Inspection Reports for
Linn Manor Care Center
1140 Elim Drive, Marion, IA, 523025899
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
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.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Complaint Details
Investigation of complaint #2675516-C was part of the visit; no concerns were observed and deficiencies were corrected.
Findings
No concerns were observed during the revisit, and all deficiencies were corrected effective November 10, 2025. The facility is in substantial compliance.
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
Date: Oct 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent falls and to provide individualized care plan interventions for a resident with trauma-related behavioral symptoms.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent multiple falls for Resident #1, including a fall causing a left hip fracture. The facility also failed to provide adequate individualized care planning for the resident's trauma-related behavioral symptoms and PTSD.
Findings
The facility failed to provide adequate supervision to prevent multiple falls resulting in a hip fracture for one resident, and failed to provide individualized care plan interventions addressing trauma and behavioral symptoms for the same resident. The resident experienced several falls, including one resulting in a left hip fracture requiring surgery, and exhibited PTSD-related behaviors that were not adequately managed in the care plan.
Deficiencies (2)
Failure to provide adequate supervision to prevent falls, resulting in a hip fracture.
Failure to provide individualized Care Plan interventions to address resident trauma and behavioral symptoms.
Report Facts
Residents census: 35
Number of falls reported for Resident #1: 8
BIMS score: 5
Fall Scale score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Reported rounds and fall incident on 9/8/25 |
| Staff D | Certified Nurse Aide (CNA) | Reported finding Resident #1 on floor after fall on 9/8/25 |
| Staff E | Certified Nurse Aide (CNA) | Reported rounds and fall incident on 9/8/25 |
| Staff F | Licensed Practical Nurse (LPN) | Reported on fall and supervision issues for Resident #1 |
| Staff H | Licensed Practical Nurse (LPN) | Reported Resident #1's combative behavior and falls |
| Staff I | Licensed Practical Nurse (LPN) | Reported Resident #1's combative behaviors |
| Staff J | Certified Nurse Aide (CNA) | Reported Resident #1's behaviors including hitting and yelling |
| Staff G | Registered Nurse (RN) | Reported PTSD-like symptoms and behaviors of Resident #1 |
| Staff B | Certified Nurse Aide (CNA) | Reported Resident #1's triggers and behaviors |
| Director of Nursing | Director of Nursing (DON) | Reported on interventions and supervision failures related to Resident #1 |
| Registered Nurse Consultant | Registered Nurse Consultant (RNC) | Reviewed and confirmed care plan tasks related to Resident #1's behaviors |
| Social Service staff | Social Service staff | Completed Trauma Informed Care assessment for Resident #1 |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Facility failed to provide adequate supervision to prevent a fall resulting in a hip fracture for one resident.
Facility failed to provide individualized care plan interventions to address trauma-related behaviors for one resident.
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
Date: 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.
Complaint Details
Investigation was related to complaint #126947-C and facility reported incident #126696-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
Annual survey inspection of Linn Manor Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaints #122808-C and #123040-C were not substantiated. Facility self report #123044-I was not substantiated.
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint survey revisit and investigation of a facility reported incident #121711-I.
Complaint Details
Complaint investigation of incident #121711-I was conducted and found not substantiated.
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.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to document routine assessments and interventions for Resident #8 and failure to ensure safe mechanical lift transfers for Residents #5 and #11.
Complaint Details
The complaint investigation found substantiated deficiencies related to Resident #8's care documentation and mechanical lift transfer safety for Residents #5 and #11. Resident #8 experienced a decline leading to hospitalization. Residents #5 and #11 fell during mechanical lift transfers, sustaining injuries.
Findings
The facility failed to document complete assessments related to a decline in condition for Resident #8 and failed to ensure safe transfers for Residents #5 and #11 during mechanical lift transfers, resulting in falls and injuries. The facility implemented interventions and updated policies following these incidents.
Deficiencies (2)
Failure to document routine assessment and interventions for Resident #8 related to decline in condition.
Failure to ensure safe mechanical lift transfers for Residents #5 and #11, resulting in falls and injuries.
Report Facts
Residents affected: 1
Residents affected: 2
Census: 34
Dates of incidents: Dec 13, 2023
Dates of incidents: Dec 17, 2023
Dates of incidents: Apr 12, 2024
Dates of incidents: Apr 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #8's condition on 12/16-12/17/23 |
| Staff D | Registered Nurse (RN) | Interviewed regarding Resident #8's condition and symptoms |
| Staff F | Certified Nursing Assistant (CNA) | Involved in mechanical lift transfer fall of Resident #11 |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding incidents and facility policies |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: 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.
