Inspection Reports for Linn Manor Care Center
1140 Elim Drive, IA, 523025899
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 2, 2025 found no deficiencies and confirmed the facility was in substantial compliance after correcting earlier issues. Prior inspections showed a mixed pattern with some deficiencies related mainly to resident supervision, care planning, and safe transfer practices. Earlier reports also cited problems with medication management, abuse reporting and investigation, and quality assurance, including an immediate jeopardy finding in 2022 related to abuse and staff competencies. Several complaint investigations were unsubstantiated, but some complaints were substantiated, particularly those involving falls, supervision, and documentation. The facility appears to have addressed many prior deficiencies, showing improvement in the most recent revisit.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 2, 2025
Visit Reason
An onsite revisit of the survey ending October 16, 2025 and investigation of complaint #2675516-C and facility reported incidents #2663326-I and #2674196-I was conducted from December 1 to December 2, 2025.
Findings
No concerns were observed during the revisit, and all deficiencies were corrected effective November 10, 2025. The facility is in substantial compliance.
Complaint Details
Investigation of complaint #2675516-C was part of the visit; no concerns were observed and deficiencies were corrected.
Report Facts
Complaint number: 2675516
Facility reported incident numbers: #2663326-I and #2674196-I reported incidents investigated
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Oct 16, 2025
Visit Reason
The inspection was conducted following an investigation of a facility-reported incident #2621990-1, related to a resident fall and supervision issues.
Findings
The facility failed to provide adequate supervision to prevent a fall resulting in a hip fracture for one resident. Additionally, the facility failed to provide individualized care plan interventions to address trauma-related behaviors for the same resident.
Complaint Details
The visit was triggered by a complaint investigation related to a resident fall resulting in a hip fracture. The complaint was substantiated as deficiencies were found in supervision and care planning.
Severity Breakdown
G: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide adequate supervision to prevent a fall resulting in a hip fracture for one resident. | G |
| Facility failed to provide individualized care plan interventions to address trauma-related behaviors for one resident. | D |
Report Facts
Resident census: 35
Number of residents reviewed: 3
Fall dates documented: 8
Dates of care plan interventions: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2025
Visit Reason
A complaint investigation for complaint #126947-C and facility reported incident #126696-I was conducted from March 10, 2025 to March 11, 2025.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Complaint Details
Investigation was related to complaint #126947-C and facility reported incident #126696-I; facility found in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 5, 2024
Visit Reason
The facility's annual recertification survey was conducted from December 2, 2024 to December 5, 2024.
Findings
The facility was found to be in substantial compliance with the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 5, 2024
Visit Reason
A complaint survey was conducted for complaints #122808-C and #123040-C, as well as a facility reported incident #123044-I, during the period of 11/4 - 11/5/2024.
Findings
Complaints #122808-C and #123040-C were not substantiated, and the facility self-report #123044-I was also not substantiated. The facility was found in substantial compliance at the time of the survey.
Complaint Details
Complaints #122808-C and #123040-C were not substantiated. Facility self report #123044-I was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint survey revisit and investigation of a facility reported incident #121711-I.
Findings
The facility was found in substantial compliance as of 6/13/24, and the complaint investigation conducted on 6/25/24 - 6/26/24 was not substantiated.
Complaint Details
Complaint investigation of incident #121711-I was conducted and found not substantiated.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
May 23, 2024
Visit Reason
The inspection was conducted as a result of complaints #118167-C, #120078-C, #120704-C, #120780-C and a facility reported incident #118720-I from May 19, 2024 to May 23, 2024. Complaints #120078-C, #120704-C, and #120780-C were substantiated.
Findings
The facility failed to document routine assessment and interventions for one resident, failed to ensure safe transfers for two residents using mechanical lifts, and failed to follow their policy for falls from mechanical lifts. The facility reported a census of 34 residents during the inspection.
Complaint Details
Complaints #120078-C, #120704-C, and #120780-C were substantiated based on investigation findings.
Severity Breakdown
Level D: 1
Level G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to document routine assessment for a single resident's decline from 12/13/23 to 12/17/23. | Level D |
| Facility failed to ensure safe transfers for 2 of 5 residents reviewed for mechanical lift transfers. | Level G |
Report Facts
Residents reviewed: 6
Residents reviewed: 5
Census: 34
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2024
Visit Reason
Investigation of Complaint #117034 and a Facility Self-Reported Incident #117546 conducted on January 2-3, 2024.
