Lincoln Village Healthcare

Inspectors wroteBased on interview and record review the facility failed to prevent a fall for one resident (R1) of three residents reviewed for falls in the sample of five.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide adequate staffing requirements for Registered Nurse coverage and a full-time Director of Nursing meeting the requirements of a Facility with a Resident census over the amount of 60 Residents. This failure has the potential to affect all 83 Residents residing in the Facility.

Inspectors wroteThe Facility failed to document accurate and timely medication administration for six of six Residents (R1, R2, R3, R4, R5 and R6) reviewed for medication administration in a sample of six.

Inspectors wroteBased on interview and record review the Facility failed to ensure authorized personnel were signing for intravenous medication administration in the electronic Medication Administration Record for two of three Residents (R2 and R3) reviewed for medication administration in a sample of six.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate supervision, safe transfer practices, post-fall assessment, and timely medical evaluation for one (R1) of four residents reviewed for accidents in the sample list of four. This failure resulted in R1 sustaining multiple rib fractures and a spinal compression fracture following a fall from R1's bed on 3/10/26, with no physician evaluation or diagnostic testing completed until seven days later.

Inspectors wroteBased on interview and record review, the facility failed to assess, document, and communicate the residents' Activities of Daily Living (ADL) needs, and ensure a comprehensive, person-centered care plan was timely reviewed and revised for one (R1) of four residents reviewed for care plan revision in the sample list of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a physician timely regarding frequent refusals of a (mood stabilizer) medication for one of three residents (R3) reviewed for physician notification of change in a sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for two residents of four residents (R13 and R15) reviewed for abuse in a sample of 17.

Inspectors wroteBased on interview and record review the Facility failed to protect a wound from insect contamination and failed to provide appropriate physician ordered wound care leading to a decline in the Resident's physical well-being for one of three Residents (R1) reviewed in sample of five. This failure resulted in R1 requiring emergent transport to the local hospital and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the residents were not receiving their prescribed pain relieving opioid medications, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for three of three residents (R2, R14, and R22) reviewed for pain in the sample of 30. These findings resulted in R2 experiencing restlessness and unrelieved pain after seven days of going without his prescribed opioid medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back, and R22 experiencing unrelieved severe pain to the lower back and legs.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a process for the timely ordering and reordering of medications, failed to notify the physician of the need for opioid analgesic medications and anti-anxiety medication prescription refill orders, failed to notify the physician of the need for an alternative to ordered Ozempic, and failed to obtain physician ordered opioid analgesic medications, anti-antianxiety medication, and weight-loss medication from the pharmacy for four of four residents (R2, R14, R18, and R22) reviewed for pharmacy services in the sample of 30. [...]

Inspectors wroteBased on interview and record review the facility failed to issue a written notice of room moves for three of four residents (R13, R14, and R27) reviewed for room moves in a sample of 30.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's responsible party after a significant weight loss was identified for one of four residents (R1) reviewed for notifications of change in a sample of 30.

Inspectors wroteBased on record review and interview the facility failed to protect a resident from staff-to-resident verbal abuse for one of three residents (R13) reviewed for staff-to-resident abuse in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to obtain consent prior to administering psychotropic medications for one of three residents (R1) reviewed for psychotropic medications in a sample of 30.

Inspectors wroteBased on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of resident abuse to the State Agency and Administrator for one of seven residents (R13) reviewed for Abuse in the sample of 30.

Inspectors wroteBased on record review and interview the facility failed to immediately investigate an allegation of resident abuse for one of seven residents (R13) reviewed for Abuse in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, and R14) reviewed for hospital transfers in a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received a consultation with a lymphedema specialist and a nephrologist, as ordered by the physician, for one of four residents (R26) reviewed for physician orders in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to update a pressure ulcer care plan and implement pressure relieving interventions for one of three residents (R1) reviewed for pressure ulcers in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor an indwelling urinary catheter for urine output, urine color, and urine consistency, perform a voiding trial as ordered by a physician, follow-up with urology as ordered by a physician, and provide catheter care every shift for one of four residents (R4) reviewed for indwelling urinary catheters in the sample of 30.

Inspectors wroteBased on record review and interview the facility failed to update weight loss care plans with weight loss interventions for two of four residents (R1 and R16) reviewed for significant weight loss in the sample of 30.

Inspectors wroteBased on record review and interview the facility failed to obtain a physician ordered Basic Metabolic Panel for one of five residents (R19) reviewed for laboratories in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions during direct cares for one of five residents (R22) reviewed for infection control in the sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R5) reviewed for abuse in a sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one resident (R8) reviewed for abuse in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and implement a treatment order for one resident (R3) and failed to follow its policy for labeling and dating wound dressings after treatments for two (R1, R6) residents reviewed for wound care/treatments in a sample of four.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide supervision and implement fall prevention interventions to prevent resident falls for two of three residents (R1 and R4) reviewed for falls in the sample of 24. These failures resulted in R1 falling and sustaining an injury to right eyelid and R4 falling and experiencing left hip pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate staffing to deliver resident cares efficiently and in a timely manner. This failure has to potential to affect all 72 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to respond to resident call lights in a timely manner for seven of seven residents (R2, R3, R4, R6, R8, R9 and R10) reviewed for call light response time in the sample of 24.

