Lincoln Glen Skilled Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 22 (Residents 35, 9, 24, 15, 14, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 253, 38, 37, 1, 50 and 11) of 22 residents who used side or bed rails when: 1. Twenty-two (22) of 22 residents who used side or bed rails were without care plans, 2. The risks of entrapment prior to the installation of side or bed rails were not assessed for 22 of 22 residents who used bed rails, and 3. The bed rail assessments were not updated in a timely manner for 18 of 22 residents (Residents 35, 9, 24, 15, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 38, 37 and 11). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the exterior of the kitchen's ice machine free of dust. This failure placed all 51 residents at risk of food contamination (unintended presence of potentially harmful substances such as microorganisms, chemicals, or physical objects in food.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when: 1. Opened medications without open date were found in Station 1 and Station 2 medication carts, and one expired medication was found in Station 1 medication cart. This had the potential for residents to be given expired or past open-period medications. 2. A medication cart with medications was left unlocked. This had the potential for access to medications by unauthorized persons such as unauthorized staff, residents, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper infection control procedures when: 1. Certified Nursing Assistant F (CNA F), Certified Nursing Assistant G (CNA G), and Activities Leader H (AL H) delivered meal trays to Resident 6, Resident 21, and Resident 24 without sanitizing their hands; 2. Licensed Vocational Nurse E (LVN E) used paper towel to wipe the first drop of blood on Resident 4's finger; 3. Employee food was placed on Resident 27's overbed table; 4. Resident 40's filter of oxygen concentration was dusty, and her humidifier bottle was not changed within 5 days; 5. Home Health Aids I (HHA I) walked out of Resident 46's room without sanitizing her hands; and, 6. For Resident 7, LVN E did not perform proper hand hygiene practices during wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat the residents with dignity for one of two residents, (Resident 1), when Resident 1's urine drainage bag was not covered. This failure had the potential to cause embarrassment and feeling low self-esteem for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool and care screening tool) for pressure ulcers for one of 14 sampled residents (Resident 7). This failure could lead to an inaccurate resident assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident care plans were reviewed and updated for effectiveness in four of fourteen sampled residents, (Residents 6, 35, 43 and 44), when the activity care plans of these four residents were not reviewed and updated quarterly. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, the residents received the necessary care and services for one of 13 residents, (Resident 40), when there were no physician order and no care plan for Resident 40's skin discoloration on her left and right forearm. This failure had the potential to affect the resident's care and could jeopardize her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of care and services related to pressure ulcers were consistent with professional standards of practice for one of fourteen sampled residents (Residents 35), when there were no wound measurements for Resident 35's three wound assessments. These failures had the potential for the residents with pressure ulcers, not being properly monitored and treated which could delay the healing or worsen the wound.

Inspectors wroteBased on interview and record review, the facility failed to ensure the effective use of medications for one of 13 residents (1) when Resident 1 received ferrous sulfate (iron, for prevention/treatment of iron deficiency) and Calcium+D3 (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the resident to not receive the amount of prescribed iron supplement.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 5 residents (42) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 42 received Lorazepam (used to treat people with anxiety who frequently have intense, excessive and persistent worry and fear about everyday situations) without specific and documented indication. This failure resulted in unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, and memory loss.

Inspectors wroteBased on observation, interview and record reviews the facility failed to follow their policy and procedure (P&P) by using bed side rails (SR: adjustable metal or rigid plastic bars that attached to the side of head of the bed) before attempting to use alternatives first for 14 of 14 residents (Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202). This failure had the potential to put the residents at risk for entrapment, serious injury and limiting their sense of independence.

