult failure to thrive. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicted severe cognitive impairment. […]

• Actual harm, isolatedF689May 23, 2024

  Based on record review, staff interviews, and policy review the facility failed to ensure safe transfers for 2 of 5 residents reviewed for mechanical lift transfers (Residents #5 and #11). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview of Mental Status of 3, indicating severely impaired cognition. The MDS documented she was dependent on staff to assist her with transfers, toileting, moving herself in a wheelchair, and dressing. The MDS also documented her primary diagnosis of stroke and also has dementia, depression, and anxiety. […]

• No harm, potential for more than minimal, widespreadF865Nov 9, 2023

  Based clinical record review, staff interview, and facility policy review, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) Program that focuses on indicators of the outcomes of care and quality of life. The facility reported a census of 34 residents. Findings Include: A review of the Summary Statement of Deficiencies and provider's Plan of Correction (POC) dated 7/18/22, with corrections initially dated 8/18/22 and revised to 10/1/22, identified the following deficiencies: a. F609 - Reporting of Alleged Violations. b. F657 - Care Plan Timing and Revision. c. F684 - Quality of Care. d. F689 - Free of Accident Hazards/Supervision/Devices. e. F727 - Sufficient Nursing Staff. f. […]

• No harm, potential for more than minimal, widespreadF727Jul 18, 2022

  Based on staff interview, Facility Schedule review and Facility Assessment Review, the facility failed to provide the required 8 hours a day Registered Nurse (RN) coverage for 9 out of 30 days reviewed. The facility reported a census of 32 residents. Findings Include: Review of the Nursing Schedule from June 12 through July 12, 2022, lacked an RN in the facility 9 out of 30 days (6/12/22, 6/18/22, 6/19/22, 6/26/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/10/22). On 7/14/22 at 7:25 AM, The Director of Nursing (DON), said she worked Monday, Tuesday, Thursday, Fridays and another RN works Wednesdays. The DON said she worked the weekends to make the RN coverage. […]