Lincoln Care and Rehab

Inspectors wroteThe facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for current certified nurse aide certifications. Based on interview and record review, the facility failed to ensure one CNA had a current and valid certificate. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for CNA NN and CNA LL. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 37 residents. The facility had one main kitchen where dietary staff prepare all the food. Based on observation, interview and record review the facility failed to store food items in a sanitary manner when staff failed to date food items in the refrigerator and freezer. This placed the residents at risk of food-borne illness.

Inspectors wroteThe facility reported a census of 37 residents. Five Certified Nurse Aide (CNA) staff, who worked in the facility were reviewed for required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 37 residents, with 12 residents sampled. Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 31, R22, R4, R6, R32, and R1 or their responsible party to care plan meetings. The deficient practice placed the residents at risk for impaired resident rights and decreased autonomy.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

Inspectors wroteThe facility reported a census of 37 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the enhanced barrier precaution (EBP-a set of infection control measures that use goggles, gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing tube feeding care (a specialized medical flexible tube made of either silicone or plastic to deliver liquid nutrition directly int the stomach) or providing a shower to the resident with the tube feeding. Additionally, staff failed to disinfect the Hoyer lift (full body mechanical lift) after use and failed to utilize adequate hand hygiene. This placed the residents at risk for infections.

Inspectors wroteThe facility reported a census of 37 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person cannot make their own decisions). Based on interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)7 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by a physician rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored.

Inspectors wroteThe facility reported a census of 37 residents with 12 residents sampled. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 7's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date or a specified duration which included the physician's rationale for extended use. This deficient practice placed the R7 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 31, R32, and R1. This placed the residents at risk for impaired rights related to returning to the facility.

Inspectors wroteThe facility reported a census of 37. The sample included 12 residents. Based on interviews and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for Resident (R)22, R6 and R31. This placed the residents at risk for unidentified care needs and inadequate plan of care.

Inspectors wroteThe facility reported a census of 37. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide professional standards of care for Resident (R) 22 when staff failed to contact the physician for blood sugars greater than 400 milligrams (mg) per deciliter (dL) or lower than 60 mg/dL. This placed the resident at risk for impaired care and complications related to high or low blood sugar.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair in accordance with the resident's preferences for Resident (R) 2. This placed the resident at risk for impaired dignity and poor hygiene.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents with one reviewed for visual services. Based on interview and record review, the facility failed to provide visual services or facilitate access to visual services for Resident (R) 31 who had impaired visual function. This placed the resident at risk for further deterioration of vision.

Inspectors wroteThe facility reported a census of 37 residents. There were 12 residents in the sample including two residents reviewed for respiratory care. Based on observation, interviews and record review the facility failed to provide sanitary respiratory care and services when staff failed to clean the nebulizer (a device for administering inhaled medication) after each use for Resident (R) 14 and also failed to store the continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask in a sanitary manner for R22. This placed the residents at risk for infection and increased respiratory complications.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents sampled with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide nonpharmacological dementia care and services to promote Resident (R) 7's highest practicable level of function and well-being. This placed the resident at risk for decreased quality of life.

Inspectors wroteThe facility reported a census of 37 residents, with 12 residents sampled, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) for Resident (R) 32. The deficient practice had the potential to lead to the residents receiving unnecessary medications.

Inspectors wroteThe facility reported a census of 37 residents. The sample included 12 residents with one reviewed for dental services. Based on interview and record review, the facility failed to provide dental services or facilitate access to dental services for Resident (R) 31 who had widespread dental decay. This placed the resident at risk for further deterioration of dentition (of or having to do with teeth) and related complications.

Inspectors wroteThe facility reported a census of 39 residents with five residents sampled and one resident reviewed for served food in a form that met the resident's individual needs. Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 2 with her prescribed mechanical soft diet (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing) with ground meat texture, and instead served cut-up chicken to the resident, on her plate. R2 began to cough and choked on her food. The staff had to suction R2 when R2 could not clear her airway with coughing. The facility transferred R2 to the hospital later that evening. The hospital admitted R2 for fever, pneumonia, and dehydration. This deficient practice placed all residents at risk in immediate jeopardy. Findings Included: [...]

Inspectors wroteThe facility reported a census of 39 residents with five residents sampled. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for Resident (R) 3's risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). This deficient practice placed the resident at risk for inadequate care and services.

Inspectors wroteThe facility reported a census of 39 residents with five residents sampled and one resident reviewed at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)3, identified as a moderate risk for elopement. At approximately 11:28 AM on 02/22/25 R3 exited the facility when Certified Nurse Aide (CNA) L opened the exit door at the front entrance for another resident to enter into the facility. CNA L reported R3 quickly went out the door and she came back into the facility leaving R3 outside by himself, to inform the Licensed Nurse (LN) E. This deficient practice could potentially result in an injury.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to secure and provide appropriate storage of medications in the medication cart.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment to help prevent cross contamination and the spread of infections in the laundry, and to ensure appropriate handling, storage, processing, and transportation of linen for the residents of the facility. Findings Included: - The laundry tour on 10/03/23 at 09:10 AM, with laundry staff H, reported she did not use a gown, goggles/face shield when sorting soiled laundry. She reported she only used gloves when sorting soiled laundry. She reported she was not aware laundry staff should wear a gown and goggles/face shield when sorting contaminated soiled laundry to prevent cross contamination and the spread of infections. [...]

