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 Community Nursing Home during CMS and state inspections, most recent first.
Food storage and meal service standards were not followed in the kitchen and two kitchenette areas. Surveyors found multiple undated freezer items, observed dietary staff serving meals without hair nets while leaning over open warming drawers, and saw a probed thermometer used on multiple foods without being cleaned between items. The CDM verified the thermometer issue, and a dietary staff member stated she did not know freezer items had to be labeled and dated.
The facility failed to complete and document a facility assessment that identified the nursing resources needed for daily operations and emergencies. With a census of 41 residents, the assessment did not list specific RN, LPN/LVN, CMA, or CNA staffing levels for each unit or shift. An Administrative Nurse stated the minimum staffing pattern included two staff who could pass meds, one of whom was an LPN, for both neighborhoods on day and evening shifts, and one LPN plus two nurse aides on nights, but this was not reflected in the assessment. The facility also did not provide a facility assessment policy when requested.
A resident with dementia and severe cognitive impairment was admitted to hospice, but the care plan did not include a coordinated hospice plan of care or key service details such as hospice contact info, visit frequency, medications, supplies, equipment, or what care hospice staff would provide. The record and an admin nurse confirmed the missing information, even though the hospice agreement called for a joint plan of care and the facility policy described collaboration between hospice and facility staff.
Failure to change gloves during perineal care: a CNA and an LN cared for a resident in bed after urinal use, and the CNA continued incontinent care and repositioning with the same soiled gloves after urine spilled on her gloves. The CNA touched the resident’s bedding, O2 tubing, legs, curtain, and clean supplies before removing the gloves, despite the facility’s perineal care protocol requiring removal of soiled gloves and hand hygiene before donning clean gloves.
A resident with multiple health conditions, who primarily used a wheelchair, was pushed by a maintenance staff member despite her repeated requests to stop and her wish to go to the activity room. Several staff witnessed the incident, filed grievances, and reported it to a nurse and administrator, but no formal investigation was conducted, staff were not interviewed, and the incident was not reported to the State Agency as required by facility policy.
A resident with multiple health conditions, who primarily used a wheelchair and required staff assistance, was observed by several staff being pushed by a maintenance staff member despite her objections. Staff filed grievances, but they were not individually interviewed, and the administrator did not conduct a formal investigation or report the incident to the State Agency, contrary to facility policy.
A facility failed to prevent accidents and falls for two residents. One resident, with severe cognitive impairment, was allowed to exit unsupervised through an unlocked gate, remaining outside for hours before being noticed. Another resident, with a history of falls and high fall risk, lacked adequate care plan interventions for multiple falls. These deficiencies highlighted failures in maintaining a safe environment, placing residents at risk for injury.
The facility failed to store food properly and ensure effective dishwashing, risking foodborne illness for residents. Observations revealed missing thermometers, unsealed and expired food, and inadequate dishwashing logs. Dietary staff confirmed these deficiencies, highlighting lapses in food safety protocols.
The facility failed to implement a water management program to prevent Legionella disease, placing 38 residents at risk. Interviews and record reviews revealed a lack of documentation for Legionella preventative measures, such as risk area identification and disinfection procedures. Maintenance staff confirmed the absence of a water distribution map, and the Infection Control Preventionist noted missing documentation for the water management plan, despite policy requirements.
The facility failed to ensure the Consultant Pharmacist identified and reported unapproved indications and inadequate monitoring for psychotropic medications for several residents. This oversight placed the residents at risk for unnecessary medication use and side effects.
The facility failed to ensure approved indications and adequate monitoring for psychotropic medications for several residents, placing them at risk of unnecessary medication use. Residents were administered psychotropic drugs without specific targeted behaviors or side effect monitoring documented, and physicians declined GDR recommendations without providing specific rationales. The facility's policy on psychotropic medication use was not adequately implemented, leading to deficiencies in monitoring and documentation.
The facility failed to offer pneumococcal immunizations to four residents, despite physician orders and facility policy. The residents had received a previous Pneumovax dose but lacked documentation of being offered further vaccinations. Interviews revealed a lack of systematic tracking and offering of the vaccine, with staff confirming the absence of a list of eligible residents. This oversight placed the residents at risk for complications related to pneumococcal pneumonia.