Inspectors wroteBased on interview and record review, the facility failed to document the status of residents' advance directives (AD, a written set of instructions, such as a living will or durable power of attorney for health care when the individual is incapacitated) for two of seven residents (Residents 20 and 34), when their clinical records lacked documentation for them. These failures had the potential for residents' wishes to not be fulfilled, should they become incapacitated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment with comfortable sound levels, for one of fourteen sampled residents (Resident 201), when there were episodes of noise in the adjacent room of Resident 201 that was loud and bothersome to her. This failure had the potential to affect the sleep, comfort, and overall well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Office of the State Long-Term Care (a range of services and supports residents may need to meet their personal care needs for daily living) Ombudsman (advocates for residents in nursing home) was notified in writing when Resident 10 was transferred to the general acute care hospital (GACH). This failure had left the Long-Term Care Ombudsman unaware of of Resident 10's hospital transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, and provide safe environment for residents when: 1. Wheelchairs (a mobility aid device with wheels for use indoors and outdoors, intended for residents who are unable to walk and bear weight on their feet) were placed in-front of room A's bathroom door, which blocked it; and, 2. An antiskid mat was peeling off in room B's bathroom entrance. These failures had the potential for accidents that may result in injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate psychosocial services were provided for two of fourteen sampled residents, (Residents 40 and 1), when: 1. For Resident 40, no psychosocial follow up was done after her altercation with Resident 1; and, 2. For Resident 1, no psychosocial follow up was done after her altercation with Resident 40 and a room transfer. These failures had the potential for the residents, not to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision was provided to three of three sampled residents (Resident 40, Resident 7, and Resident 28) when: 1. Resident 40, who was at risk for falls and injury as indicated in the care plan, was not given staff supervision with oversight and cues while walking in his room and while in the corridor or hallway; 2. One staff used an EZ stand lift (battery-powered equipment designed to facilitate toileting, changing of briefs and conducting pivot transfers for weight bearing residents for Resident 7 when two staff were required; and 3. For Resident 28, facility staff did not provide supervision while using a merry walker (adaptive equipment, walker/chair combination) in the hallway. These failures had the potential to result in injury and/or accidents to Resident 40, Resident 7, and Resident 28. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to make certain all nursing staff (licensed nurses and certified nursing assistants) had completed the appropriate competency and skill check to demonstrate the proper and safe use of EZ stand lift during resident care. Competency and skills check would ensure staff had demonstrated the correct use of the equipment which would help prevent any possible accidents and/or injury during care. During an observation on 5/16/22 at 1:33 p.m., certified nursing assistant H (CNA H) used EZ stand lift (a battery powered equipment designed to facilitate toileting, changing of briefs and conducting pivot transfers for weight bearing residents) to change Resident 7's incontinent pad by herself when this resident required two staff assistance with transfer and toilet use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored safely and properly when: 1. One Levemir insulin (long acting insulin) vial for Resident 8 was being used past the discard date; 2. One discontinued Lactulose (laxative for treatment of chronic constipation in adults and geriatric patients) solution for Resident 39 was still in the medication cart and with no open date; 3. One nursing staff did not count the narcotic (controlled substance) tablets properly during end of shift narcotic count.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure the registered dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services when temperatures were not properly monitored for the refrigerator and freezer. Failure to ensure dietetic services systems are accurately and effectively evaluated may result in the potential for foodborne illness thus compromising the nutritional status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu was followed for six residents (Residents 13, 19, 24, 32, 34, and 38) on pureed diets (texture modified diets for people with chewing or swallowing difficulties) and two residents (Residents 8 and 36) on controlled carbohydrate soft diet (CCHO, modified diet for people with diabetes to keep the same amount of carbohydrates every day). This failure had the potential to result in not meeting the nutritional needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food service safety when: 1. Outdated ground beef was stored in the kitchen refrigerator; 2. Undated shakes were stored in the resident food refrigerator. This failure had the potential to expose the residents to expired food products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for COVID-19 (cause of global pandemic; highly infectious respiratory virus) on a yellow unit (unknown COVID-19 status) when: 1. Registered nurse C (RN C) failed to wear required personal protective equipment (PPE, protective equipment including goggles, face shield, masks, gowns, and are designed to protect the wearer from infection) face shield or goggles while in close contact with Resident 12; 2. Certified nursing assistant A (CNA A) failed to wear required PPE while providing direct resident care to Resident 35. 3. CNA I did not perform hand hygine in between resident contact while distributing meal trays to four residents and before assisting Resident 4 with her meals. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound treatment as indicated in the physician's order, and failed to ensure timely follow-up with the wound clinic to clarify what appropriate treatment would be continued after her appointments were canceled twice for one of two sampled residents (Resident 29). This deficient practice had the potential for Resident 29's heel to worsen. A review of Resident 29's facesheet indicated diagnoses of non-pressure chronic ulcer (arterial ulcers that results from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus, trauma, etc.) on the left foot and congestive heart failure (CHF, a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 396) was free of a significant medication error when Resident 396's Eliquis (a prescription medicine used as a prophylaxis (preventive treatment) against stroke with atrial fibrillation (AF, an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not administered as ordered by the physician. This resulted in Resident 396 not receiving 18 doses of Eliquis while in the facility. This deficient practice could increase Resident 396's risk of developing a blood clot due to diagnosis of AF and history of cerebrovascular accident (CVA, the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain).

Inspectors wroteBased on observation interview, and record review, the facility failed to provide a safe and comfortable environment; 1. Alcohol beverages for a resident was stored open to the resident's hallway in unlocked pantry, without any inventory system for the alcohol, and without any tracking for the resident; 2. An accessible blanket heater in operation was stored open to the resident's hallway in an unlocked linen closet; This had the potential to adversely affect the health and safety of those 48 residents and any visitors in the facility.