Inspectors wroteThe facility reported a census of 44 residents. The facility identified four Certified Nurse Aides (CNAs) employed greater than one year. Based on interview and record review, the facility failed to develop, implement and permanently maintain an in-service training program for staff that is appropriate and effective to ensure the continuing competence of CNAs and appropriate care and services to the residents of the facility.

Inspectors wroteThe facility reported a census of 44 residents with 12 residents selected for review, including three residents reviewed for use of side rails, Resident (R)18, R7 and R6. Based on observation, interview, and record review, the facility failed to perform routine inspections of the bed rails to ensure they met safety standards and were not a risk for resident entrapment or perform safety assessments of residents with bed rails attached to their beds. The facility reported 24 residents had a rail or other assistive device on the bed, and nine of those bedrails were loose. These deficient practices led to the possibility of injury or entrapment for these 24 residents.

Inspectors wroteThe facility reported a census of 44 residents with 12 residents sampled. Based on interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS), for one of the 12 residents sampled, resident (R)12, related to her life expectancy of six months or less for this resident that received hospice services.

Inspectors wroteThe facility reported a census of 44 residents with 12 sampled for review. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) with complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage and decrease in weekend staffing.

Inspectors wroteThe facility reported a census of 34 residents, with 12 residents included in the sample and one resident sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). The facility identified 26 residents with full code status, indicating the resident wishes for life saving measures to be utilized in emergent situations, to include CPR. Based on interview and record review, the facility staff failed to initiate CPR on a full-code Resident (R)86 on [DATE] at approximately 01:25 PM, when Licensed Nurse (LN) C and Certified Nurse Aide (CNA) D found the resident without respirations and pulseless. The staff thought the resident was a Do Not Resuscitate (DNR) due to the nursing report sheet did not list FULL beside R86's name to indicate the resident's full code status. [...]

Inspectors wroteThe facility had a census of 34 residents. Based on interview and record review the facility failed to ensure the minimum required members attended the Quality Assessment and Performance Improvement (QAPI) meetings on at least a quarterly basis.

Inspectors wroteThe facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to provide evidence of monthly monitoring of medication regimen by a licensed pharmacist for Resident (R)21, R5, R3, R33.

Inspectors wroteThe facility had a census of 34 residents with five residents reviewed for unnecessary medications. Based on interview, observation, and record review, the facility failed to ensure two residents, Resident (R)21 and R5, were free of unnecessary medications by the failure to check blood sugars (BS) and give medications as ordered.

Inspectors wroteThe facility reported a census of 34 residents. The facility had one main kitchen where the food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to ensure the dishes and cookware were washed under sanitary conditions due to the lack of accurate chemical monitoring.

Inspectors wroteThe facility reported a census of 34, with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure staff notified Resident (R)3's representatives of changes.

Inspectors wroteThe facility census totaled 34 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide written notice to the State Ombudsman of the 10/09/21 facility-initiated hospitalization transfer of Resident (R)1.

Inspectors wroteThe facility census totaled 34 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide Resident (R)1 or their representative with a bed hold policy upon transfer to the hospital on [DATE].

Inspectors wroteThe facility census totaled 34 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to revise the care plan to include the use of oxygen therapy and care of oxygen equipment for Resident (R)21 and update the care plan to include new fall interventions to prevent further falls for R3.

Inspectors wroteThe facility reported a census of 34, with 12 residents included in the sample, and one resident reviewed for accidents. Based on observation, interview, and record review the facility failed to identify causal factors related to a fall experienced by R3, which resulted in a hematoma to his head, and failed to implement new fall prevention intervention after the fall.

Inspectors wroteThe facility census totaled 34 residents with 12 included in the sample and 1 resident reviewed for respiratory services. Based on observation, interview, and record review the facility failed to obtain physician orders prior to the use of oxygen therapy for Resident (R) 21.

Inspectors wroteThe facility reported a census of 34 residents with 12 included in the sample and one resident reviewed for dialysis (the clinical purification of blood, as a substitute for the normal function of the kidney). Based on observation, interview, and record review, the facility failed to ensure staff documented assessments of Resident (R) 3's dialysis fistula (a surgical connection between an artery and a vein used for dialysis treatment) site and post dialysis weights.

Inspectors wroteThe facility reported a census of 34, with 12 residents included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure completion of targeted behavior monitoring for Resident (R)3 and continued to administer R33's as needed (PRN) psychotropic medication longer than 14 days without a renewed physician order or reason provided by the physician for the continued administration of lorazepam (anti-anxiety medication) on a PRN basis.

Inspectors wroteThe facility reported a census of 34 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to inform the residents who attended resident council of the location of the state survey notebook and failed to inform residents of the right to read the survey results. This notebook contained only two years of survey results in the notebook (2020 and 2021).

Inspectors wroteThe facility census totaled 37 residents. The facility had one main kitchen where dietary staff prepared all food. Based on observation, interview, and record review the facility failed to prepare food items in a sanitary manner by the failure of dietary staff to change gloves between the touching of food items and dirty surfaces and failed to store food items in a sanitary manner by the failure to date food items placed in the refrigerator. These failures had the potential to affect all residents.