Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linn Manor Care Center during CMS and state inspections, most recent first.
Failure to obtain informed consent for psychotropic medication increases for two residents with intact cognition. One resident had sertraline increased and another had venlafaxine increased, but the EHR lacked documentation of consent from the resident or representative. A nurse consultant stated the consents were not available when the medications were increased, despite the facility policy requiring the resident or legal representative to be fully informed and able to participate in or refuse treatment.
Care plans were not updated to reflect an indwelling catheter and EBP for one resident with traumatic spinal cord dysfunction, incomplete quadriplegia, and an infected kidney stone, or TBP for another resident diagnosed with RSV and placed on droplet isolation. The DON later stated that EBP, TBP, and an indwelling catheter should be documented on the care plan.
Wheelchair Transport Without Foot Pedals: A resident who had recently returned after a hip fracture and surgical repair was transported by a CNA in a wheelchair without foot pedals attached, despite being identified as at risk for falls and needing assistance with mobility. The resident said she could hold her legs up, and the CNA agreed and pushed her through the hallway until a Social Services Designee intervened and attached the foot pedals. The DON stated the resident would not be able to safely hold her legs up because of lower extremity weakness.
An LPN administered Novolog insulin to a resident with diabetes after the vial had already exceeded the 28-day opened expiration period. The resident had an active sliding-scale insulin order, and the vial’s opened date was later confirmed on the box. The DON stated staff were expected to check the open date before giving insulin.
The facility failed to have the minimum required members present at QAA meetings. Review of sign-in sheets showed the Administrator, Medical Director, DON, and at least two other staff attended, but the Infection Preventionist was not present at the quarterly meetings reviewed. A Corporate Nurse confirmed there was no Infection Preventionist at those meetings, and the QAPI plan did not state that the Infection Preventionist should attend.
A resident with traumatic spinal cord dysfunction, incomplete quadriplegia, and an indwelling catheter was not properly placed on EBP in the care plan, and staff did not consistently use gowns, gloves, or hand hygiene during hands-on care. CNAs touched linens, clothing, and other items without gloves or hand hygiene, drained the catheter, and continued touching items and entering the bathroom with the same gloves on.
Failure to supervise a resident with dementia and severe cognitive impairment led to repeated unwitnessed falls and a final fall with a left hip fracture. The resident had a documented history of falls, self-transfers, and fall-risk interventions, but staff left him alone in the bathroom after checking on him and reminding him to use the call light. He was later found on the floor with severe hip pain and was sent to the hospital for surgical repair.
A resident with severe cognitive impairment, PTSD-related memories, and repeated aggressive and resistive-to-care behaviors did not have individualized care plan interventions addressing his trauma history. The care plan focused on general behavior management measures such as a calm environment, avoiding overstimulation, and removing him from group activities, while staff interviews confirmed his behaviors were linked to military trauma, war memories, and triggers. The DON stated there was no formal care plan policy, and the trauma-informed care assessment was filed without the physician section completed.
The facility failed to ensure safe transfers for two residents using mechanical lifts, resulting in falls and injuries. One resident with severely impaired cognition fell headfirst out of a lift, sustaining a head laceration, while another resident with multiple conditions fell due to improper sling placement by a family member. The facility's policy on falls was not followed in both cases.
The facility failed to document routine assessments and interventions for a resident who experienced a decline in condition, leading to a hospital diagnosis of small bowel obstruction, acute respiratory failure, acute renal failure, aspiration pneumonia, and sepsis. Staff interviews revealed inconsistencies in following the facility's bowel management policy.
Failure to Obtain Informed Consent for Psychotropic Medication Increases
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications with black box warnings for 2 of 5 residents reviewed. Resident #12 had a BIMS score of 15 out of 15, indicating intact cognition, and diagnoses that included anxiety disorder, depression, and non-Alzheimer's dementia. The MDS showed the resident received an antidepressant, and the order summary reflected sertraline (Zoloft) was increased from 50 mg every morning to 100 mg every morning starting 9/27/25. The resident's medical record did not contain documentation of informed consent for the psychotropic medication from the resident or the resident representative. Resident #13 also had intact cognition, with a BIMS score of 14 out of 15, and diagnoses including generalized anxiety disorder and major depressive disorder, recurrent, moderate. The physician orders showed venlafaxine was increased starting 1/22/26, but the EHR lacked documentation of psychotropic consent. On 2/11/26, Staff B, Nurse Consultant, stated that consents were not available for Residents #12 and #13 when their psychotropic medications were increased. The facility policy stated that before initiating or increasing a psychotropic medication, the facility must ensure the resident or legal representative is fully informed and has the right to participate in or refuse treatment.