A resident with severe cognitive impairment and multiple health issues was transferred to a hospital without being provided the required bed hold policy information. An administrative nurse confirmed the lack of documentation, which is against the facility's revised policy. This oversight placed the resident at risk of not being able to return to the facility.
A facility failed to complete a discharge summary for a resident, omitting a recapitulation of the resident's stay and treatment. The resident, who had multiple medical conditions, was discharged without this essential documentation, contrary to the facility's policy. This oversight was confirmed by an administrative nurse, highlighting a risk for unmet care needs.
A resident with multiple diagnoses, including dementia and psychotic disturbance, was not assessed for trauma-informed care needs, contrary to the facility's policy. Despite documented behavioral issues and high-alert medications, neither the administrative nurse nor social services completed the required assessment, placing the resident at risk for unmet emotional and psychosocial needs.
Food Storage and Meal Service Standards Not Followed
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in one kitchen and two kitchenettes. In the kitchen, surveyors observed multiple undated food items in the freezer, including filet steak patties, grilled shrimp, French fries, chicken strips, popcorn chicken, taco meat, tater tots, chicken patties, breaded mushrooms, and an unsealed bag of choriquesco. A dietary staff member verified the items and stated she was unaware the freezer food items needed to be labeled and dated. During meal service in the small dining room kitchenette, a dietary staff member served breakfast without a hair net while standing over the food with the bottom warming drawer open on the oven. In the large dining room kitchenette, another dietary staff member also served food without a hair net and with her head over the warming drawer while plating the noon meal. In the kitchen, a dietary staff member checked the temperature of smothered pork chops with a probed thermometer and then used the same probe on mixed vegetables and scalloped potatoes without cleaning it between food items; the CDM verified the thermometer had not been cleaned and stated it should have been cleaned.
Facility Assessment Missing Required Staffing Details
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the nursing resources needed to care for residents competently during day-to-day operations and emergencies. With a census of 41 residents, the assessment did not include specific staffing levels or the number of RN, LPN/LVN, CMA, and CNA staff needed for each unit, resident needs, census, or each shift. Review of the assessment showed it lacked the staffing levels required for day, evening, and night shifts. During interview, Administrative Nurse D stated the facility's minimum staffing pattern was two staff who could pass medications, including one licensed nurse, for both neighborhoods, with two CNAs scheduled for each neighborhood on day and evening shifts and one licensed nurse plus two nurse aides on the night shift for both neighborhoods. Administrative Nurse D also stated she participated in the facility assessment process and believed this staffing pattern was included, but the facility assessment did not reflect it. The facility did not provide a facility assessment policy when requested.
Hospice Care Plan Lacked Required Service Details
Penalty
Summary
The facility failed to ensure that Resident 9’s hospice care plan included a plan of care and a description of the services provided, including contact information, visit frequency, medications, and medical equipment. Resident 9 had a diagnosis of dementia, a BIMS score of 00 indicating severe cognitive impairment, and required supervision with most ADLs. The resident’s care plan, revised after hospice admission, documented that the resident was admitted to hospice services and directed staff to administer pain and other medications for comfort as ordered, but it did not include the hospice contact number, what supplies, equipment, or medications hospice would provide, when hospice staff would be in the building, or what care they would provide. The resident’s record showed hospice admission and a hospice agreement stating that hospice and the facility would jointly develop and agree upon a coordinated plan of care. Observation on 02/24/26 showed Resident 9 sitting at a dining room table and independently eating breakfast with no signs or symptoms of pain. On 02/25/26, Administrative Nurse D verified that the care plan lacked information about the hospice services provided, including visit frequency, contact information/phone numbers, and medical supplies. The facility’s End of Life, Palliative, and Hospice Care Policy stated that hospice staff would participate in team meetings when possible to promote communication, collaboration, and an integrated plan of care.
