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Deficiency Records for Lincoln County Nursing and Rehab
A list of the most recent deficiencies for Lincoln County Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lincoln County Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement a program that monitors antibiotic use. | Health | 2024-05-23 | 2024-08-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-05-23 | 2024-07-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-05-23 | 2024-07-05 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-05-23 | 2024-07-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-23 | 2024-07-05 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-23 | 2024-07-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-23 | 2024-07-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-23 | 2024-07-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-23 | 2024-07-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-23 | 2024-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-23 | 2024-07-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide activities to meet all resident's needs. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide appropriate foot care. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-05-23 | 2024-07-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-23 | 2024-07-05 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-05-23 | 2024-07-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-23 | 2024-07-05 | N |
| Post nurse staffing information every day. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-23 | 2024-07-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-23 | 2024-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-23 | 2024-07-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-23 | 2024-07-05 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-05-23 | 2024-07-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-23 | 2024-07-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-23 | 2024-07-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-23 | 2024-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | 2024-07-05 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-23 | 2024-07-05 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-05-23 | 2024-07-05 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-23 | 2024-07-05 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-23 | 2024-07-05 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-23 | 2024-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-23 | 2024-07-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-23 | 2024-07-05 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Meet other general requirements. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-05-23 | 2024-07-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-29 | 2024-04-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-29 | 2024-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-29 | 2024-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-29 | 2024-04-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-29 | 2024-04-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-29 | 2024-04-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-03 | 2024-02-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-03 | 2024-02-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-17 | 2023-11-12 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-10-17 | 2023-11-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-17 | 2023-11-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-27 | 2022-12-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-27 | 2022-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-27 | 2022-12-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-27 | 2022-12-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-27 | 2022-12-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-27 | 2022-12-10 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-27 | 2022-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-12-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-27 | 2022-12-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-27 | 2022-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-27 | 2022-12-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-27 | 2022-12-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-27 | 2022-12-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-10-27 | 2022-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-27 | 2022-12-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-27 | 2022-12-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-27 | 2022-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-12-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-27 | 2022-12-10 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-10-27 | 2022-12-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-27 | 2022-12-10 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-27 | 2022-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-27 | 2022-12-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-27 | 2022-12-10 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-27 | 2022-12-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Meet other general requirements. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-27 | 2022-12-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-20 | 2019-08-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-20 | 2019-08-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-20 | 2019-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-20 | 2019-08-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-20 | 2019-08-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-06-20 | 2019-08-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-20 | 2019-08-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-06-20 | 2019-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-08-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-20 | 2019-08-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-06-20 | 2019-08-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Establish methods for sharing information. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-20 | 2019-08-01 | N |
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