Linn Manor Care Center

Inspectors wroteBased on staff interview, clinical record review, facility investigation review, and facility policy review the facility failed to ensure all staff responded appropriately to a sounding door alarm for 1 of 3 residents reviewed for inadequate nursing supervision (Resident #1). On 3/24/26 a confused, ambulatory resident (Resident #1), known to have exit seeking behaviors, exited the facility's East door unattended and was seen by staff walking in the road away from the facility. The facility failed to ensure the staff member who responded to the door alarm initiated resident checks to ensure all residents were accounted for after the door alarm sounded, and failed to communicate that no one was seen at and outside the door. The facility reported a census of 35 residents. The facility corrected the deficient practice per past noncompliance through the following actions: [...]

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to obtain informed consent for psychotropic medications that have black box warnings (safety warning used by the Food and Drug Administration (FDA) and requires the healthcare provider to have a comprehensive discussion with the resident/representative about the risks, benefits and alternatives for use) for 2 of 5 resident reviewed for psychotropic medications (Resident #12, and Resident #13). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to update and revise the care plan to reflect the presence of an indwelling catheter, Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 2 of 12 residents reviewed for Comprehensive Care Planning (Residents #24 and Resident #29). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility failed to apply foot pedals to the wheelchair when transporting 1 of 3 residents reviewed for accidents (Resident #27). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure an opened insulin vial was not expired prior to administration for 1 of 1 resident (Resident #12) reviewed for insulin. The facility reported a census of 36 residents.

Inspectors wroteBased on facility record review, staff interview, and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities were necessary. The facility identified a census of 36 residents.

Inspectors wroteBased on clinical record review, observation, staff and resident interviews, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for EBP (Resident #24) and demonstrate proper hand hygiene practices to prevent cross contamination for 1 of 12 residents reviewed for infection control (Resident #24). The facility reported a census of 36.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to provide individualized Care Plan interventions to address resident trauma one out of one resident reviewed (Resident #1). The facility reported a census of 35 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, staff and physician interviews, and policy review the facility failed to document routine assessment and interventions completed by the facility for 1 of 6 residents reviewed (Resident #8). The facility reported a census of 34 residents.

Inspectors wroteBased 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. F868 - QAA Committee. [...]

Inspectors wroteBased on observations, clinical record review, staff and resident interviews and facility policy review, the facility failed to assess for the safety and competency of self-administration of inhalant medications for 1 of 7 residents observed during medication administration (Resident #25) . The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 9/06/23, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of indicating intact cognition. The MDS included diagnoses of chronic respiratory failure with hypoxia, shortness of breath, dyspnea, and generalized muscle weakness. The Care Plan, revised 08/30/23, revealed a focus area for impaired Activities of Daily Living (ADLs) and mobility independence related to chronic respiratory failure with hypoxia. [...]

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, review of a Maintenance Work Order, the facility failed to maintain good repair of a floor heating register in resident room for 1 of 8 resident's rooms screened for a homelike environment (Resident #21). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 7/07/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses of late-onset cerebellar ataxia, multi-system degeneration of the autonomic nervous system, adjustment disorder with anxiety, and depression. The MDS, revealed Resident #21 required extensive assistance of two staff for bed mobility, transferring, and toileting and non-ambulatory. [...]

Inspectors wroteBased on clinical record review, staff interviews, employee file review, and facility policy review, staff failed to report to the facility and the facility failed to identify situations as an alleged violation involving abuse and to report allegations within required regulatory time frames for 3 of 3 residents reviewed (Residents #9, #26 and #28). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to complete a thorough investigation of alleged violations of abuse, maintain documentation, and prevent further incidents. (Residents #9 and #26). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I of the MDS signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). A document titled Self-Report dated 2/1/23 revealed another resident touched and patted Resident #9 on the breast on 1/12/23 in a common area of the facility. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to conduct a Comprehensive Assessment of a resident in accordance with the timeframes specified for 1 of 1 residents reviewed (Resident #138). The facility reported a census of 34. Findings Include: A Minimum Data Set (MDS) 3.0 Assessment Summary in the Electronic Health Record, labeled Entry with a target date of 10/26/23, revealed 33 questions remained with a status of 'in progress' and 7 days overdue. An MDS Assessment for Resident #138 dated 11/1/23, revealed an unsigned document with Section K completed 11/7/23, Section F completed 11/8/23, and Sections C and D completed 11/8/23. The remaining assessment sections were incomplete. The MDS summary revealed 365 questions remained with a status of 'in progress' and 1 day overdue. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy review, the facility failed to implement interventions, monitor for effectiveness, and modify interventions to minimize the likelihood of falling for 1 of 2 residents reviewed for accidents (Resident #12). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 8/28/23, revealed Resident #12 required limited assistance of one staff for transfers, locomotion and required extensive assistance of one staff for toileting, dressing, and personal hygiene. The MDS indicated Resident #12 unsteady with transfers or ambulation but able to stabilize without staff assistance. The Care Plan, initiated 8/21/23, listed diagnoses of dementia and anxiety initiated. [...]