Lincoln Community Care Center

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #6, #26, and #46) out of 16 sampled residents. The facility census was 44.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 44. 1. Review of the facility's policy titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, revised 12/16, showed the following:-Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. [...]

Inspectors wroteBased on record review and interview, facility staff failed to refund resident funds within 30 days of discharge for 17 residents (Resident # 255, #256, #257, #258, #259, #260, #260, #262, #263, #264, #265, #266, #267, #268, #269, #270, and #271) out of 41 sampled residents. The facility census was 55. 1. Review of the facility's refunds policy, undated, showed the policy did not contain direction for staff on resident refunds after discharge. 2. Review of the facility's aging report (report showing outstanding invoices and balances), dated [DATE], showed the following residents had money in the facility's operating account: -Resident #255 was discharged on [DATE]: with a balance of $3,503.61; -Resident #256 was discharged on [DATE]: with a balance of $3,658.59; -Resident #257 was discharged on [DATE]: with a balance of $5,492.79; -Resident #258 was discharged on [DATE]: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure care plans were reviewed and revised to include appropriate fall interventions for six (Resident #10,#12, #13, #19, #35, and #42) out of eight sampled resident's. Staff failed to ensure care plans reflected the use of side rails for one (Resident #42) out of eight sampled residents. The facility census was 55. 1. Review of the facility's Care Plans, Comprehensive Person-Centered, revised December 2016, showed: -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments after unwitnessed falls for two residents (Resident #35, and #42) of 14 sampled residents. Staff failed to get physician orders to self-administer eye drops for two residents (Resident #33 and #39) of 14 sampled residents. The facility census was 55. 1. Review of the facility's policy titled, Falls- Clinical Protocol, revised 09/12, showed the nurse shall assess and document/report the following: -Vital signs; -Neurological status; -Falls should be identified at witnessed or unwitnessed events. Review of the nurse's Fall Reports, showed the report directed staff neurological checks must be initiated if not witnessed. Review of the facility's Neurological Evaluation Flow Sheet, showed staff are directed to: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet three residents (Resident #4, #16 and #24) out of 14 sampled residents interest on the weekends. The facility census was 55. 1. Review of the facility's policy titled, Activity Programs, revised 6/18, showed it directed staff as follows: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities; -Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs; -Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for four residents (Residents #16, #24, #36 and #42) out of four sampled residents who use side rails, to ensure the environment remained safe and free of accident hazards. The facility census was 55. 1. Review of the facility's policy titled, Proper Use of Side Rails, revised 12/16, showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Risk of entrapment from the use if side rails; -That the bed's dimensions are appropriate for the resident's size and weight. [...]

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to separate four residents (Resident #1, #2, #3, and #4) who tested positive for COVID-19 from four residents (Resident #5, #6, #7 and #8) who had tested negative for COVID-19, which placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 50. The Director of Nursing and Assistant Administrator were notified on 09/30/23 at 02:04 P.M. of an Immediate Jeopardy (IJ) which began on 09/23/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. Facility staff failed to prohibit the reuse of single-service containers for food storage. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. The facility census was 48. 1. Review of the facility's Food Receiving and Storage Policy, dated July 2014, showed: -Food in designated dry storage areas shall be kept off the floor (at least 18 inches); -All foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #8,#10, #22, and #30). The facility census was 48. Review of the facility's Care Plans, Comprehensive Person-Center Policy, dated March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objective timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; [...]

Inspectors wroteBased on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 48. 1. Review of the resident trust fund account for March 2022 through February 2023, showed an average monthly balance of $43,373.99 which requires a surety bond of $64,500.00. The current ledger amount showed $49,567.63. Review of the Department of Health and Senior Services (DHSS) database, showed the facility with an approved non-cancelable Escrow Agreement Account in the amount of $60,000.00. During an interview on 03/29/23 at 10:53 A.M., the Business Office Manager (BOM) said he/she is in charge of ensuring the bond is sufficient, but he/she only received two days of training before going on maternity leave and he/she did not know the bond was insufficient.