Lincoln Glen Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Lincoln Glen Skilled Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF700Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 22 (Residents 35, 9, 24, 15, 14, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 253, 38, 37, 1, 50 and 11) of 22 residents who used side or bed rails when: 1. Twenty-two (22) of 22 residents who used side or bed rails were without care plans, 2. The risks of entrapment prior to the installation of side or bed rails were not assessed for 22 of 22 residents who used bed rails, and 3. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to keep the exterior of the kitchen's ice machine free of dust. This failure placed all 51 residents at risk of food contamination (unintended presence of potentially harmful substances such as microorganisms, chemicals, or physical objects in food.) Findings: During an observation and interview with the Food Service Manager (FSM) on 3/20/25 at 2:00 p.m. in the facility's kitchen, the exterior side panel of the ice machine was covered in dust. Clean plates were also placed next to the dusty side of the ice machine. […]

• No harm, potential for more than minimal, patternF761Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when: 1. Opened medications without open date were found in Station 1 and Station 2 medication carts, and one expired medication was found in Station 1 medication cart. This had the potential for residents to be given expired or past open-period medications. 2. A medication cart with medications was left unlocked. This had the potential for access to medications by unauthorized persons such as unauthorized staff, residents, and visitors. Findings: 1a. […]

• No harm, potential for more than minimal, patternF880Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control procedures when: 1. Certified Nursing Assistant F (CNA F), Certified Nursing Assistant G (CNA G), and Activities Leader H (AL H) delivered meal trays to Resident 6, Resident 21, and Resident 24 without sanitizing their hands; 2. Licensed Vocational Nurse E (LVN E) used paper towel to wipe the first drop of blood on Resident 4's finger; 3. Employee food was placed on Resident 27's overbed table; 4. Resident 40's filter of oxygen concentration was dusty, and her humidifier bottle was not changed within 5 days; 5. Home Health Aids I (HHA I) walked out of Resident 46's room without sanitizing her hands; and, 6. […]

• No harm, potential for more than minimal, patternF700Nov 13, 2023

  Based on observation, interview and record reviews the facility failed to follow their policy and procedure (P&P) by using bed side rails (SR: adjustable metal or rigid plastic bars that attached to the side of head of the bed) before attempting to use alternatives first for 14 of 14 residents (Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202). This failure had the potential to put the residents at risk for entrapment, serious injury and limiting their sense of independence. Findings: During the initial tour of the facility conducted on 11/6/2023 at 8:30 a.m., Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202, all had quarter SR elevated for their beds. […]