Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, facility staff failed to provide a safe, clean,
comfortable and homelike environment when the facility failed to provide routine
maintenance services to maintain resident room doors, and handrails in good repair. The
facility census was 53.
1. Review of the facility’s Maintenance Service Policy, dated (MONTH) 2009, showed it
directed staff as follows:
-Maintenance services shall be provided to all areas of the building, grounds, and
equipment;
-Maintain the building in compliance with current federal, state, and local laws,
regulations, and guidelines;
-Maintain the building in good repair service;
-Maintain the grounds, including sidewalks, parking lots, etc., in good repair;
-Provide routine scheduled maintenance service to all areas.
2. Observation on 3/20/19 at 10:02 A.M., showed deep gouges and scuffs on the bottom of
the entrance door to rooms 301, 302, 304, and the 300 hall clean utility room.
3. Observation on 3/20/19 at 10:07 A.M., showed deep gouges and scuffs on the bottom of
the entrance door to rooms [ROOM NUMBERS]
4. Observation on 3/20/19 at 11:38 A.M., showed gouges and scuffs on the bottom of the
entrance door to room [ROOM NUMBER].
5. Observation on 3/20/19 at 11: 46 A.M., showed gouges and scuffs on the bottom of the
entrance door to rooms [ROOM NUMBER].
6. Observation on 3/20/19 at 12:10 P.M. showed gouges and scuffs on the bottom of the
entrance door to room [ROOM NUMBER].
7. Observation on 3/21/19 at 2:35 P.M., showed scuffs and marks of varnish removed along
the base boards and the hand rails down the 400 hallway.
8. Observation on 3/21/19 at 2:36 P.M., showed numerous gouges, and scuffs to the resident
handrails on 100 Hall.
9. Observation on 3/21/19 at 2:36 P.M., showed deep gouges and scuffs on the bottom of the
entrance door to rooms 401, 402, 407, and 412.
10. Observation on 3/21/19 at 2:41 P.M., showed scuffs and marks of varnish removed along
the base boards and the hand rails down the 300 hallway.
11. Observation on 3/21/19 at 2:43 P.M., showed deep gouges and scuffs on the bottom of
the entrance door to rooms 305, 307, 309, and 310.
During an interview on 3/21/19 at 2:47 P.M., the Maintenance Director said he/she has a
system in place to check the handrails and doors at least once a month to ensure they are
in good repair. He/she said the staff and residents scratch the doors and handrails with
equipment and he/she is not able to keep up with the repairs.
During an interview on 3/21/19 at 4:11 P.M., the administrator said it is the
responsibility of the maintenance team to inform him/her of the condition of the handrails
and doors. He/she said he/she expects staff to maintain the doors and handrails in good
repair until they can be replaced.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on record review, observation, and interview, facility staff failed to ensure the
environment remained free of hazards and accidents by failing to store hazardous
chemicals, and sharps in a secure manner. The facility census was 53.
1. Review of the Facility’s Medical Waste Policy, dated (MONTH) 2012, directed staff as
follows:
-Medical waste containers shall be located throughout the facility and treatment areas and
must be kept covered at all times;
-Medical waste containers are located in the service hall, shower rooms, laundry,
medication carts, treatment carts, and medication rooms;
-Medical waste containers used by the facility will be:
-Closable;
-Constructed to contain all contents and prevent leakage of fluids during handling,
storage transport, and shipping;
-Labeled or color-coded;
-Closed prior to removal from the facility;
-Impermeable.
2. Observation on 3/19/19 at 11:27 A.M., showed the 100 Hall shower room unlocked and
unattended. Further observation showed an open tube of skin protectant (an ointment used
on skin to protect it from moisture), labeled if swallowed get medical help or contact
poison control center right away. Additional observation, showed a half-full bottle of
clear liquid disinfectant spray. Further observation showed the label directed staff to
call a poison control center or doctor for treatment advice if not handled appropriately.
3. Observation on 3/19/19 at 11:51 A.M., showed the 200 Hall men’s shower room unlocked
and unattended. Further observation showed an unlocked unattended cabinet which contained
three razors. Additional observation showed confused residents in the hallway.
4. Observation on 3/20/19 at 9:51 A.M., showed the 200 Hall men’s shower room unlocked and
unattended. Further observation showed an unlocked, unattended cabinet which contained a
razor.
5. Observation on 3/20/19 at 9:55 A.M., showed the 300 hall shower room unlocked and
unattended. Further observation, showed a three quarter-full bottle of clear liquid
disinfectant spray. Additional observation, showed the label directed staff to call a
poison control center or doctor for treatment advice if not handled appropriately.
