Lincoln County Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Lincoln County Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Oct 17, 2023

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection in a review of ten sampled residents. Staff failed to obtain physician orders for a newly identified pressure ulcer, failed to conduct and document assessment of the resident's pressure ulcers to determine if the wounds were deteriorating and required a change in treatment, and failed to complete dressing changes as ordered by the physician. The pressure ulcers deteriorated and became infected. Staff failed to begin treatment of the infection with antibiotics as ordered by the wound consultant nurse practitioner. […]

• Actual harm, patternF689May 23, 2024

  Based on observation, interview, and record review, the facility failed to have a system in place to ensure staff served hot beverages at an appropriate temperature, in an appropriate cup and placed within one resident's (Resident #63), of 24 sampled residents, reach. The resident sustained a third degree burn and required treatment for the burn. The facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice, and as necessary, to reduce the risk of falls for two residents (Resident #42, and #52). Resident #42 was sent to the emergency room after he/she experienced a dislocated right shoulder and a laceration above his/her right eye requiring sutures, injuries requiring treatment at the hospital. […]

• Actual harm, isolatedF600Apr 16, 2026

  Based on record review and interview, the facility failed to ensure two residents (Resident #74 and #25) were free from verbal abuse. On 03/30/26, Housekeeper A yelled at Resident #74 after the resident requested assistance with care and screamed and cursed at Resident #25 when the resident confronted him/her about how he/she talked to Resident #74. The facility census was 85. The administrator was notified of the past noncompliance on 04/09/26, which occurred on 03/30/26. On 03/30/26, the facility terminated Housekeeper W from employment at the facility for the allegation of staff to resident abuse and inserviced all staff on abuse prevention. Review of the facility's undated policy, Abuse Policy, showed the following: -Each resident will be free from abuse. […]

• Actual harm, isolatedF697May 23, 2024

  Based on observation, interview and record review, the facility failed to routinely assess pain as ordered for one resident, (Resident #38), in a review of 24 sampled residents. The facility failed to make the resident aware he/she had as needed (PRN) medication available for pain and failed to offer PRN pain medications when the resident complained of pain. The resident was agitated and unable to sleep due to pain. The census was 67. During an interview on 05/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to pain management. 1. […]

• Actual harm, isolatedF742May 23, 2024

  Based on interview and record review, the facility failed to ensure one resident (Resident #40), who was admitted to the facility with mental illness, received appropriate person-centered and individualized treatment and services to meet his/her assessed needs. Resident #40 presented with behaviors including entering another resident's room (Resident #21) wearing no pants and only a brief, taking a cigarette from another resident and lighting it in the tea room and throwing the lit cigarette in a trash can causing trash to ignite, smoking in his/her room, and yelling and cussing at another resident (Resident #15). The resident frequently made threatening gestures (threats or attempts to choke) other residents. […]