Rose Linn Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. On 4/24/26 at 11:48 AM Staff 1 (Interim Administrator) acknowledged the QAPI program did not recognize or address the following identified concerns: - Obtaining consent when psychotropic medications were used. - Implementing physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 4/24/26 at 10:43 AM Staff 1 (Interim Administrator) stated performance reviews were to be completed annually and acknowledged annual performance reviews were not completed for Staff 5, Staff 6, Staff 7 and Staff 8.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 7 of 7 randomly selected staff members (#s 5, 6, 7, 8, 9, 10, and 11) reviewed for in-service training. This placed residents at risk for lack of quality care. Findings include:On 4/24/26 at 9:30 AM Staff 12 (Human Resources/Payroll Director) provided minutes for all-staff meetings and sign in sheets for 4/2025-4/2026. The minutes showed Staff 5, 6, 7, 8, 9, 10, and 11 attended various all-staff meetings, but did not indicate what topics were covered and how many hours of training were provided.On 4/24/26 at 9:39 AM Staff 12 stated staff were expected to attend the all-staff meetings to receive the required trainings. If the staff member was not in attendance, they received a packet of the materials covered. Staff 12 could not produce a record of topics covered and how many hours each CNA had attended or received.On 4/24/26 at 10:43 AM Staff 1 (Administrator) acknowledged the 12 hours of annual in-service trainings for CNAs was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications. Findings include:Resident 8 was admitted to the facility in 3/2026 with diagnoses including depression and dementia.Resident 8's 3/2026 Physician Orders indicated the resident was prescribed sertraline (antidepressant) for depression.Resident 8's 4/2026 MAR revealed the resident received sertraline daily.Review of Resident 8's medical record revealed no indication the resident was informed in advance of the risks and benefits of sertraline.On 4/23/26 at 1:24 PM, Staff 3 (LPN Resident Care Manger) acknowledged Resident 8 was not informed of the risks and benefits for the use of sertraline.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 5 and 40) reviewed for wound care and bowel medications. This placed residents at risk for constipation and worsening skin impairment. Findings include:1. Resident 40 admitted to the facility in 4/3/2026 with diagnoses including bipolar disorder. A review of Resident 40's Physician Orders dated 4/3/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder, medications indicated for constipation on a PRN basis. The Physician Orders also included a bowel routine for Resident 40 which indicated the resident was to receive Milk of Magnesia for no bowel movement after three days, bisacodyl suppository after four days and fleets enema after five days. A review of Resident 40's Care Plan dated 4/6/26 revealed the resident had bowel incontinence and was dependent on staff for all toileting tasks. A review of Resident 40's bowel record indicated the resident had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to provide treatment, services, equipment, and assistance to maintain or improve mobility related to the use of a brace 1 of 1 sampled resident (#30) reviewed for mobility. Findings include:Resident 30 was admitted to the facility in 6/2018 with diagnoses including abnormalities of gait and mobility. A 1/16/26 Quarterly MDS indicated Resident 30 had a BIMS score of 4 indicating the resident was not cognitively intact. The MDS indicated the resident used a walker and wheelchair. The MDS indicated Resident 30 did not use a brace but she/he performed ROM exercises four days a week. A 6/20/25 Referral to Prosthetics and Orthotics indicated Resident 30 required an AFO (ankle foot orthosis) due to ankle weakness and instability and the length of need was lifetime. The referral indicated the current AFO did not fit properly. A 10/23/25 Care Conference indicated Resident 30's AFO fit properly when her/his black shoes were worn. A 3/6/26 Restorative services referral indicated Resident 30 performed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to implement care plan interventions to prevent falls for 1 of 4 sampled residents (#60) reviewed for accidents. This placed residents at risk for falls. Findings include:Resident 60 was admitted to the facility in 2/2026 with diagnoses including a stroke and femur fracture.Resident 60's 2/10/26 admission MDS revealed the resident was cognitively impaired.Resident 60's 2/3/26 care plan indicated she/he was a high fall risk which required a one person assist with transfers and to ensure her/his call light was within reach.A 3/18/26 and 4/13/26 Fall Assessment revealed Resident 60 had two unwitnessed falls which was a result of the resident's attempt to self-transfer to the bathroom independently.Observations between 4/20/26 at 8:30 AM and 4/22/26 at 2:48 PM revealed multiple occasions of Resident 60's sitting in her/his wheelchair near the foot of her/his bed and her/his call light draped over the head of her/his bed which was out of reach of the resident. On 4/20/26 at 9:08 AM Staff 5 (CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to properly clean a suprapubic catheter for 1 of 1 sampled resident (#5) reviewed for catheter care. This placed residents at risk for infection. Findings include:Resident 5 was admitted to the facility on [DATE] with diagnoses including acute cystitis (sudden bladder infection). A 3/30/26 admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact. A 3/18/26 MAR indicated staff performed daily care to Resident 5's suprapubic catheter (a tube inserted through the stomach to drain urine from the bladder). Orders specified staff were to clean the site with warm soapy water or other gentle cleanser, pat dry and apply gauze. On 4/23/26 at 1:31 PM, Staff 13 was observed performing care to Resident 5's suprapubic catheter. Staff 13 cleaned the site with warm water and did not use soapy water or a cleanser. Staff 13 acknowledged she did not use soapy water or a cleanser and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure PPE was used when wound care and catheter care was performed for 1 of 1 sampled resident (#5) reviewed for wound care. This placed residents at risk for infection. Findings include:A 2/2024 CDC Implementation of Personal Protective Equipment (PPE) Use In Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms indicated enhanced barrier precautions was required during high-contact activities including device care or wound care. Resident 5 was admitted to the facility on [DATE] with diagnoses including acute cystitis (sudden bladder infection). A 3/30/26 admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact.A 3/14/26 MAR indicated staff performed daily wound care to Resident 5's left elbow. The order indicated the wound did not require a dressing. A 3/18/26 MAR indicated staff performed daily wound care to Resident 5's suprapubic catheter (a tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents (#s 114 and 115) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities and the right to an appeal. Findings include: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) indicated notices are valid when all patient specific information required by the notice is included. 1. Resident 114 was admitted to the facility in 9/2024 with diagnoses including diabetes and schizophrenia (mental health disorder). Resident 114's clinical record indicated the resident had Medicare Part A coverage. Resident 114's Profile indicated her/his financial and care POA (Power of Attorney) was Witness 3 (Family). A 9/25/24 facility email was sent to Witness 3 by Staff 9 (Former Social Services Director) that indicated Resident 114 was provided a Notice of Medicare Non-Coverage (NOMNC) form. The NOMNC form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed residents at risk for falls with injury. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including dementia. The 8/16/23 revised Care Plan indicated Resident 1 was at risk for falls related to cognitive impairment and required assistance with mobility. Interventions included the use of a Hoyer (mechanical lift) for transfers. The Care Plan also indicated Resident 1 was resistant to care with interventions including to use a calm tone/approach and to not rush during care. A 9/28/23 facility fall investigation indicated Staff 5 (CNA) transferred Resident 1 using a Sara lift (sit to stand transfer device) when the resident's foot slipped and the resident lost her/his balance. The resident hit her/his mouth and sustained a cut on the lower lip with bruising. Resident 1 was care planned for a two-person transfer using a hoyer lift. Staff 5 did not follow the Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled resident (#s 22 and 39) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: 1. Resident 22 admitted to the facility in 12/2022 with diagnoses including dementia and depression. Social Service Hearing and Vision Summaries revealed the following: -2/28/23: Resident 22 had difficulty hearing a speaker at conversational volume when there was background noise but could hear well once background noise was eliminated. Resident 22 was not seen for an audiology appointment since her/his admission. The resident and Witness 1 (Family Member) requested Resident 22 be seen because the resident had hearing aids in the past. Social Services was to schedule an appointment. -5/15/23 and 8/1/23: Resident 22 was in the process to receive hearing aids through an audiology appointment per the resident and Witness 1's request. A 7/27/23 Quarterly MDS revealed Resident 22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for medication complications and side effects. Findings include: Resident 6 admitted to the facility in 12/2022 with diagnoses including chronic heart failure and atrial fibrillation (an irregular, often rapid heart rate). A physician order dated 12/19/22 directed staff to administer digoxin (a cardiac stimulant [can cause many adverse side effects, is involved in multiple drug interactions, and can result in toxicity]) one time a day for chronic heart failure. A Pharmacy Recommendation dated 7/1/23 indicated the facility to consider drawing digoxin level because no digoxin level was on file since admission in 12/2022. On 9/7/23 at 11:45 AM Staff 7 (Pharmacy Consultant) stated she completed monthly pharmacy reviews for Resident 6 and requested a digoxin level in 7/2023 but it was not completed. Staff 7 stated she could not locate a digoxin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility 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) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus. Findings include: Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A review of Resident 39's medical record revealed no information regarding her/his COVID-19 vaccination status. On 9/7/23 at 1:52 PM and 9/8/23 at 9:03 AM Staff 2 (DNS) and Staff 4 (RN) confirmed there was no documentation regarding Resident 39's COVID-19 vaccination status.