Care Plan Not Updated for Catheter and Isolation Precautions
Penalty
Summary
The facility failed to update and revise the comprehensive care plan to reflect an indwelling catheter and Enhanced Barrier Precautions for Resident #24. The Minimum Data Set assessment showed diagnoses of traumatic spinal cord dysfunction, C5-C7 incomplete quadriplegia, and kidney stone. Nursing progress notes documented that the resident returned from the hospital with an indwelling catheter for an infected kidney stone until a follow-up urology appointment. On observation, the resident was noted to have a catheter, but the care plan initiated in 2019 did not document the indwelling catheter or EBP until after the DON was questioned about it. The facility also failed to update and revise the care plan to reflect Transmission Based Precautions for Resident #29. The Minimum Data Set showed moderately impaired cognition, and nursing progress notes documented a diagnosis of RSV. During observation, a droplet isolation sign was noted on the resident’s door, indicating TBP was in place, but the care plan initiated in 2023 did not document TBP until after the DON was questioned about it. The DON stated that EBP, TBP, and an indwelling catheter should be documented on the care plan, and the facility policy on care planning included catheters, infections, and isolation precautions.
Wheelchair Transport Without Foot Pedals
Penalty
Summary
The facility failed to ensure a wheelchair was equipped with foot pedals during transport for a resident who had been readmitted for skilled nursing services after a fall with a right hip fracture and surgical repair. The resident’s admission/readmission nursing assessment showed the resident required assistance of 2 staff for bed mobility and toileting and 1 staff for transfers. The care plan identified the resident as at risk for falling and included an intervention to utilize a wheelchair for mobility. During observation, a CNA pushed the resident in a wheelchair without foot pedals attached while the resident held her legs up above the ground from her room to the common area. The resident asked to be pushed in the wheelchair and stated she could hold her legs up, and the CNA agreed. A Social Services Designee later removed the foot pedals from a bag on the back of the wheelchair and attached them. The Social Services Designee stated wheelchair transport without foot pedals was not allowed because a resident could fall out or be injured if the feet went down. The DON stated the resident would not be able to safely hold her legs up due to lower extremity weakness following the recent hip fracture.
Expired Opened Insulin Administered
Penalty
Summary
The facility failed to ensure that an opened insulin vial was not expired before administration for one resident with diabetes mellitus and intact cognition. The resident had an active order for Novolog insulin Aspart 100 units/mL to be given subcutaneously by sliding scale based on blood sugar readings, and the Medication Administration Record showed the resident received 2 units for a blood sugar of 194 during the 11:30 AM dose. During observation, an LPN prepared and administered Novolog insulin to the resident and returned the vial to the medication cart afterward. The vial had an opened date written on the outside of the box, and the LPN later reviewed the medication expiration document and confirmed that Novolog expires 28 days after opening. When the opened date was checked, the LPN stated the insulin was expired and would be discarded and replaced. The DON stated nursing staff were expected to check the open date of insulin before administration and reported that the provider had been notified.
QAA Committee Lacked Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to have the minimum required members present at Quality Assessment and Assurance (QAA) meetings to identify issues requiring quality assessment and assurance activities. The facility had a census of 36 residents. Review of QAA sign-in sheets showed that the Administrator, Medical Director, DON, and at least two other staff attended the meetings, but the Infection Preventionist was not present at the April 2025 or December 2025 quarterly meetings. During an interview on 2/12/26 at 12:40 PM, Staff E, Corporate Nurse, reported that there was no Infection Preventionist present at the quarterly meetings in April and December. She also stated that the previous ADON was the Infection Preventionist in April 2025, but that person was not listed on the April QAA sign-in sheet. The facility's QAPI Plan did not include information indicating that the Infection Preventionist should attend the quarterly meetings.
Failure to Follow EBP and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for Resident #24, whose MDS documented traumatic spinal cord dysfunction and C5-C7 incomplete quadriplegia. The nurse's progress notes stated the resident returned from the hospital with an indwelling catheter for an infected kidney stone until a follow-up urology appointment. The care plan initiated in 2019 did not document the indwelling catheter or that the resident was in EBP, and it was not updated to include either until after the DON was questioned about it. During observations, staff did not follow the facility's EBP and hand hygiene practices while providing care to Resident #24. One CNA made the bed and placed the resident's call light without wearing a gown or gloves, despite the EBP sign on the door and the resident's catheter status. In another observation, a CNA touched the resident's linens and clothing without gloves, left the room and touched various items without hand hygiene, returned for supplies without hand hygiene, then performed hand hygiene and applied gloves before draining the catheter; afterward, the CNA touched various items and entered the bathroom twice with the same gloves on. Another CNA changed gloves during catheter care without performing hand hygiene before donning a new pair. The DON stated the resident should have had gloves on to begin care, hand hygiene should occur between doffing and donning gloves, and gloves should be changed after catheter emptying with hand hygiene performed.