Findings
The facility was found to be in substantial compliance following the investigation.
Complaint Details
Investigation related to Complaint #117034 and Facility Self-Reported Incident #117546; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 4, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey to verify compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification of compliance effective December 4, 2023.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 7
Nov 9, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaints #115305-C and Facility Self-Reported Incidents #115448-I and #110841-I from November 6 to November 9, 2023.
Findings
The facility was found deficient in multiple areas including resident self-administration of medications, safe and homelike environment maintenance, reporting and investigation of alleged violations, comprehensive assessments, accident hazard prevention, and quality assurance and performance improvement (QAPI) program implementation.
Complaint Details
The visit was triggered by complaints and self-reported incidents involving allegations of abuse, neglect, and safety concerns for residents #9, #26, and #28. The facility failed to report and investigate these allegations timely and adequately.
Severity Breakdown
SS=D: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Resident self-administration of medications was not clinically appropriate; the facility failed to assess and secure medications properly. | SS=D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment, including failure to repair a floor heating register cover. | SS=D |
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within required time frames for 3 residents. | SS=D |
| Failure to thoroughly investigate alleged violations of abuse and prevent further incidents for 2 residents. | SS=D |
| Failure to conduct comprehensive assessments in accordance with required timeframes for 1 resident. | SS=D |
| Failure to implement and monitor interventions to minimize fall risk and accidents for 1 resident. | SS=D |
| Failure to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life. | SS=F |
Report Facts
Resident census: 34
Incident reports reviewed: 8
MDS questions incomplete: 365
MDS questions overdue: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Former Director of Nursing | Investigated abuse allegations involving Resident #9 and #26; provided statements about resident behaviors and reporting expectations |
| Staff H | Licensed Practical Nurse | Witnessed abuse incident involving Resident #9; provided statements about resident behaviors and reporting expectations |
| Staff I | Health Services Supervisor | Determined abuse incident involving Resident #9 should have been reported regardless of investigation results |
| Staff C | Certified Nurses Aide | Witnessed abuse incident involving Resident #28; failed to report incident timely |
| Staff D | Certified Nurses Aide | Alleged perpetrator of abuse incident involving Resident #28 |
| Staff A | Licensed Practical Nurse | Denied knowledge of abuse report by Staff C; expected staff to report incidents |
| Staff G | Certified Medication Aide | Observed administering medications to Resident #25; reported resident self-administered inhaled medications |
| Director of Nursing | Director of Nursing | Confirmed expectations for medication self-administration assessment and medication storage; reported on fall interventions and care plan updates |
| Administrator | Facility Administrator | Provided statements on abuse reporting expectations, QAPI program deficiencies, and fall prevention oversight |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 13, 2022
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection event (Event ID - DUB012).
Findings
The document references deficiencies from a previous inspection but does not provide specific findings or details within this report.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 13, 2022
Visit Reason
A revisit of the Recertification Survey ending July 18, 2022 and for a Facility Self-Reported Incident investigation ending August 31, 2022 was conducted on October 12 to October 13, 2022.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 1, 2022. The plan of correction was not effectuated.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Aug 22, 2022
Visit Reason
The inspection resulted from an investigation of a Facility Self-Reported Incident #107004-I concerning abuse and neglect, conducted from August 22, 2022 to August 31, 2022.
Findings
The facility was found to have failed to ensure residents were free from abuse and neglect, including sexual abuse, and failed to have sufficient staff competencies to care for residents with mental and psychosocial disorders. The facility was cited for immediate jeopardy related to a resident's attempted suicide and inappropriate sexual behaviors toward other residents.
Complaint Details
The Facility Self-Reported Incident #107004-I was substantiated. The investigation revealed failure to prevent abuse and neglect, including sexual abuse, and failure to provide adequate staff training and interventions for residents with mental health needs. Immediate Jeopardy was identified related to resident safety and suicide risk.
