Lincoln Meadows Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered in accordance with manufacturer guidelines and prescriber instructions for one (1) of ten (10) sampled residents (Resident 47), when the facility failed to identify and correct the inappropriate administration times for glipizide, a medication requiring administration approximately 30 minutes before meals for effective blood sugar control. Glipizide doses were instead scheduled at standardized times that did not align with mealtimes or manufacturer recommendations. This failure created the potential for uncontrolled blood sugar and disease related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate remained below 5%. The facility's medication error rate was 6.67%, with two errors identified during 30 medication administration opportunities. Errors were observed for two of five sampled residents (Resident 47 and Resident 16) when Resident 47 received glipizide, a medication used to control blood sugar, at the wrong time, which was not in accordance with the physician's orders or the manufacturer's specifications and Resident 16 did not receive her as needed (PRN) dose of hydralazine, a medication prescribed for the treatment of high blood pressure, despite having an elevated blood pressure reading that met the parameters for administration per the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 16) was free from a significant medication error when staff did not administer a prescribed as needed (PRN) antihypertensive medication as ordered by the physician. This deficient practice placed the resident at risk for complications associated with uncontrolled high blood pressure, including stroke, heart attack, and kidney damage.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that two out of 19 sampled residents (Resident 7 and Resident 85) received an ongoing activity program that met their psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs important to a person), as required by their comprehensive plans of care. The facility did not maintain documentation showing that either resident received ongoing activities. This failure placed both residents at risk for psychosocial, emotional, spiritual, and mental decline and prevented them from achieving their highest practicable well being.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services necessary to maintain or improve range of motion (ROM) and mobility for one of 19 sampled residents (Resident 10) when the facility did not follow the physician ordered Restorative Nursing Program (RNA program-program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency for active range of motion (AROM) and bed mobility exercises. This failure had the potential for Resident 10 to experience decline in ROM, decreased mobility, and failure to achieve her highest practicable well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure emergency kits (e kits) were replaced within the facility's required timeframe and failed to prevent staff from removing medications from previously opened e kits. This deficient practice had the potential to result in medications not being available when needed for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an opened foil medication pouch containing budesonide ampules (an inhaled medication used to reduce airway inflammation) for Resident 28 which was observed stored in 2B Medication Cart (one of two medication carts sampled) was labeled with the date it was opened, as required by manufacturer specifications and the facility's policies and procedures. This failure created the potential for administering expired or ineffective medication to Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the prepared menu and did not meet the nutritional needs of two out of 19 sampled residents (Resident 21 and Resident 5) when staff did not serve Resident 21 and Resident 5 an 8 fl oz (fluid ounce- unit of volume used to measure liquids) of milk during 5/18/26 lunch meal. This failure had the potential to result in Resident 21 and Resident 5 not meeting and maintaining their nutritional needs and achieving their highest practicable wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate assistive eating utensil to one out of 19 sampled residents (Resident 85) when staff did not provide Resident 85 with a scoop plate (an adaptive, high-walled dish designed to help individuals with limited motor skills, tremors, or single-hand dexterity to eat independently) during the 5/18/26 lunch meal. This failure had the potential to result in Resident 85 being unable to independently eat properly which could have caused nutritional problems.

