Eventide Lincoln Care Center

Inspectors wroteLicensure Reference Number NAC 175 12-006.09(H)Based on record review and interviews, the facility failed to follow physician orders for 1 (Resident 2) out of 3 sampled residents. The facility census was 134.

Inspectors wroteLicensure Reference Number 174 NAC 12-006.11 (A) Based on record review and interview, the facility failed to provide the correct therapeutic diet for one resident (Resident 3) of 5 sampled residents. The facility census was 142.

Inspectors wroteBased on record review and interview, the facility failed to revise post fall care plan interventions for Resident 2, Resident 5, and Resident 6 of five residents sampled . The facility reports a census of 141. A. A review of an admission Record indicated the facility admitted Resident 1 on 06/08/2026 with diagnoses that included dementia and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2026, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A review of Resident 1's Progress Notes revealed fall documentation for 06/08/2026 and 06/22/2026. Review of Resident 1' s Care Plan initiated on 06/08/2026, revealed the resident had a potential for falls and had fallen on 06/08/2026 and 06/22/2026. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E), 12-007.01(A) Based on observations, record review and interview, the facility failed to ensure foods stored were not expired, had been sealed and dated when opened, and the facility failed to prevent cross-contamination between spices and the meat products. This had the potential to affect all residents who had meals from the kitchen. The facility census was 140.

Inspectors wroteLicensure Reference Number NAC 175 12-006.07(C) Based on interviews and record review, the facility failed to reevaluate and revise the plan of corrective action to prevent recurrence of past performance issues. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 140.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observations, record reviews, and interviews, the facility failed to ensure their medication error rate was less than 5%. There were 39 opportunities for error and five errors observed, for a total medication error rate of 12.82%. The facility census was 140.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(i)(1)Based on record reviews, observations, and interviews, the facility failed to store medications securely for Residents 5, 7, 14, 26, 43, 54, 55, 78, 83, 96, 108, and 154; and the facility failed to ensure medication carts were kept locked when unattended. The facility census was 140.

Inspectors wroteLicensure Reference Number 175 NAC St. 71-6022(2) Based on record review and interview, the facility failed to notify the Ombudsman (an independent official who investigates complaints against organizations-typically government agencies or specific industries like healthcare-to resolve disputes and protect rights) of the hospitalizations on 2/8/26, 3/9/26, 4/4/26 and 4/17/26 for Resident 123, and 2/27/2026 for Resident 5, out of 28 residents sampled. The facility census was 140.

Inspectors wroteLicensure reference number 175 NAC 12-006.09C1a Based on observation, interview, and record review; the facility failed to ensure the baseline care plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) had interventions to address healthcare needs for Resident 125 who had an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) This failure had the potential to affect 1 of 2 sampled residents recently admitted to the facility. The facility census was 147.

Inspectors wroteLicensure Reference Number 175 12- 0006.09(E) (iii) Based on observations, interviews, and record review, the facility failed to care plan the services that are provided to attain or maintain the resident's highest practicable well-being for two residents (Resident 16 and Resident 110) out of eight residents sampled. The facility census was 140 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to ensure Physicians orders were followed for one (Resident 9) of 3 sampled residents. The facility census was 140.

Inspectors wroteLicensure reference number 175 12-006.09D3(1) Based on observation, interview, and record review the facility failed to ensure an active physician's order for the continued use of an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) and associated maintenance care was established for 1 (resident 125) of 1 resident reviewed. The facility census was 147.

Inspectors wroteLicensure reference number 175 NAC 12-006.18(B)(D) Based on observations, interviews and record reviews, the facility failed to ensure proper hand hygiene was completed, glove use during wound care for Resident 6, medication administration for Resident's 54 and 78, and failure to store C-pap(continuous positive airway pressure machine is the primary treatment for obstructive sleep apnea using a mask and steady airflow to keep airways open) to prevent cross contamination for 4 out of 4 sampled resident's. The facility census was 140.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on observations, record review and interview, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 2 (Residents 1 and 6) out of 6 sampled residents. The facility census was 131. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on record reviews and interviews, the facility failed to assess Resident 6 for a change of condition. This affected 1 of 4 residents sampled for changes of condition. The facility census was 132.

Inspectors wroteLicensure Reference Number 175 NAC 12 -006.17(A)(v)Based on record reviews and interviews, the facility failed to maintain a complete and accurate medical record for 1 (Resident 6) of 6 sampled residents. The facility census was 132.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure Yellow Zone signs were posted at the entrances to the 100 hallway, ensure [NAME] Zone signs were posted on the entrances of [NAME] and Good Houses, and ensure passive screening education was posted at Good, [NAME], and [NAME] Houses to prevent the spread of COVID-19. This had the potential to affect all residents in the facility. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(A)(1) Based on observation, interview, and record review; the facility failed to follow recipes when preparing resident meals. This had the potential to affect the 93 residents who received food from the kitchen. The facility identified a census of 139.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) related to the use of an anticoagulant (a medication used to prevent and treat blood clots in blood vessels and the heart) for 1 (Resident 30) of 5 sampled residents. The facility census was 139. Findings Are: A record review of the Resident Assessment Instrument (RAI, a manual used to provide instructions on how to complete the MDS and the care plans) User's Manual, with effective date of October 1, 2019, under N0410: Medications Received - Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR Level II, a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) for 1 (Resident 4) of 4 sampled residents was completed as required. The census of the facility was 139.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E)(i) Based on interview and record review, the facility failed to develop and implement a resident centered Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) that accurately reflected the care needs of the resident for 1 (Resident 3) of 5 sampled residents. The facility census was 139.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on interviews and record reviews the facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) for 1 (Resident 14) of 3 sampled residents. The census of the facility was 139.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview; the facility failed to ensure a medication error rate of less than 5%. Observation of administration of 28 medications revealed 7 errors resulting in an error rate of 25%. The medication errors affected 1 (Resident 94) of 7 sampled residents. The facility census was 139.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to code anticoagulant medication on the Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) for 1 (Resident 84) of 5 sampled residents. The facility census was 137.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D3 Based on record review and interview; the facility failed to monitor bowel movements and administer as needed medications to prevent constipation which affected 1 (Resident 71) of 1 sampled resident. The facility census was 137.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility failed to rinse out a nebulizer (machine that changes medication from a liquid to a mist which is inhaled into the lungs through a mask worn over the nose and mouth) mask equipment after each use and failed to change out the nebulizer mask equipment weekly to prevent the risk of potential infection for 1(Resident 79) of 2 sampled residents. The facility census was 137.

Inspectors wroteBased on interviews and record review, the facility failed to provide prompt emergency care to 1 (Resident 1) of 3 residents sampled for emergency treatment. The facility census was 146.

Inspectors wroteLicensure Reference 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to ensure that an assistive device was used in the recommended manner during a transfer for Resident 1. This resulted in a fall causing a fracture. This affected 1 of 3 resident reviewed for accidents. The facility census was 146.