Additionally, the observation showed a red sharps only container, without a lid and with
used razors spilling over the top, on top of the paper towel dispenser.
During an interview on 3/20/19 at 9:58 A.M., Certified Medication Technician (CMT) A said
he/she was not sure why the sharps container did not have a lid, and it should have one at
all times. Furthermore, he/she said it’s the responsibility of whoever is using the shower
room to properly dispose of the sharps and containers.
6. Observation on 3/20/19 at 10:01 A.M., showed the 300 Hall shower room unlocked and
unattended. Further observation showed a bottle of disinfectant spray hung on the trash
can with a label which read, Hazardous to humans and domestic animals.
7. Observation on 3/20/19 at 10:37 A.M., showed the 100 Hall shower room unlocked and
unattended. Further observation showed an open tube of skin protectant, labeled if
swallowed get medical help or contact poison control center right away.
8. Observation on 3/21/19 at 2:35 P.M., showed the 300 Hall shower room unlocked and
unattended. Further observation showed a bottle of disinfectant spray hung on the trash
can with a label that reads, Hazardous to humans and domestic animals. Additional
observation showed the cart with treatment medications also unlocked and unattended.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
During an interview on 3/21/19 at 3:01 P.M., Certified Nursing Assistant (CNA) B said
staff use the disinfectant spray to clean the shower rooms. Furthermore, he/she said
disinfectants, razors, and ointments should be stored in locked cabinets in the shower
rooms. He/she said the shower room doors do not automatically lock, and that is why staff
should lock the items in the cabinets.
During an interview on 3/21/19 3:02 P.M., Licensed Practical Nurse (LPN) C said staff are
expected to store all disinfectants, razors, and ointments in locked cabinets out of reach
of residents. Furthermore, he/she said staff should dispose of sharps only containers when
they get to the fill line. LPN C said he/she expects the person who filled the sharps
container to get a new one, and dispose of the full one. He/she said nothing should be
above the full line, and staff should not remove the top of the container.
During an interview on 3/21/19 at 4:15 P.M., the Director of Nursing (DON) said staff are
expected to dispose of razors properly, and he/she expects staff to alert someone if the
sharps only container needs to be disposed of. He/She said staff should not remove the top
of the sharps only container. Furthermore, he/she said staff are expected to store
chemicals and new razors locked in cabinets in the shower room, and kept out of reach of
residents.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, facility staff failed to serve food
items to all residents in accordance with the nutritionally calculated menus. The facility
census was 53.
1. Review of the facility menus dated 03/19/19 (Day 2, Monday) showed staff were directed
to provide the residents with regular and mechanical soft diets with a #8 (four ounce)
scoop of autumn fruit crumble and one slice of bread with margarine.
Observation on 03/19/19 during the noon meal service beginning at 11:51 A.M., showed Cook
H served the residents on regular and mechanical soft diets a #12 (2.6 ounce) scoop of
autumn fruit crumble (1.4 ounces less than directed by the menus.) Further observation
showed staff did not offer or serve the bread with margarine to the residents as directed
by the menus.
During an interview on 03/19/19 at 12:24 P.M., Cook H said they do serve bread with meals,
but he/she just missed that the menu showed bread to be served with the meal. The cook
also said he/she thought the menu showed to use a #12 scoop for the dessert and he/she did
not see the #8 scoop for the portion to be used.
2. Review of the facility menus dated 03/19/19 (Day 2, Monday) showed staff were directed
to provide the residents on pureed diets with the following:
-a #8 scoop of pureed garlic herbed pork loin;
-a #8 scoop of pureed stuffing;
-a #8 scoop of pureed yams;
-a #10 (3.2 ounce) scoop of pureed autumn fruit crumble;
-a #20 (1.6 ounce )scoop of pureed bread with margarine.
Observation on 03/19/19 at 12:56 P.M., showed Cook H placed five one half cup scoops of
ground pork into the food processor, gradually added a large unmeasured amount of cold

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 3)
chicken broth and blended. Observation showed the cook added three and one half slices of
bread to the pureed product and blended. Observation showed the cook poured unmeasured
amounts of the pureed pork into five divided plates. Observation showed the consistency of
the pureed pork to be thin like soup.
Observation on 03/19/19 at 1:09 P.M., showed Cook H prepared pureed stuffing in the food
processor. Further observation showed the cook scooped unmeasured amounts of the pureed
stuffing into five divided plates.