Inspectors wroteBased on observation, interview and record review, staff failed to provide a clean environment for residents when one of three outside dumpsters did not keep waste properly contained with the lid closed. This failure created the potential for an unsafe environment due to garbage storage area not being maintained in a sanitary condition to prevent a fly, rodent, or pest infestation that could spread diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not follow and maintain an effective infection prevention and control program for one out of 19 sampled residents (Resident 5) when a visiting hospice staff did not wear the required personal protective equipment (PPE) during high-contact care for Resident 5, who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] by targeted gown and glove use). This failure increased the risk of cross contamination and exposed Resident 5 to germs and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was functioning properly for 2 residents (Resident 1 and Resident 2) residing in room [ROOM NUMBER]. This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets (modified diets from regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during lunch on 3/12/25 when: 1. 19 Residents (Resident (3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291, and 341) with regular portion with regular texture diets got 6 ounces (oz.) (3/4 cup) of pasta instead of 4 oz. (1/2 cup) 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve in a safety manner when: 1. Various sizes of metal pans were found having issues stored in the clean and ready-to-use storage areas: - Stacked wet - Were not clean with food particles 2. The storage areas for storing the clean and ready-to-use metal pans were not clean 3. The blade of the can opener was not well maintained 4. Dietary Aide (DA) 1 was not able to verbalize the process of manual dishwashing by 2-compartment sink 5. DA 2 was not able to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely assistance with incontinence (a condition where a person experiences involuntary loss of urine or stool) care for four of 25 sampled residents (Resident 23, Resident 339, Resident 340, and Resident 60). This failure resulted in residents not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Dietary Aide (DA) 1 and DA 2 had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 was unable to verbalize the correct process of manual dishwashing with 2-compartment sink (cross refer to F812, #4); 2. DA 2 was unable to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas (cross refer to F812, #5), and 3. DA 2 was unable to verbalize and demonstrate the correct procedure for testing and proper temperature when preparing the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution) (cross refer to F812, #6). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Oxygen tubing was on the floor for Resident 18, Resident 12 and Resident 36. 2. Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was dragging on the floor while on the wheelchair. 3. Tube feeding formula was left uncapped and open to air while disconnected from Resident 45. These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of 25 sampled residents (Resident 63), when the call light was not within reach. This failure had the potential to result in Resident 63 not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 58) received appropriate pain management services consistent with professional standards of practice and facility's policy and procedure (P&P) when Resident 58's pain was not managed during wound care treatment. This failure had the potential for Resident 58 not achieve relief from pain and not attain her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices for one resident (Resident 1) out of four sampled residents when staff did not use proper personal protective equipment (PPE, specialized clothing or equipment worn for protection against infectious material) when they performed wound care on Resident 1. This failure had the potential to increase the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency and local law enforcement, and the facility failed to report the results of all investigations to the State Survey Agency within five working days of the incident for one of four sampled residents (Resident 1). This failure had the potential to result in a delayed investigation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's) right was exercised timely when the resident's representative (RR) was not notified of Resident 1's change in condition and/or the resident's emergency transfer to a hospital. This failure resulted in RR feeling astounded and upset when the hospital contacted her regarding Resident 1's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services according to professional standards of quality for three of 23 sampled residents (Resident 39, Resident 240 and Resident 5), when: 1. Resident 39's and Resident 240's administered oxygen was not consistent with physician's order and care plan; and 2. Resident 5 was not provided with an incentive spirometer (a medical device used to help improve lung function) as ordered by the physician. These failures decreased the facility's potential to safely follow the physician's orders when providing respiratory services and increased the residents' risk of developing lung problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents 6, 189 and 190) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.42% error rate when five medication errors out of 48 opportunities were observed during a medication pass for two out of five residents (Residents 5 and 189). This failure resulted in medications not given in accordance with the prescriber's orders, manufacturer specifications and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a special eating utensil for one of 23 sampled residents (Resident 28), when Resident 28 was not provided with a rocker knife (a knife that can make it easier to cut food for one-handed individuals due to weakness or paralysis) during meals. This failure decreased the facility's potential to provide adaptive utensils designed to meet the clients' nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a sanitary manner for a census of 90 when: 1. Dietary staff did not use hair nets and/or beard guards while in the kitchen; 2. Several food items were opened and not dated with their open date and expired food items were in the reach-in refrigerator and dry storage; and, 3. Expired left-over roast beef with used by date 3/26/24 was available to use on 3/27/24. These failures had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when: 1. Dietary [NAME] 1 (DC1) did not perform proper hand hygiene practice while in the kitchen for a census of 90; and, 2. Licensed Nurse 5 (LN 5) did not change gloves and perform hand hygiene during wound care for one of 23 sampled residents (Resident 140). These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administered medications kept at bedside for one of 23 sampled residents (Resident 189) were reviewed and approved by the physician. This failure had the potential for unsafe medication use, exposure to unwanted side effects and duplication of therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's respect and quality of care were maintained for one of 23 sampled residents (Resident 62) when Resident 62 was not able to reach for the call light. This failure had the potential to increase the residents' fear of not able to reach for the call light when needing assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for one of 23 sampled residents (Resident 37), when Resident 37's room was disorderly and cluttered with personal bags and boxes. This failure decreased the facility's potential to ensure residents' autonomy when using their personal belongings.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) was accurate for three of 23 sampled residents (Resident 70, Resident 64 and Resident 88) when: 1. Resident 70's impaired vision was not reflected in his most recent quarterly MDS assessment; 2. Resident 64's MDS indicated she had no feeding tube; and, 3. Resident 88 was discharged to home and MDS indicated hospitalization. These failures had the potential for residents to not receive appropriate care and interventions.