Failure to Change Gloves During Perineal Care
Penalty
Summary
The facility failed to ensure a sanitary environment to help prevent the potential development and transmission of communicable diseases and infections when staff did not change gloves during incontinence care for a resident. During observation, a CNA and an LN entered the resident’s room while the resident was in bed with a urinal under the covers. After the resident said he was finished using the urinal, the CNA and LN put on gloves, and the CNA removed the urinal, spilling urine on the bed pad and her gloves. The LN poured the urine into the toilet, discarded her gloves, and put on new gloves. The CNA then continued perineal care and repositioning of the resident while wearing the same soiled gloves. She touched the resident’s bedding, oxygen tubing, and legs, provided incontinent care to the resident’s buttocks, removed the wet incontinent brief and bed pad, touched the privacy curtain, closed the lid on the incontinent wipe package, retrieved a new incontinent brief, and placed it under the resident’s buttocks without changing gloves. The CNA later assisted with repositioning the resident and fastening the brief before removing the soiled gloves. The CNA stated she had not changed her gloves after providing perineal care and said she should have. The Administrative Nurse stated staff were expected to change gloves after performing perineal care, and the facility’s Perineal Care Protocol instructed staff to remove soiled gloves, wash hands, don clean gloves, and not touch anything with soiled gloves after the procedure.
Failure to Report and Investigate Resident's Objection to Staff Handling
Penalty
Summary
The facility failed to report an incident involving a resident with multiple medical conditions, including hypertension, pain, muscle weakness, and major depressive disorder, who primarily used a wheelchair for mobility. On the date in question, multiple staff members witnessed a maintenance staff member pushing the resident in her wheelchair despite her repeated requests to stop and her desire to go to the activity room. Staff members, including a CNA and dietary staff, observed the resident expressing her wish for the maintenance staff to stop, and one staff member reported that the resident did not appear jovial about the interaction. Grievances were filed by staff who witnessed the event, but they were not interviewed about what they saw. The incident was reported up the chain to a licensed nurse and then to administrative staff, who acknowledged being informed that the resident was taken by the maintenance staff and that her whereabouts were temporarily unknown. Although the administrator later interviewed the resident, who downplayed the incident, no formal investigation was conducted, and the staff who filed grievances were not individually interviewed. The facility did not report the incident to the State Agency as required by its own abuse, neglect, and exploitation policy, nor did it complete a written investigation into the staff grievances related to the event.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving a resident with multiple medical conditions, including hypertension, pain, generalized edema, and major depressive disorder. The resident, who primarily used a wheelchair and required staff assistance for mobility and activities of daily living, was observed by multiple staff members being pushed in her wheelchair by a maintenance staff member despite her objections and requests to stop. Staff members, including a CNA and dietary staff, witnessed the incident, noted the resident's distress, and filed grievances regarding the event. However, these staff members were not individually interviewed about what they witnessed. The licensed nurse reported the incident and submitted the grievances to administrative staff, who acknowledged being informed of the situation and seeing the resident and maintenance staff together. The administrator conducted only a brief, informal interview with the resident and did not conduct a written investigation or interview the involved staff individually. No report was made to the State Agency, and no formal investigation documentation was completed, despite the facility's policy requiring immediate investigation and reporting of all alleged or suspected abuse, neglect, or exploitation.
Failure to Prevent Accidents and Falls for Residents
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for a cognitively impaired resident, identified as R35. On the morning of 05/23/24, a dietary staff member allowed R35 to exit through a door leading to the patio without ensuring additional supervision. The patio area had an unlocked gate, which R35 used to leave the facility unsupervised. It was not until approximately 3.5 hours later that staff realized R35 had been outside without supervision. R35 was found in her room, having returned on her own. The resident's medical records indicated severe cognitive impairment, a history of falling, and a need for supervision with ambulation. The facility also failed to provide adequate interventions to prevent falls for another resident, identified as R12. R12 had a history of multiple falls, with the care plan lacking interventions for several incidents. R12's medical records documented conditions such as spinal stenosis, cognitive-communication deficit, and Alzheimer's disease, which contributed to a high fall risk. Despite this, the care plan did not consistently address the falls, leaving R12 at risk for further incidents. The facility's policies on accident prevention and fall prevention were not effectively implemented, as evidenced by the incidents involving R35 and R12. The unlocked gate and lack of supervision for R35, along with the insufficient fall prevention measures for R12, highlighted deficiencies in maintaining a safe environment for residents. These failures placed both residents at risk for injury, with R35's situation being classified as immediate jeopardy.
Removal Plan
- Updated Elopement and Elopement Risk Policies
- The facility started a sign-off sheet to include charge nurses' verification that a resident was able to go outside the facility without staff or a family member.
- Staff participated in an elopement drill.
- R35's care plan was updated.
- Initiated daily maintenance checks of the patio gates to make sure they are secured.