Inspectors wroteBased on interview, observation and record review, the facility failed to remove and discard unlabeled multi-dose insulin vials and multi-dose insulin delivery pens from four active medication carts for 17 of 17 residents (R3 through R6, and R12 through R24) reviewed for insulin usage in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to implement all components of their abuse policy for one of four residents (R1) reviewed for abuse in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse for one of four residents (R1) reviewed for abuse in the sample of 24.

Inspectors wroteBased on record review and interview the Facility failed to provide weekly showers for seven of eight Residents (R1, R2, R3, R4, R5, R7 and R8) reviewed for showers in a sample of nine.

Inspectors wroteBased on observation, interview, and record review the Facility failed to follow their Dietary Menu and provide condiments for six of nine Residents (R1, R2, R4, R5, R6, R7) reviewed for dietary preferences in a sample of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was dated, bagged, and kept off the floor per facility policy and professional standards for four (R20, R28, R39, and R125) of six residents reviewed for respiratory therapy in a sample of 26.

Inspectors wroteBased on record review and interview the facility failed to document in the resident's medical records or provide written notification to residents and/or resident representatives for hospital transfer/discharges. This failure has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the Facility failed to employee a full time Director of Nursing. This failure has the potential to affect all 75 Residents residing in the Facility.

Inspectors wroteBased on interview and record review the facility failed to notify a family member of a resident fall for one (R1) of three residents reviewed for falls in the sample of eight.

Inspectors wroteBased on interview and record review the facility failed to implement complete neurological assessments, provide continuous monitoring, and provide timely hospital transfer for one (R1) of three residents reviewed for quality of care in the sample of eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safety during resident cares, keep supplies in reach, and do a thorough fall investigation for one (R6) of three residents reviewed for fall safety during cares.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent misappropriation of controlled substance medications for eight of ten residents (R2, R7, R9, R10, R11, R12, R13, and R14) reviewed for misappropriation of resident medications in a sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician orders for use and care of an indwelling urinary catheter (R1), failed to notify a physician of a resident's abnormal urine laboratory testing results (R1), failed to timely treat a urinary tract infection/UTI (R1), and failed to obtain a physician ordered urine laboratory test (R4) for two of three residents (R1 and R4) reviewed for indwelling urinary catheters and UTIs in the sample of six. These failures resulted in R1 experiencing lower abdominal pain; urine with increased sediment in R1's indwelling urinary catheter tubing and bag; abnormal urine laboratory test results with a delay of physician notification and treatment. R1 was subsequently transferred to two different local area hospitals and admitted to the intensive care unit with a diagnosis of UTI with septic shock.

Inspectors wroteBased on interview and record review, the facility failed to designate an Infection Preventionist onsite, who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program (IPCP) to prevent and control infections in the facility. This has the potential to affect all 72 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to take and record the food temperature of foods on the tray line (steam table); check and record the wash and rinse temperatures and the Chlorine level on the dish machine; Check and record the amount of sanitizing solution in the sanitizer bucket; Keep cases of food off of the floor in the kitchen, walk-in cooler and walk-in freezer; Keep thawing raw meat in non-porous containers; store raw eggs on the bottom shelf to prevent contamination of ready to eat foods underneath the raw eggs; label and date all foods stored; use sanitizer wipes to clean the thermometer before and between uses and keep chemicals off of the floor and on shelves six inches off of the floor. This has the potential to affect all 69 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide range of motion programming to residents with limitations in range of motion for 7 of 7 (R3, R11, R27, R52, R55, R57, R63) residents reviewed for limited range of motion in a sample of 69 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident with a physician ordered calorie supplement, care plan weight loss and ensure resident weights were being scheduled and documented for residents with high-risk diagnoses, fluid fluctuation and weight loss for five of eleven residents (R52, R55, R57, R63, R64) reviewed for nutrition in the sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to have a Practitioner Order For Life-Sustaining Treatment/ POLST in the Medical Record for one resident (R171) in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Seroquel (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of one resident (R36) reviewed for antipsychotic medications in the sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a history of falling was supervised while toileting for one of three residents (R2) reviewed for falls in the sample of three. This failure resulted in R2 getting out of the bathroom on her own and suffering a fall that resulted in head injury and required transfer to the local emergency room for treatment of a headache and a six centimeter hematoma to the right frontal scalp.