Complaint Details
Complaints #120078-C, #120704-C, and #120780-C were substantiated based on investigation findings.
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.
Deficiencies (2)
Facility failed to document routine assessment for a single resident's decline from 12/13/23 to 12/17/23.
Facility failed to ensure safe transfers for 2 of 5 residents reviewed for mechanical lift transfers.
Report Facts
Residents reviewed: 6
Residents reviewed: 5
Census: 34
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
Investigation of Complaint #117034 and a Facility Self-Reported Incident #117546 conducted on January 2-3, 2024.
Complaint Details
Investigation related to Complaint #117034 and Facility Self-Reported Incident #117546; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Routine
Census: 34
Deficiencies: 7
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication administration, abuse reporting, resident assessments, fall prevention, and quality assurance at Linn Manor Care Center.
Findings
The facility was found deficient in multiple areas including failure to assess resident competency for self-administration of inhalant medications, failure to maintain safe environment due to disrepair of a floor heating register, failure to timely report and investigate alleged abuse incidents, failure to complete comprehensive resident assessments timely, failure to implement and monitor effective fall prevention interventions, and failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.
Deficiencies (7)
Failed to assess for safety and competency of self-administration of inhalant medications for Resident #25.
Failed to maintain good repair of a floor heating register in Resident #21's room.
Failed to timely report suspected abuse and failed to identify and report allegations within required regulatory time frames for Residents #9, #26, and #28.
Failed to respond appropriately to alleged violations of abuse and failed to complete thorough investigations for Residents #9 and #26.
Failed to conduct a comprehensive assessment of Resident #138 in accordance with required timeframes.
Failed to implement, monitor, and modify fall prevention interventions effectively for Resident #12.
Failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Census: 34
Incident reports: 8
MDS questions incomplete: 365
MDS questions incomplete: 33
Days overdue: 7
Days overdue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Medication Aide (CMA) | Observed medication administration and self-administration issues with Resident #25 |
| Director of Nursing (DON) | Director of Nursing | Confirmed failure to assess Resident #25 for self-administration and involved in heating register repair and fall prevention discussions |
| Staff C | Certified Nurses Aide (CNA) | Reported abuse incident involving Resident #28 |
| Staff D | Certified Nurses Aide (CNA) | Alleged perpetrator of abuse to Resident #28 |
| Staff B | Registered Nurse (RN)/Former Director of Nursing (DON) | Involved in abuse reporting and investigation for Residents #9 and #26 |
| Staff H | Licensed Practical Nurse (LPN) | Witnessed abuse incident involving Resident #9 and involved in Resident #26 care |
| Staff A | Licensed Practical Nurse (LPN) | Denied knowledge of abuse reports involving Staff C and Staff D |
| Staff I | Health Services Supervisor | Determined abuse incident involving Resident #9 should have been reported |
| Staff J | Housekeeping Staff | Reported on heating register cover issues |
| Staff K | Unknown | Created Progress Note regarding Resident #26 fall incident |
| Staff E | Registered Nurse (RN) | Responsible for MDS completion during transition period |
| Staff F | Facility Consultant | Confirmed Resident #138 MDS assessments were late |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Nov 9, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to maintain a safe environment, failure to investigate alleged abuse thoroughly, and failure to prevent falls and accidents for residents.
Complaint Details
The complaint investigation revealed incidents of alleged abuse involving Resident #9 being touched inappropriately by another resident, with delayed reporting and inadequate investigation. Resident #26 experienced falls related to roommate behavior, with insufficient preventive measures and documentation. The facility also failed to prevent falls for Resident #12 despite multiple incidents and high fall risk assessments.
Findings
The facility failed to maintain good repair of a floor heating register cover in a resident's room, failed to complete thorough investigations of alleged abuse incidents and maintain proper documentation, and failed to implement and monitor effective interventions to prevent falls for residents at risk.
Deficiencies (3)
Failed to maintain good repair of a floor heating register cover in Resident #21's room.
Failed to complete thorough investigation of alleged abuse, maintain documentation, and prevent further incidents involving Residents #9 and #26.
Failed to implement, monitor, and modify interventions to minimize the likelihood of falls for Resident #12.