- R35 received 15-minute checks.
- Updated R35's wander/elopement risk assessment which shows moderate risk for elopement.
Improper Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to proper food storage and dishwashing protocols, which placed residents at risk for foodborne illness. During an inspection, it was observed that the stainless-steel double-door refrigerator lacked a thermometer in the refrigerator section, and the freezer section contained seven opened, unsealed, and unlabeled bags of frozen foods. Additionally, the thermometer on the door shelf was not functioning. The walk-in freezer had boxes of various food items stored directly on the floor, and the white refrigerator in the hallway contained expired frozen products. Furthermore, the walk-in freezer lacked an independent backup thermometer, which is essential for monitoring temperature fluctuations. The dishwashing machine logs revealed inconsistencies in recording temperatures and sanitizer levels, with several days lacking documentation entirely. The facility's policy required daily checks for expired food and proper labeling and dating of opened food items, which were not followed. Dietary staff confirmed these deficiencies, acknowledging the lack of proper labeling, expired food, and inadequate monitoring of dishwashing temperatures and chemical sanitation. These oversights in food storage and dishwashing practices compromised the safety and well-being of the residents.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility, with a census of 38 residents, failed to implement a comprehensive water management program to prevent Legionella disease, a bacterium that can cause pneumonia, particularly in adults over 50 and those with weakened immune systems. The deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of Legionella preventative measures, such as identifying risk areas and actions taken to mitigate risk. The Water Temperature Check Log documented weekly checks of various areas, but there was no evidence of a map of water distribution or documentation of disinfection of shower heads, especially in unused resident halls. During interviews, Maintenance Staff V confirmed the absence of a water distribution map and documentation of disinfection procedures, while the Infection Control Preventionist CC verified the lack of required documentation to show adherence to the water management plan. The facility's Water Management Policy outlined minimum standards, including risk assessments, system descriptions, and action plans for controlling Legionella, but these were not implemented. This failure placed residents at risk of contracting Legionella pneumonia due to inadequate management of waterborne pathogens.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported unapproved indications for the use of psychotropic medications, as well as the lack of monitoring for side effects and targeted behaviors for several residents. For Resident 6, the CP did not report the lack of side effects and targeted behavior monitoring, nor the unapproved indication for Zyprexa. The resident's care plan lacked specific targeted behaviors and monitoring related to high-alert medications, placing the resident at risk for unnecessary medication side effects. Resident 13's care plan also lacked specific targeted behaviors and side effect monitoring for high-alert medications. The CP failed to identify and report these inadequacies, and the physician's denial of a gradual dose reduction (GDR) lacked a patient-specific rationale. This oversight placed the resident at risk of unnecessary psychotropic medication use and related side effects. Similarly, for Residents 22 and 21, the CP did not report the unapproved indications for antipsychotic medications and failed to ensure adequate monitoring of targeted behaviors. The lack of documentation and communication regarding these issues placed the residents at risk for unnecessary psychotropic medication use and potential side effects.
Inadequate Monitoring and Indication for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that several residents had approved indications and adequate monitoring for the use of psychotropic medications, placing them at risk of receiving unnecessary medications. Resident 6, who had severe cognitive impairment and was dependent on staff for functional abilities, was administered multiple psychotropic medications without specific targeted behaviors or monitoring for side effects documented in the care plan. Despite recommendations for gradual dose reductions (GDR) for some medications, the physician declined these without providing a specific rationale, and the clinical record lacked evidence of a risk versus benefit analysis for the continued use of antipsychotic medication. Resident 13, who had intact cognition and no signs of delirium or psychosis, was also administered several psychotropic medications without specific targeted behaviors or side effect monitoring documented. The physician declined GDR recommendations without recording a patient-specific rationale, and the medication regimen reviews did not identify or report the lack of monitoring. Similarly, Resident 22, who had intact cognition but exhibited delusions and verbal behaviors, was administered an antipsychotic medication without an approved indication, and the consultant pharmacist's evaluation lacked information regarding this unapproved use. Resident 21, with moderate cognitive impairment, was administered psychotropic medications without evidence of targeted behavior monitoring. The physician declined GDR recommendations, citing clinical contraindications, but the clinical record lacked evidence of monitoring for targeted behaviors or adverse reactions. The facility's policy required monitoring for the need and benefits of psychotropic medications, but this was not adequately implemented, leading to the risk of unnecessary medication use and related side effects for the residents involved.