Observation on 03/19/19 at 1:20 P.M., showed Cook H prepared pureed yams in the food
processor. Further observation showed the cook scooped unmeasured amounts of the pureed
yams into five divided plates. Further observation at this time, showed the DM wrapped the
divided plates of pureed foods with foil and delivered the plates to staff in the assisted
dining room for service to residents on pureed diets. Further observation showed staff did
not prepare or offer the pureed bread to the residents.
During an interview on 03/19/19 at 1:16 P.M., Cook H said it is his/her usual practice to
divide the pureed products out from the food processor onto the divided plates without the
use of measured serving utensils. They cook said the food items are portioned when placed
into the food processor so he/she does not measure them again.
3. During an interview on 03/21/19 at 8:51 A.M., the Dietary Manager (DM) said staff
should serve meals in accordance with the menus. The DM said the the menus should be
reviewed prior to service by staff that serve the meal. The DM said bread should be served
with meals when on the menu and by resident choice.
4. During an interview on 03/21/19 at 12:10 P.M., the administrator said staff should
prepare foods in accordance with the recipes, serve food items in accordance with the
menus and all staff are trained on this requirement.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, facility staff failed to store food in
a manner to prevent potential contamination and outdated use. Facility staff also failed
to allow sanitized kitchenware to air dry between uses. The facility census was 53.
1. Review of the facility’s Food Receiving and Storage policy dated (MONTH) 2014, showed
All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by
date). Further review showed the following for food items and snacks kept on the nursing
units:
-Food items are to be labeled with a use by date;
-Beverages must be dated when opened and discarded after 24 hours;
-Other opened containers must be dated and sealed or covered during storage.
2. Observation on 03/19/19 at 10:03 A.M., showed the following in the glass front reach-in
cooler in the cook’s station:
-a cut raw onion in a plastic bag undated and open to the air;
-an opened and undated 32 ounce (oz.) bag of smoked ham slices;
-an undated plastic resealable bag of cooked sausage patties. Further observation showed a
heavy accumulation of condensation inside the bag.
3. Observation on 03/19/19 at 10:12 A.M., showed the following on lower shelf in the
cook’s station:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 4)
-a 32 oz. box of baking soda open to the air and undated;
-a 28 oz. box of cream of wheat opened to air and undated;
-an opened and undated 12 oz. bottle of mustard;
-an opened and undated 16 oz. bottle of low sodium vegetable base;
-an opened and undated one pound jar of chicken stock base;
-an opened and undated 42 oz. carton of old fashioned oats;
-an opened and undated one gallon bottle of soy sauce;
-two opened and undated 14 oz. bottles of ketchup;
-an opened and undated 48 oz. container of vegetable shortening;
-an opened and undated 48 oz. bottle of vegetable oil.
4. Observation on 03/21/19 at 7:43 A.M., showed the following on the lower shelf in the
cook’s station:
-a 32 oz. box of baking soda open to the air and undated;
-a 28 oz. box of cream of wheat opened to air and undated;
-an opened and undated 12 oz. bottle of mustard;
-an opened and undated 16 oz. bottle of low sodium vegetable base;
-an opened and undated one pound jar of chicken stock base;
-an opened and undated one gallon bottle of soy sauce;
-two opened and undated 14 oz. bottles of ketchup;
-an opened and undated 48 oz. bottle of vegetable oil.
5. Observation on 03/21/19 at 7:46 A.M., showed an opened and undated 46 oz. carton of
honey thickened water and an opened and undated 32 oz. bag of smoked ham slices in the
glass front reach-in cooler in the cooks’s station.
6. During an interview on 03/21/19 7:51 A.M., Cook G said opened food items should be
dated and resealed.
7. Observation on 03/21/19 at 8:26 A.M., showed the following in the main dining room
refrigerator: -an opened and undated 46 oz. carton of honey thickened water;
-an opened and undated 22 oz. bottle of caramel syrup;
-an opened 46 oz. carton of kiwi strawberry nectar thickened juice dated 12-19. Review of
the product label showed instruction to discard the juice within 10 days after opening.
8. Observation on 03/21/19 at 8:31 A.M., showed the following in the assisted dining room
refrigerator:
-an opened and undated 46 oz. carton of honey thickened iced tea;
-an opened and undated 46 oz. carton honey thickened golden fruit punch;
-an opened and undated 46 oz. carton of honey thickened water;
-an opened and undated 46 oz. carton of honey thickened orange juice. Further observation
showed staff poured the juice into a glass and served the juice to Resident #40;
-an opened and undated 46 oz. carton of honey thickened cranberry juice cocktail. Further
observation showed staff poured the juice into two glasses and served the juice to
Residents #40 and #46.