Severity Breakdown
Immediate Jeopardy: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure all residents remained free from potential dependent adult abuse, including physical and sexual abuse. | Immediate Jeopardy |
| Facility failed to have sufficient staff competencies and skills to care for residents with mental and psychosocial disorders, resulting in resident's attempted suicide and continued inappropriate sexual behaviors. | Immediate Jeopardy |
Report Facts
Census: 31
Deficiencies cited: 2
Training hours: 6
Frequency of audits: 4
Frequency of audits: 3
Monitoring frequency: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN), Health Services Supervisor | Reported resident fondling another resident and observed inappropriate behaviors |
| Staff D | Licensed Practical Nurse (LPN) | Observed resident inappropriate touching and instructed resident |
| Director of Nursing (DON) | Director of Nursing | Provided information on resident behaviors, monitoring, and suicide risk assessments |
| Staff A | Social Service Designee (SSD) | Recorded resident depression and suicidal ideation |
| Staff B | Licensed Practical Nurse (LPN) | Recorded resident suicidal statements and suicide attempt |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident refusal to eat and expressed suicidal feelings |
| Staff F | Certified Nursing Assistant (CNA) | Monitored resident and reported on resident's call light usage and suicidal comments |
| Staff G | Certified Nursing Assistant (CNA) | Reported resident's increased depression and monitored behaviors |
| Staff H | Certified Nursing Assistant (CNA) | Reported resident's suicidal statements and desire to leave facility |
| Staff I | Certified Nursing Assistant (CNA) | Reported resident suicide attempt and transfer to hospital |
| Staff KG | Completed Alzheimer's and suicide intervention training | |
| Staff AB | Completed Alzheimer's and suicide intervention training | |
| Staff JS | Completed Alzheimer's training |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 5
Jul 18, 2022
Visit Reason
The inspection was the facility's annual recertification survey and investigation of a reported incident #105511-I conducted from July 11, 2022 to July 18, 2022.
Findings
The facility was found to have multiple deficiencies including failure to notify physicians and resident representatives of incidents, failure to report alleged abuse incidents timely, inadequate resident care plans, failure to monitor medication side effects, and insufficient staffing coverage. The facility also failed to properly supervise residents to prevent inappropriate interactions and failed to maintain required quality assurance meetings.
Complaint Details
The visit included investigation of a facility reported incident #105511-I which was substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to notify the physician and resident representative of resident incidents for 3 out of 3 residents reviewed. |
| Failure to report alleged abuse incidents to the State Agency timely and failure to investigate and intervene appropriately. |
| Failure to maintain comprehensive care plans addressing resident needs including monitoring of medications and resident interactions. |
| Failure to supervise residents adequately to prevent inappropriate behavior and contact. |
| Failure to provide required nursing services including adequate RN coverage and quality assurance meetings. |
Report Facts
Census: 32
Deficiencies cited: 5
Staffing coverage days reviewed: 30
BIMS scores: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maegan Oelsner | PCC representative | Reported difficulty implementing Secure Conversation due to upcoming software version change. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding incident reporting expectations, care plan updates, and staffing issues. |
| Staff B | Licensed Practical Nurse (LPN) | Observed inappropriate resident behavior and reported incidents to Nurse Supervisor. |
| Staff A | Registered Nurse (RN)/Instructor | Reported observations of resident interactions and inappropriate behavior. |
| Staff C | Therapy Director | Reported observations of resident interactions and removal of resident from room. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2022
Visit Reason
A complaint investigation was conducted for Complaints #104840-C and Facility Self-Reported Incidents #102762-I, #102855-I, and #104843-I from June 20, 2022 to June 23, 2022.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation involved Complaints #104840-C and Facility Self-Reported Incidents #102762-I, #102855-I, and #104843-I; facility found in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 12, 2021
Visit Reason
The visit was a Recertification Survey conducted from August 9-12, 2021, to assess the facility's compliance with federal regulations.
Findings
The facility was found to be in substantial compliance with the Code of Federal Regulations (42CFR) Part 483, Subpart B-C at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #91379 and a Facility Self-Reported Incident #88121.
Findings
Both the complaint and the self-reported incident were investigated and found to be not substantiated.
Complaint Details
Investigation of Complaint #91379 and Facility Self-Reported Incident #88121 completed 7/8-9/2020; both were not substantiated.
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 0
Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/17/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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