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal immunizations to four residents, despite physician orders and facility policy requiring such vaccinations. The residents involved were R13, R25, R12, and R24, all of whom had received a previous dose of the Pneumovax vaccine but lacked documentation of being offered or refusing further vaccinations. The facility's policy, aligned with CDC recommendations, required offering two pneumococcal vaccines to adults aged 65 years or older, with specific intervals between doses. However, the facility did not adhere to this policy, as evidenced by the absence of documentation and the failure to screen residents for eligibility for a second dose. Interviews with facility staff revealed a lack of systematic tracking and offering of the pneumococcal vaccine. Administrative Nurse E confirmed that four of the six reviewed residents had not received a second pneumonia immunization since admission, and the facility had not screened them for eligibility. Administrative Nurse D acknowledged that the facility had not compiled a list of residents eligible for a second vaccination, despite the information being available in their EHR. The facility's reliance on the pharmacy to review and administer vaccinations further contributed to the oversight, as the pharmacy had not been provided with a list of eligible residents. This inaction placed the residents at risk for complications related to pneumococcal pneumonia.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding the bed hold policy when the resident was transferred to the hospital. The resident, identified as R17, had diagnoses of congestive heart failure and an acute upper respiratory infection, and was dependent on staff for most activities of daily living due to severely impaired cognition. The resident's care plan required oxygen at night due to breathing difficulties. Despite these needs, when R17 was admitted to the hospital, there was no evidence in the clinical record that the facility provided the required bed hold policy information. An administrative nurse confirmed the oversight, acknowledging the absence of documentation that the bed hold policy was given to R17 or their representative at the time of hospital transfer. The facility's bed hold policy, revised earlier in the year, mandates that such information be provided before a resident is transferred to a hospital or goes on therapeutic leave. This failure to communicate the bed hold policy placed the resident at risk of not being permitted to return and resume residence in the nursing facility.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as R39, which included a recapitulation of the resident's stay and course of treatment. This deficiency was identified during a review of the resident's electronic medical record (EMR) and through interviews. R39 was admitted to the facility with multiple diagnoses, including idiopathic peripheral neuropathy, enterocolitis due to clostridium, edema, vomiting, kidney calculus, anemia, urinary tract infection, abdominal pain, and leg pain. The resident's care plan indicated a desire to return to live in the community, and a physician's order was documented for discharge back to her apartment with the same medication orders. On the day of discharge, a progress note recorded that R39 left the facility with a family member, taking medications and instructions. However, the discharge summary in the EMR lacked a recapitulation of the resident's stay, which was confirmed by an administrative nurse. The facility's policy required documentation of the resident's clinical record, including medical treatment, care responses, and changes in condition, as well as the resident's functional status at admission and discharge. The absence of a recapitulation summary placed the resident at risk for unidentified and unmet care needs.
Failure to Conduct Trauma-Informed Care Assessment
Penalty
Summary
The facility failed to assess a resident, identified as R22, for trauma-informed care needs, which could have helped in eliminating or mitigating triggers that may cause re-traumatization. R22's electronic medical record documented diagnoses including hypertension, mild cognitive impairment, muscle weakness, chronic pain, and dementia with psychotic disturbance. Despite these conditions, the facility did not conduct a trauma-informed care assessment to identify potential mental health needs. The resident's care plan included high-alert medications such as valproate and olanzapine, and there were documented instances of behavioral issues, including conflict with another resident. Interviews with facility staff revealed that neither the administrative nurse nor the social services had completed a trauma-informed care assessment for R22. The facility's policy required an initial screening for a history of trauma within 48 hours of admission, but this was not done for R22. The lack of assessment placed the resident at risk for unmet emotional and psychosocial needs, as the care plan did not account for trauma-informed care strategies that could help manage the resident's behavioral symptoms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Linn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Villa | 17.9 mi | ★★★★★ | 14 | 0 |
| Advena Living Of Clay Center | 20 mi | — | 0 | 0 |
| Clay Center Presbyterian Manor | 20.9 mi | ★★★★★ | 0 | 0 |
| Leonardville Nursing Home | 25 mi | ★★★★★ | 0 | 0 |
| Cambridge Place | 26.7 mi | ★★★★★ | 29 | 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.