Lincoln County Care Center

In the surveyor’s words

From the most serious findings on record at Lincoln County Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Apr 15, 2026

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or residents were injured due to unsafe areas in the facility. […]

• No harm, potential for more than minimal, patternF761Apr 15, 2026

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication rooms and 1 of 1 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication, to receive expired medications with decreased efficacy, and residents to receive the wrong medication due to the medication label being illegible. […]

• No harm, potential for more than minimal, isolatedF552Apr 15, 2026

  Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 2 of 3 residents (#1 and #35) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include:The facility's Medication Therapy policy, version 1.1, documented 1. Each resident's medication regimen shall include only those medications necessary to treat existing condition and address significant risks. 2. […]

• No harm, potential for more than minimal, isolatedF554Apr 15, 2026

  Based on observation, resident and staff interviews, policy review and record review, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #35). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:The facility's Self-Administration of Medications policy, revised date February 2021, documented, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the… […]

• No harm, potential for more than minimal, isolatedF558Apr 15, 2026

  Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 12 residents (#12 and #35) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Answering the Call Light policy, version 1.3, documented. The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Ensure that the call light is accessible to the resident. […]