Inspectors wroteBased on interviews and record review, the facility failed to implement the abuse policy for a thorough investigation and suspension of an employee for an allegation of abuse for one resident (R2) of three residents reviewed for allegation of abuse in a sample of three.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of abuse to the State Agency for one (R2) of three residents reviewed for abuse in a sample of three.

Inspectors wroteBased on interviews and record review, the facility failed to do a thorough investigation for an allegation of staff to resident abuse for one resident (R2) of three residents reviewed for abuse in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident's pain in control following a hip fracture with surgical repair for one of three residents (R1) reviewed for pain management in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic pain medication was available upon a resident's readmission following hip surgery for one of three residents (R1) reviewed for pain in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's physician of an ordered pain medication not being acquired from pharmacy and a resident being in severe pain for one of three residents (R1)reviewed for pain in the sample of six.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident was free from misappropriation of a narcotic pain medication for one of three residents (R1) reviewed for misappropriation in the sample of five.

Inspectors wroteBased on interview and record review the failed to provide sufficient staff for care of its residents on the night shift. This has the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to provide timely and palatable supper meals to three residents (R7, R8, R9) reviewed for meals in a sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a Dietary Manager to supervise the prevision of meals which has the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient staff to carry out the meal preparation safely and effectively, keep the kitchen clean and sanitary, and to serve residents' meals on time. These failures have the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation interview and record review the facility failed to ensure meals were served on time and as per the scheduled meal times. This failure has the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen was clean, without food debris and spills on the floor, the slicer was covered and without food debris covering the stand, clean dishes were removed from the dish machine area and protected from splashes and food debris, food prep surfaces were clean, the grill was cleaned and free of grease and food debris, individual hand towels were available at the hand washing station, empty and full boxes were kept off the floor, a food temperature log was maintained and food temperatures on the serving steam table were monitored. These failures have the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident did not develop a shear pressure injury for one of three residents (R1) reviewed for pressure ulcers in a sample of eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the wheels of a recliner were locked and a transfer safety belt was used during a resident transfer which affected one of three residents (R1) reviewed for transfers in a sample of eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's perineal area was cleansed from the front to the back for one of three residents (R3) reviewed for incontinence care in a sample of eight.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hand hygiene was performed in between tasks during incontinence care for three of three residents (R1, R2, R3) reviewed for infection control practices in a sample of eight.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean, homelike environment for one of three residents (R1) reviewed for clean, comfortable, homelike environment in the sample of three. Findings Include: The facility's Housekeeping Services Policy undated documents it is the policy of the facility to maintain a clean, comfortable and orderly environment in all healthcare and public areas and documents resident rooms are to be maintained in a sanitary manner. This same policy states, 4. The department shall routinely clean the environment of care, using accepted practices, to keep the facility free from offensive odors, the accumulation of dust, rubbish, dirt and hazards. The facility's Resident Rights Statement undated documents the facility will provide a safe, clean, comfortable and homelike environment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who requires assistance with activities of daily living was showered weekly and failed to ensure a resident's clothing was changed daily for one of three residents (R1) reviewed for activities of daily living/ADLs in the sample of three. Findings Include: The facility's Shower/Tub Bath Procedure revised August 2002 documents the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This same procedure documents the following information should be recorded in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., a reddened area, sores, etc. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident with known skin impairments, failed to ensure pressure ulcer dressing changes were completed as ordered by the physician, failed to complete weekly wound assessments, and failed to notify the physician of a change in a resident's wound status for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to stay at a resident's bedside to ensure a resident consumed all of their morning medications during medication pass for one of three residents (R1) reviewed for medications in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date open food items, store dry food on shelves, maintain clean equipment, and clean the kitchen between meals. This has the potential to affect 64 of the 71 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear Personal Protective Equipment (face masks) in compliance with the local Community COVID Outbreak Transmission Rate. This failure has the potential to affect all 71 residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter tubing and urinary drainage bags were kept off the floor for four residents (R19, R61, R62 and R63) and ensure an indwelling urinary catheter drainage bag was maintained below the bladder for one out five residents (R64) reviewed for indwelling urinary catheters in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an assessment and include alternative interventions attempted prior to initiating the use of side rails for four out of four residents (R19, R33, R58 and R62) reviewed for side rails in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean homelike environment for one resident (R19) out of 30 residents reviewed for environment in a sample of 30

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a written notice of transfer for two (R44 and R49) of two residents reviewed for hospitalization in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an admission wound assessment, obtain a physician's order, and complete treatments for wounds for one resident (R319) of two residents reviewed for wounds in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen concentrators included humidification per physician order for one out of two residents (R28) reviewed for oxygen in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and identify potential triggers for a resident with a diagnosis of PTSD (Post-Traumatic Stress Disorder) and failed to provide specific personalized interventions for a resident with a diagnosis of PTSD for one of two residents (R36) reviewed for mood and behavior in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received medications as physician ordered for one (R58) of one resident reviewed for medication errors in the sample of 30.