Failure to Supervise a High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with dementia and severe cognitive impairment, resulting in a left hip fracture. The resident’s record showed diagnoses including dementia, heart failure, atrial fibrillation, malnutrition, and adult failure to thrive. The resident’s MDS documented a BIMS score of 5 out of 15, indicating severe cognitive impairment, and the care plan identified the resident as at risk for falls with interventions including assistance with transfers, proper footwear, call light use, and toileting assistance. The resident had a history of repeated falls, including multiple unwitnessed falls and one witnessed fall. Facility documentation showed the resident was found on the floor in his room, near his bed, in the bathroom doorway, and in the bathroom on several occasions. After one fall, the facility added an intervention stating the resident could not be left in a wheelchair in his room. Despite this, staff later found the resident in the bathroom on the toilet and left him there after reminding him to use the call light. Staff interviews confirmed that the resident had a pattern of attempting to self-transfer and that staff were aware of prior falls related to getting up from the wheelchair. On the day of the fracture, staff checked on the resident in the bathroom shortly before the fall and cued him to use the call light when finished, but none of the staff assisted him off the toilet. The facility investigation stated the resident took himself to the bathroom and fell while attempting to go back to bed from his wheelchair. A CNA later found the resident on the floor between the bed and bathroom with his wheelchair at his side, and he complained of severe left hip pain. The resident was transferred to the hospital, where the facility was notified that he had a closed left hip fracture and remained there for surgical repair.
Failure to Individualize Care Plan for Resident With PTSD and Trauma History
Penalty
Summary
The facility failed to provide individualized care plan interventions to address a resident’s trauma history and PTSD-related behaviors. The resident’s admission MDS showed severe cognitive impairment with a BIMS score of 5, and the trauma-informed care assessment documented repeated disturbing memories and upsetting dreams related to stressful past experiences, including the resident’s military special forces service. The assessment noted that the resident repeatedly talked about vivid memories of seeing bad things during military service, but the physician section for psychological services was left blank. The resident’s CAA identified resistive-to-care behaviors during the lookback period and noted contributing factors including new admission status, pneumonia, UTI, malnutrition, failure to thrive, impaired cognition, and antidepressant use. The CAA stated the resident was at risk for unmet needs, depression and/or anxiety, frustration, agitation, physical or verbal behaviors, falls, decline in ADL function, social isolation, and decreased quality of life related to behavioral symptoms. The care plan, however, focused on general behavioral symptoms such as avoiding overstimulation, maintaining a calm environment, removing the resident from group activities when behavior was unacceptable, and later using plastic silverware and moving the resident to a quiet, calm environment when socially inappropriate or disruptive. Staff interviews showed the resident had combative, aggressive, and PTSD-related behaviors, including hitting, yelling, grabbing, kicking, cursing, screaming, threatening, and refusing care. Multiple staff stated the resident did better with male staff, that his approach needed to be delicate because of PTSD, and that his behaviors were related to war memories and triggers. The social services staff reported completing the trauma-informed care assessment but said nursing completed most of the care plan and that she did not directly communicate the resident’s war-related comments to the provider. The DON stated there was no formal policy for care plans, and the care planning procedure listed PTSD and trauma-informed care as items that may be used as a guide for comprehensive care planning.
Failure to Ensure Safe Transfers Using Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe transfers for two residents using mechanical lifts, resulting in falls and injuries. Resident #5, who has severely impaired cognition due to a stroke and other conditions, fell headfirst out of a mechanical lift during a transfer, sustaining a head laceration. The incident occurred despite the presence of two staff members, and it was the first fall from a mechanical lift for this resident. The Director of Nursing (DON) confirmed that the resident jerked forward and fell through the side of the lift straps during the transfer. Resident #11, who has no cognitive impairment but suffers from traumatic brain dysfunction, dementia, quadriplegia, and a bladder disorder, also fell out of a mechanical lift during a transfer. This incident involved a newer CNA and the resident's family member, who insisted on assisting with the transfer. The family member improperly placed the lift sling, causing the resident to fall and hit his head. The DON revealed that the family member did not want the incident reported, and the CNA initially mistook the family member for an employee due to her assertive behavior. The facility's policy on falls was not followed in both cases.
Failure to Document Routine Assessments and Interventions
Penalty
Summary
The facility failed to document routine assessments and interventions for a resident who experienced a decline in condition. The resident, who was cognitively intact and independent with toileting and walking, had a primary diagnosis of other neurological conditions along with diabetes, anemia, malnutrition, and Parkinson's. From 12/13/23 to 12/17/23, the resident's electronic health record lacked complete assessments related to his decline. Notable events included a medium formed bowel movement, emesis with no new orders from the doctor, a medium loose bowel movement, a headache, and administration of a magnesium laxative before being sent to the hospital. The hospital diagnosed the resident with a small bowel obstruction, acute respiratory failure, acute renal failure, aspiration pneumonia, and sepsis. Interviews with the Director of Nursing, an LPN, an RN, and the resident's physician revealed that the facility's staff were aware of the resident's symptoms but did not consistently document or act upon them according to the facility's bowel management policy. The policy required regular bowel movement tracking, administration of laxatives or stool softeners, and timely physician notification for residents who had not had a bowel movement in two or more days. The resident's symptoms and decline were not adequately documented or addressed, leading to a significant health deterioration that required emergency hospital care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silver Oak Nursing And Rehabilitation Center Llc | 1.4 mi | ★★★★★ | 14 | 0 |
| Oakview Nursing & Rehablitation - Marion | 1.7 mi | ★★★★★ | 5 | 0 |
| Cottage Grove Place | 2.4 mi | ★★★★★ | 2 | 1 |
| Terrace Glen Village | 2.5 mi | ★★★★★ | 5 | 0 |
| Winslow House Care Center | 2.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.