Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 31, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide accurate and complete Notice of Medicare Non-Coverage (NOMNC) forms to residents, specifically for two sampled residents.
Findings
The facility failed to ensure that residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents reviewed. Resident 114 received an incomplete NOMNC form missing key information, and Resident 115 was not provided a NOMNC form at all, placing residents at risk of not being informed of financial liabilities and the right to appeal.
Complaint Details
The visit was complaint-related, focusing on the failure to provide proper Notice of Medicare Non-Coverage forms to residents. The deficiency was substantiated as the facility did not provide a valid NOMNC form to Resident 114 and did not provide any NOMNC form to Resident 115.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide accurate and complete Notice of Medicare Non-Coverage (NOMNC) forms to residents, including missing effective coverage dates, end dates, and appeal contact information. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | Social Services Director | Acknowledged the NOMNC form issues for Residents 114 and 115 |
| Staff 9 | Former Social Services Director | Sent email regarding Resident 114's NOMNC form |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1, where the facility allegedly failed to follow the resident's plan of care to prevent falls.
Findings
The facility failed to follow the care plan for Resident 1, who required two-person assistance with a Hoyer lift for transfers. Staff 5 used a sit-to-stand lift alone instead, resulting in the resident falling and sustaining a cut on the lower lip. Staff 5 was terminated due to this incident.
Complaint Details
The complaint investigation found that Staff 5 did not follow the care plan for Resident 1, who required two-person assistance with a Hoyer lift. Staff 5 used a sit-to-stand lift alone, leading to a fall and injury. Staff 5 was aware of the care plan but did not comply. The incident was substantiated and resulted in Staff 5's termination.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow the resident's plan of care to prevent a fall for Resident 1, including improper use of transfer equipment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Date of fall incident: Sep 28, 2023
Date of survey completion: Jun 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 5 | Certified Nursing Assistant (CNA) | Named in the fall incident for not following the care plan and using improper transfer equipment. |
| Staff 2 | Registered Nurse Care Manager (RNCM) | Interviewed regarding the fall and care plan compliance. |
| Staff 6 | Licensed Practical Nurse (LPN) | Present during the incident and provided statements about the event. |
| Staff 3 | Certified Medication Aide (CMA) | Assisted during the incident and provided statements. |
| Staff 1 | Administrator | Acknowledged Staff 5's termination due to the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 8, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide timely audiology and ENT appointments, address pharmacy recommendations for medication monitoring, and properly document COVID-19 vaccination status for sampled residents.
Findings
The facility failed to ensure timely audiology appointments for Resident 22 and ENT appointments for Resident 39, failed to follow up on pharmacy recommendations for monitoring digoxin levels for Resident 6, and failed to document COVID-19 vaccination status for Resident 39. These deficiencies placed residents at risk for communication barriers, medication complications, and COVID-19 exposure.
Complaint Details
The visit was complaint-related, focusing on failure to provide timely audiology and ENT appointments, failure to follow up on pharmacy recommendations, and failure to document COVID-19 vaccination status. Staff acknowledged delays and lack of documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled residents (#22 and #39), including failure to schedule audiology and ENT appointments timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications, specifically monitoring digoxin levels. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampled residents (#39). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for hearing: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for COVID-19 vaccine immunization: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | RN Care Manager (RNCM) | Spoke with family member and scheduled audiology appointment for Resident 22 |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged delays in scheduling appointments and lack of documentation |
| Staff 4 | Registered Nurse (RN) | Acknowledged delays in scheduling appointments and lack of documentation |
| Staff 7 | Pharmacy Consultant | Completed monthly pharmacy reviews and requested digoxin level for Resident 6 |
Inspection Report
Annual Inspection
Deficiencies: 12
Aug 1, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey of Rose Linn Care Center to assess compliance with regulatory requirements related to resident care, safety, staffing, and medication management.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (e.g., mattress replacement), failure to implement advance directive policies, inadequate cleanliness, failure to follow care plans resulting in resident injury, failure to follow physician orders, lack of restorative therapy services, inadequate staffing levels, lack of RN coverage for required hours, medication errors including duplicate therapy and inappropriate psychotropic medication use, and failure to provide required therapy services after a resident fall.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Actual harm: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure a resident's environment accommodated individual needs and preferences, resulting in risk for skin breakdown due to a sunken mattress. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement policies regarding residents' rights to formulate an advance directive, placing residents at risk for not having health care preferences honored. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a clean and sanitary environment in one of two halls, placing residents at risk for cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff adhered to professional standards of practice regarding a two-person assist for transfers, resulting in a resident sustaining a deep laceration requiring sutures. | Level of Harm - Actual harm |
| Failed to follow physician orders for daily weights and notification, placing residents at risk for a change in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received restorative aid therapy to prevent ADL decline, placing residents at risk for physical decline. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate transfer supervision to prevent injury, resulting in a resident sustaining a deep laceration requiring sutures. | Level of Harm - Actual harm |
| Failed to provide sufficient nursing staff to meet resident needs, placing residents at risk for unmet needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure RN coverage for eight consecutive hours per day on multiple days, placing residents at risk for lack of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from unnecessary medications, resulting in duplicate therapy with two dopamine agonist medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an appropriate indication for use of psychotropic medications, placing residents at risk for unnecessary medication and adverse side effects. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain therapy services for a resident after a fall, placing the resident at risk for decline in functional abilities and accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days CNA staffing below minimum: 35
Days without 8 consecutive hours RN coverage: 7
Resident laceration size: 6
Weight gain: 4.6
Weight gain: 3.4
Number of residents requiring restorative aid: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 8 | RN Care Manager (RNCM) | Acknowledged lack of follow-up on mattress request and restorative therapy program absence. |
| Staff 17 | Former Agency CNA | Did not follow two-person assist care plan, causing resident injury. |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged multiple deficiencies including lack of RN coverage, medication errors, and staffing shortages. |
| Staff 1 | Administrator | Provided advanced directive policy and stated expectation for resident notification. |
| Staff 11 | Admissions Director | Described advance directive and POLST procedures. |
| Staff 13 | RN | Stated Resident Care Managers handle advance directive paperwork. |
| Staff 4 | Housekeeping Supervisor | Acknowledged unsanitary conditions in resident rooms. |
| Staff 26 | Maintenance Director | Acknowledged need for deep cleaning of walls with stains. |
| Staff 9 | CNA | Reported staffing shortages and inadequate care. |
| Staff 15 | Staffing Coordinator/CNA | Reported challenges in staffing and covering shifts. |
| Staff 24 | LPN | Reported frequent understaffing and high resident load. |
| Staff 25 | CMA/CNA | Reported resident alertness and therapy participation. |
| Staff 19 | Physical Therapist | Reported resident alertness and therapy progress. |
| Staff 23 | Activities Assistant | Reported resident alertness and engagement in activities. |
| Staff 21 | LPN, Resident Care Manager | Acknowledged lack of therapy orders for resident after fall. |
| Staff 3 | RN | Confirmed resident fall in bathroom. |
| Staff 18 | Social Services | Confirmed resident interest in therapy but no recommendation made. |
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