9. During an interview on 03/21/19 at 8:51 A.M., the Dietary Manager (DM) said opened food
items should be resealed in appropriate containers, labeled and dated. The DM said the
dietary aides are responsible for monitoring the refrigerators daily and he/she would
expect staff to remove anything that is not dated. The DM said he/she instructed staff to
clean out the main dining room refrigerator the day before and he/she would have expected
staff to remove the outdated thickened juice. The DM said the facility had not had any
residents who required nectar thickened liquids in quite some time and the date written on
the carton would be the date the staff opened the carton.
10. Review of the facility’s Dishwashing Machine Use policy dated (MONTH) 2010, showed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
instruction to allow dishes to air dry after running items through the entire cycle of the
dishwashing machine.
Review of a sign posted on the clean side of the mechanical dishwashing station showed
instruction to allow all dishes to dry before they are removed from the station.
Observation on 03/19/19 from 12:56 P.M. to 1:30 P.M., showed Cook H prepared pureed pork
roast in the food processor and then washed the food processor in the chemical sanitizing
mechanical dishwasher. Observation showed the cook removed the food processor from the
clean side of the dishwashing station while wet and used the food processor to prepare
pureed stuffing. Observation showed the cook washed the food processor in the mechanical
dishwasher, removed the food processor while wet from the clean side of the dishwashing
station and used the food processor to prepare pureed yams. Observation showed the cook
placed portions of the pureed food items onto divided plates, wrapped the plates with foil
and delivered the plates for service to the residents in the assisted dining room.
During an interview on 03/21/19 11:45 A.M., the DM said all dishes should be allowed to
air dry after they are washed and all staff are trained on this requirement.
11. During an interview on 03/21/19 at 12:10 P.M., the Administrator said staff should
reseal and date opened food items before they are put away. The Administrator also said
all dishes should be air dried after being washed and before they are used or put into
storage and all staff are trained on these requirements. The Administrator said the DM is
responsible to monitor food storage and dishwashing when he/she is in the building.

F 0920

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide at least one room set aside to use as a resident dining room and for
activities, that is a good size, with good lighting, air flow and furniture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, facility staff failed to provide a dining room large
enough to accommodate residents, including five sampled residents who required staff
assistance for transfers and seating (Residents #7, #9, #40, #46, and #49) in the Assisted
Dining Room (ADR). The facility census was 53.
1. Review of the facility’s Sufficient Space Policy, dated (MONTH) (YEAR), showed it
directs the staff:
-The facility shall provide sufficient space for recreation, occupational therapy,
activity, and residents’ dining space. Sufficient space means there is enough space
available and it is adaptable to a variety of uses and residents’ needs.
2. Review of the facility’s Dining Room Audits Policy, dated (MONTH) (YEAR), showed it did
not contain direction for the staff in regard to resident positioning and/or space in the
dining rooms.
3. Review of Resident #7’s quarterly Minimum Data Set (MDS), a federally mandated resident
assessment, dated 12/17/18, showed staff assessed the resident as:
– Severe cognitive impairment;
-Total physical assistance of two person for toileting and bathing;
-Total physical assistance of one person for toileting and eating;
-Extensive physical assistance of two person for bed mobility, dressing, and transfers;
-Extensive physical assistance of one person for personal hygiene;
-Range of motion limitations bilateral to both upper and lower extremities;
-[DIAGNOSES REDACTED].
-Uses a wheelchair (w/c) for mobility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0920

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
Observation on 3/19/19 at 11:51 A.M., showed the resident sat at a bedside table in the
assisted dining room. Staff assisted him/her with the meal. Additional observation showed
the two dining room tables full.
Observation on 3/20/19 at 12:11 P.M., showed the resident sat at a bedside table near the
wall in the assisted dining room. Staff assisted him/her with the meal. Additional
observation showed the two dining room tables full.
4. Review of Resident #9’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
– Severe cognitive impairment;
-Total physical assistance of one person for toileting and bathing;
-Extensive physical assistance of one person for bed mobility, dressing, and personal
hygiene;
-Extensive physical assistance of two persons for transfers;
-Limited physical assistance of one person for eating; and
-[DIAGNOSES REDACTED].