Inspectors wroteBased on interview and record review, the facility failed to develop and provide the baseline care plan (BCP) and written summary for one of 23 sampled residents (Resident 240) within 48 hours after admission. This failure decreased the facility's potential to address the residents' initial goals and current health needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 5), when Resident 5's care plan did not address the use of an incentive spirometer (a hand held device that helps people take slow, deep breaths) and compression stockings as ordered. This failure had the potential for the order to be missed and not implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of five sampled residents (Resident 189) when nursing staff failed to expel air from a syringe to ensure the full dose of heparin (a medication to treat and prevent blood clots) was administered. This failure resulted in Resident 189 receiving an incorrect dose of heparin and potential for developing blood clots leading to complications of their clinical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist one of 23 sampled residents (Resident 70) with the arrangement of an eye doctor consultation. This failure had the potential for a delayed delivery of care to help improve Resident 70's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician treatment order for a stage 4 pressure ulcer (injury to skin and underlying tissue, exposing the tendon or bone) for one of 23 sampled residents (Resident 140) when staff did not follow the treatment order for the left posterior leg as physician prescribed. This failure had the potential for the resident's current pressure ulcers to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the proper checking of a roam signal device (a device that allows sensors on doors to alarm to keep track of wandering residents) for one of 23 sampled residents (Resident 56) when Licensed Nurses (LNs) took Resident 56 near a door to test its transmitter. This failure placed Resident 56 at an increased risk for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fluid restriction orders for two of 23 sampled residents (Resident 139 and 77) when Resident 139's and Resident 77's water pitchers were at the bedside while on fluid restriction order. This failure had the potential for Resident 139 and Resident 77 not maintaining acceptable parameters of fluid intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the routine care practice and dressing change of the midline catheter (midline-a soft, long, and sterile tube inserted into a large vein in upper arm and used for administering medications into the bloodstream) for one of 23 sampled residents (Resident 76). This failure had the potential to result in serious blood stream infections causing hospitalization, organ failure, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not stored on top of medication carts (med carts) when left unattended. The deficient practice had the potential for diversion or misuse of medications from not being stored securely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the competency of Food and Nutrition Services staff when: 1. Dietary [NAME] 1 (DC1) did not correctly know cooling down process; and, 2. DC1 did not know pureed consistency, did not use measurable tools/utensils, and did not use a recipe for pureed beef, vegetable, and starch. These failures to ensure staff competency for food related tasks had the potential to cause contamination of food and provide pureed food to residents with an inappropriate consistency for medical needs resulting in choking for 88 residents who received food from the kitchen out of a census of 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a manner to conserve nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, pureed vegetable, and pureed starch. This failure had the potential to decrease the nutrients in food served and decrease food intake for five residents who received a pureed diet out of a facility census of 90.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was complete and posted on a daily basis at the beginning of each shift for a census of 90, when the Staffing Coordinator (SC) posted staffing information in the afternoon without the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This failure decreased the facility's potential to post complete staffing information on a daily basis for residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident needs were accommodated for one of three sampled residents (Resident 17), when the call light was not answered. This failure had the potential to result in the resident not attaining his highest practicable physical, psychosocial and emotional well-being.