Report Facts
Residents affected: 34
Incident reports: 8
BIMS score: 15
BIMS score: 2
BIMS score: 12
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Housekeeping Staff | Reported witnessing heat register covers off and lying on the floor and described actions taken |
| Staff H | Licensed Practical Nurse (LPN) | Witnessed abuse incident involving Resident #9 and provided statements about 15-minute checks and resident falls |
| Staff B | Former Director of Nursing (DON) | Investigated abuse incident involving Resident #9 and provided statements about resident behaviors |
| Staff I | Health Services Supervisor | Learned of abuse incident and determined it should have been reported |
| Staff K | Created Progress Note documenting Resident #26's fall incident | |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding heat register repair, resident transfer status, fall interventions, and incident report reviews |
| Administrator | Facility Administrator | Provided statements regarding heat register repair, abuse incident expectations, and QAPI Committee monitoring |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 7
Date: 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.
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.
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.
Deficiencies (7)
Resident self-administration of medications was not clinically appropriate; the facility failed to assess and secure medications properly.
Facility failed to maintain a safe, clean, comfortable, and homelike environment, including failure to repair a floor heating register cover.
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within required time frames for 3 residents.
Failure to thoroughly investigate alleged violations of abuse and prevent further incidents for 2 residents.
Failure to conduct comprehensive assessments in accordance with required timeframes for 1 resident.
Failure to implement and monitor interventions to minimize fall risk and accidents for 1 resident.
Failure to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life.
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
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (2)
Facility failed to ensure all residents remained free from potential dependent adult abuse, including physical and sexual abuse.
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.
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
Complaint Investigation
Census: 32
Deficiencies: 7
Date: Jul 18, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians and representatives of resident-to-resident incidents, failure to report suspected abuse, neglect or theft, failure to develop complete care plans addressing medication side effects and resident interactions, failure to provide adequate supervision to prevent inappropriate resident interactions, and failure to maintain required RN coverage and Quality Assurance meetings.
Complaint Details
The complaint investigation focused on failure to notify physicians and representatives of resident-to-resident incidents, failure to report suspected abuse to the State Agency, failure to update care plans, failure to supervise residents to prevent inappropriate sexual behavior, failure to maintain required RN coverage, and failure to conduct required Quality Assurance meetings. The facility reported a census of 32 residents.
Findings
The facility failed to notify physicians and representatives of resident-to-resident incidents for 3 residents, failed to report suspected abuse to the State Agency 2 out of 3 times, failed to update care plans to address medication side effects and resident interactions, failed to supervise a resident who engaged in inappropriate sexual behavior with other residents, failed to provide required RN coverage for 9 out of 30 days, and failed to provide evidence of 3 of 4 required quarterly Quality Assurance meetings.
Deficiencies (7)
Failed to notify the Physician and the Resident's Representative of resident to resident incidents for 3 residents.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for resident to resident contact 2 out of 3 times.
Failed to develop complete care plans addressing anticoagulant and antidepressant medication side effects and failed to add interventions after resident to resident interactions.
Failed to provide appropriate treatment and care according to orders and resident preferences, including failure to assess residents after incidents and failure to document assessments.
Failed to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically failed to supervise Resident #3 from inappropriate sexual behavior with other residents.
Failed to have a registered nurse on duty 8 hours a day for 9 out of 30 days reviewed.
Failed to provide evidence of 3 of 4 quarterly Quality Assurance & Assessment meetings held as required.
Report Facts
Census: 32
RN coverage missing days: 9
Quality Assurance meetings missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Observed inappropriate resident behavior and reported incidents |
| Staff A | Registered Nurse (RN)/Instructor | Reported observations of inappropriate resident interactions |
| Staff C | Therapy Director | Observed and reported inappropriate resident interactions |
| Director of Nursing (DON) | Director of Nursing | Provided statements on expectations and facility policies |
| Administrator | Administrator | Provided statements on incident reporting and staffing |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 5
Date: 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.
Complaint Details
The visit included investigation of a facility reported incident #105511-I which was substantiated.
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.
Deficiencies (5)
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
Date: 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.
Complaint Details
Investigation involved Complaints #104840-C and Facility Self-Reported Incidents #102762-I, #102855-I, and #104843-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: 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
Date: Jul 9, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #91379 and a Facility Self-Reported Incident #88121.
Complaint Details
Investigation of Complaint #91379 and Facility Self-Reported Incident #88121 completed 7/8-9/2020; both were not substantiated.
Findings
Both the complaint and the self-reported incident were investigated and found to be not substantiated.
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 0
Date: 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.
Viewing
Loading inspection reports...
