Lincoln Healthcare Center

Inspectors wroteBased on record review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment regarding discharge and dental. This is true for two (2) of (18) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56, #11 and #32. Facility census: 59.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to follow a physician's order for therapy screening for one (1) of one (1) residents reviewed for the care area of position/mobility. Resident identifier: #11. Facility census: 59.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure enhanced barrier precautions for a resident with a chronic wound. This was true for one (1) of three (3) residents reviewed for the care area of transmission-based precautions. Resident Identifier: #14. Facility census: 59. a) Resident #14 The facility's policy titled, Enhanced Barrier Precautions, with effective date 04/14/22 and revision date 02/02/23 stated enhanced barrier precautions apply to residents with infection or colonization with a novel or targeted multi-drug-resistant organisms when contact precautions do not apply. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the floor of the walk-in freezer was dirty. The racks holding the cups, bowls, and thermal warmers needed to be cleaned. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 59.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Signage for Enhanced Barrier Precautions (EBP) was not placed in a location that could be viewed by everyone entering the residents' rooms. This was true for four (4) of four (4) residents reviewed for the care area of transmission-based precautions (TBP). Resident identifiers: #16, #51, #45, and #22. Facility census: 59.

Inspectors wroteBased on observations and staff interview the facility failed to ensure an appropriate pest control program. This deficient practice had the potential to affect all residents dining or attending activities in this area. A random opportunity for discovery revealed a swarm of gnats in and around the uncovered trash can located in the dining room. Facility census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for a resident with a newly added psychiatric diagnosis. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the PASARR care area. Resident identifier: #14. Facility census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the development of a comprehensive care plan in the area of weight loss for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #24. Facility census: 59.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice was true for (1) of one (1) resident reviewed for the care area of tube feeding. Resident #2 had an order for weights to be done every Sunday and this was not done as ordered. Resident identifier: #2. Facility census: 59.

Inspectors wroteBased on observations, record reviews and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice. This deficient practice affected two (2) of two (2) residents reviewed for respiratory care. Residents #158 and #29 were not receiving oxygen therapy at the correct flow rate. Resident identifiers: #158 and #29 Facility census: 59.

Inspectors wroteBased on medical record reviews and staff interviews the facility failed to ensure resident's Physician's Order for Scope of Treatment (POST) forms conveying their end of life wishes were complete. The POST forms were not completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for two (2) of 15 POST forms reviewed for the Long-Term Care Survey Process. Resident Identifiers: #13 and #4. Facility Census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure six (6) of thirteen Residents reviewed for the care area of advance directives had the [NAME] Virginia Physician Orders for Scope of Treatment (POST) form (concerning care/treatment at the end of life) completed correctly. Resident identifiers: #5, #54, #355, #15, #50, and #51. Census: 57.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when four (4) of five Resident's reviewed for the care area of hospitalization were discharged to the hospital. Resident identifier: #55, #57, #9, and #5. Facility census: 57.

Inspectors wroteBased on record review and staff interview the facility failed to develop a comprehensive care plan for Resident #51 for accidents/falls. This failed practice was true for one (1) out of 13 residents reviewed for care plans. Facility census 57.

Inspectors wroteBased on record review and staff interview, the facility failed to revise Resident #5's care plan when pressure ulcers resolved. This was true for one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #5. Facility census: 57.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to communicate necessary information to the resident, continuing care provider and other authorized persons at the time of discharge. The facility failed to dictate a discharge summary at the time of discharge. This had the potential to effect one (1) of one (1) Resident reviewed for discharge during the long term care survey process. Resident identifier # 54. Facility Census 57. Findings Included: a) Resident # 54 A review of a facility provided policy labeled Discharge of a Resident found the following: .a discharge summary and post-discharge plan of care will be developed to assist the resident in his/her new living environment and will be provided to the resident at or before the time of discharge . .8. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible. Resident #20 was transferred with out proper staff assistance. This was true for one (1) of three (3) residents reviewed for falls. Resident Identifier: #20. Facility Census 57. Findings Included: a) Resident # 20 A review of Resident # 20's care plan revealed a care plan focus that reads as follows: Resident # 20 has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Quadriplegia, Spinal Cord trauma S/P (status post) MVA (motor vehicle accident) A further review of Resident # 20's care plan revealed care plan with interventions that reads as follows: Weight bearing status: Non weight bearing, Date Initiated: 05/04/2020 Bed mobility self-performance: Patient is assist of 2 (two) for bed mobility. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to follow physician's orders consistent with professional standards of care for oxygen therapy. This was a random opportunity for discovery. Resident identifier: #2. Facility Census: 57. Findings Included: a) Resident #2 During observation on 05/17/22 at 8:45 AM, the oxygen concentrator was noted with a setting of 4 (four) liters per minute (LPM). A review of the a physician's orders found a physician's order dated 02/12/22 for oxygen at 2 LPM via nasal cannula continuously. On 05/17/22 at 8:45 AM, Licensed Practical Nurse (LPN) #55 confirmed the oxygen concentrator setting was incorrect and should be set at 2 LPM. On 05/17/22 at 9:42 AM, the Director of Nursing (DON) was notified of the incorrect oxygen setting. No further information was obtained during the survey process. .