Rose Linn Care Center

In the surveyor’s words

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

• Actual harm, isolatedF658Aug 1, 2022

  Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency CNA) adhered to professional standards of practice regarding Staff 17 not following Resident 1's care plan of a two-person assist for transfers. This resulted in Resident 1 sustaining a deep laceration on her/his left knee that required sutures. This placed residents at risk for accidents. Findings include: Resident 1 was admitted in 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severly cognitively impaired. […]

• Actual harm, isolatedF689Aug 1, 2022

  Based on interviews and record review it was determined the facility failed to ensure adequate transfer supervision to prevent injury for 1 of 2 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a deep laceration with profuse bleeding across her/his left kneecap and required sutures at the hospital emergency department. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF867Apr 24, 2026

  Based on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving care and services for optimal resident outcomes. Findings include:The facility's 7/19/24 Quality Assurance/Performance improvement (QAPI) program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place. -The mission of [NAME] is to provide the appropriate care for our residents to make their days the best they can be. […]

• No harm, potential for more than minimal, widespreadF725Aug 1, 2022

  Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs for 2 of 2 resident halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Review of Direct Care Staff Daily Report from 6/1/22 through 7/28/22 revealed the facility failed to meet the state required minimum number of CNA staff for 35 of 58 days. The following interviews were completed by residents regarding staffing: 7/26/22 at 12:34 PM Resident 53 stated she/he has waited up to two hours for assistance from staff. Resident 53 stated she/he needed assistance with brief changes and getting back into bed. 7/26/22 at 12:45 PM Resident 20 stated staff took a long time to answer call lights. […]

• No harm, potential for more than minimal, patternF730Apr 24, 2026

  Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 7 randomly selected CNA staff (#s 5, 6, 7, and 8) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include:A review of personnel records on 4/24/26 indicated the following employees did not received their annual performance evaluations:-Staff 5 (CNA), hire date was 11/2020 and a performance review was completed in 11/2024.-Staff 6 (CNA), hire date was 8/2023 and a performance review was completed in 8/2024.-Staff 7 (CNA), hire date was 11/2011 and a performance review was completed in 11/2024.-Staff 8 (CNA), hire date was 1/2015 and a performance review was completed in 1/2025.On… […]