-Uses a wheelchair (w/c) for mobility.
Observation on 03/19/19 at 11:57 A.M., showed the resident sat sideways and back away from
the dining table in the ADR.
Observation on 3/21/19 at 12:41 P.M., showed the resident sat sideways at the dining room
table in the ADR.
5. Review of Resident #40’s significant change MDS, dated [DATE], showed staff assessed
the resident as:
– Severe cognitive impairment;
-Total physical assistance of one person for dressing, eating, personal hygiene, and
bathing;
-Total physical assistance of two person for bed mobility, and transfers;
-[DIAGNOSES REDACTED].
-Uses a wheelchair (w/c) for mobility.
Observation on 3/19/19 at 12:47 P.M., showed the resident sat at a bedside table in the
assisted dining room. Staff assisted him/her with the meal. Additional observation showed
the two dining room tables full.
Observation on 3/20/19 at 12:13 P.M., showed the resident sat at a bedside table near the
wall in the assisted dining room. Staff assisted him/her with the meal. Additional
observation showed the two dining room tables full.
Observation on 3/21/19 at 12:18 P.M., showed the resident sat at a bedside table near the
wall in the assisted dining room. Staff assisted him/her with the meal. Additional
observation showed the two dining room tables full.
During an interview on 3/19/19 at 12:48 P.M., the resident’s family member said he/she
comes in to assist during the meals and it is always full in the dining room. He/She said
often there are two more residents in the dining room that are not in the dining room
today. He/She said staff provide the bedside tables but there are no other extra tables
available in the dining room.
6. Review of Resident #46’s significant change MDS, dated [DATE], showed staff assessed
the resident as:
– Severe cognitive impairment;
-Extensive physical assistance of one person for transfers, toileting, personal hygiene,
and bathing;
-Limited physical assistance of one person for bed mobility, dressing, and eating;
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265364

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINN OAK REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

196 HIGHWAY CC
LINN, MO 65051

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)
F 0920

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-Uses a w/c for mobility.
Observation on 03/19/19 at 11:57 A.M., showed Resident #46 propelled himself/herself in
his/her wheelchair past Resident #9. Resident #46 could not navigate his/her wheelchair
through the area and attempted to back up his/her wheelchair, became entangled with
Resident #9’s wheelchair and drug his/her wheelchair along as well. Further observation
showed staff came over and removed the foot pedals from the wheelchairs and attempted to
center both residents at the table but had to go around and remove all the residents’ foot
pedals from their wheelchairs for all the residents to fit at the table.
Observation on 3/21/19 at 12:19 P.M., showed Resident #46 sat at a bedside table near the
wall in the assisted dining room. Staff assisted him/her with the meal. Additional
observation showed the two dining room tables full.
7. Review of Resident #49’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
– Mild cognitive impairment;
-Total physical assistance of one person for toileting, personal hygiene, and dressing;
-Total physical assistance of two person for bathing,
-Extensive physical assistance of two person for bed mobility, and transfers;
-[DIAGNOSES REDACTED].
-Uses a wheelchair (w/c) for mobility.
8. Observation on 3/19/19 at 12:39 P.M., showed an unidentified resident sat sideways at
the dining room table in the ADR.
9. During an interview on 3/21/19 at 12:23 P.M., Certified Medication Technician (CMT) F
said he/she feels the dining room is too small for the residents who eat in there right
now. He/She said staff have to remove the leg rests to even get the chairs to fit under
the tables and prevent injuries from the residents hitting their legs on each other’s leg
rests.
During an interview on 3/21/19 at 12:49 P.M., Certified Nursing Assistant (CNA) D said
staff have discussed how packed the room is lately and they think it is just because they
have so many heavy care residents in the ADR. He/She said staff have to remove all the
residents’ leg rests from their wheelchairs to even get the residents into the dining
room.
During an interview on 3/21/19 at 12:56 P.M., CNA B said there are too many residents in
the ADR and it isn’t safe. He/She said many times they aren’t able to sit them in there
appropriately because of the leg rests so then they have to be moved.
During an interview on 3/21/19 at 12:59 P.M., Licensed Practical Nurse (LPN) C said the
ADR is pretty crowded right now and there are a lot of heavy care residents in there.
He/She said if there were an emergency that required evacuation it would not be done
efficiently as it could due to all the leg rests and equipment in there.
During an interview on 3/21/19 at 4:20 P.M. the Director of Nursing (DON) said the ADR is
small, and does get crowded. He/she said facility staff knows it is a problem.