Linn Manor Care Center

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

heard Resident #1 yelling for help and found him in his room laying on his left side, he was between the bed and the bathroom, his wheelchair was at his side, wheels locked. Resident #1 complained of 10 out of 10 pain to his left hip. Resident had self-transferred Resident failed to have anything on his feet. Resident #1 stated this was the worst pain he had ever had. Resident #1 transferred to the ER (Emergency Room) for evaluation. The Facility Incident Summary dated 9/08/2025 reflected the ER notified the Director of Nursing (DON) of a left hip fracture and Resident #1 would remain at the hospital for surgical repair. The summary revealed staff checked on the resident in his bathroom shortly prior to the fall, and cued him to use his call light when finished. The summary identified none of the staff assisted Resident #1 off the toilet. The facility investigation read Resident #1 took himself to the bathroom and fell attempting to go back to his bed from his wheelchair.The Health Status Note dated 9/11/25 at 1:33 PM revealed, in part, Report received from [Hospital Name Redacted]; Resident is to be transferred to [Facility Name] around 1400 (2:00 PM) today.

He has a closed left hip FX (fracture), post surgery. On 9/14/25 at 9:01 AM Staff E, CNA revealed she did rounds with Staff A and they found him in the bathroom on the toilet. She said she asked him if he needed help, but he declined. She stated he took himself into the bathroom. She stated she reminded to use the call light and she and Staff A finished rounds on the hall. She reported Staff D alerted her of the fall when Staff D found Resident #1 on the floor. On 10/13/25 at 4:09 PM Staff A, CNA reported at shift change on 9/8/25 6 AM, she and Staff E found Resident #1 in his bathroom. She reported she failed to help him into

the bathroom. She stated she left him with Staff E to care for him. She confirmed Resident #1 attempted to self transfer before. She stated they used a touch call light, placed it next to him in bed, so they would know if he was getting up the light would come on.On 10/14/25 at 1:29 PM Staff H, Licensed Practical Nurse (LPN) reported Resident #1 had several falls they were due to him getting up from the wheelchair. He reported he's seen him (resident) attempt to get out to the wheelchair a few times.On 10/14/25 at 1:58 pm, Staff D, CNA reported on 9/8/25 he got to work at 6 AM and went to help a resident that called out for help further down the hall then Resident #1. He reported he heard Resident #1 calling out for help and went to find Resident #1 on the floor in his room. He alerted the nurse of the fall. He reported the other CNA assigned to the hall got report from the off going shift. He said he failed to know Resident #1 was out of bed

before finding him on the floor. Staff D reported he would never leave Resident #1 on the toilet alone. On 10/14/26 at 9:45 AM Staff F, Licensed Practical Nurse reported after the fall Resident #1 had on 9/7/25, she wouldn't have left him sitting on the toilet. On 10/15/25 at 9:15 AM, the DON reported the intervention from

the fall on 9/7/25 day before he fell and fractured his left hip, directed staff do not leave unattended in his room in the wheelchair. She stated she failed to know the difference from leaving him in the w/c or on the toilet in his room unattended. She failed to know staff used the do not leave unattended intervention on the fall from the w/c in Jun 25, 2025. She reported when staff found him on the toilet on 9/8/25, the staff should not have left him on the toilet.The Facility provided a policy titled Fall Prevention, undated, revealed the following: Risk factors for falls include: Previous falls, problems with mobility and walking, fear of falling, irregular heart beat, blood pressure that drops significantly upon standing, dizziness, confusion, problems with seeing or hearing, multiple medications, inappropriate footwear, pathological fractures. Over 40% of nursing home residents fall each year. Five percent of these falls can result in a serious injury .After each fall, complete an incident report. Look for trending. Identify the possible reason for the fall and make appropriate changes to the plan of care.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Linn Manor Care Center

1140 Elim Drive Marion, IA 52302

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Linn Manor Care Center in Marion, IA for a deficiency under regulatory tag F-F0742 during a complaint investigation conducted on 2025-10-16.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of Linn Manor Care Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-10.