Inspection Reports for
Lincoln Community Care Center
205 TIMBERLINE DR, LINCOLN, MO, 65338-2007
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
15.2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
176% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
83% occupied
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 55
Capacity: 66
Deficiencies: 3
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, focusing on hazardous areas, fire alarm system testing and maintenance, and door maintenance and inspection.
Findings
The facility failed to ensure hazardous areas had proper fire barriers and self-closing doors, failed to maintain and test the fire alarm system with complete documentation, and failed to ensure doors had proper delayed egress signage and functioned correctly during fire alarm activation. These deficiencies had the potential to affect all facility occupants.
Deficiencies (3)
K321 Hazardous Areas - The facility failed to ensure doors to hazardous areas were self-closing and resisted smoke passage, with combustible materials improperly stored in rooms over 50 square feet.
K345 Fire Alarm System - The facility failed to inspect, test, and maintain the fire alarm system properly and lacked documentation for smoke detector sensitivity testing.
K761 Maintenance, Inspection & Testing - Doors - The facility failed to ensure main entrance/exit doors had delayed egress signage and that magnetic locks released upon fire alarm activation.
Report Facts
Facility census: 55
Facility capacity: 66
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
Annual survey conducted to assess compliance with federal regulations including personal funds management, care plan timing and revision, professional standards, activities, and resident safety.
Findings
The facility was found noncompliant in multiple areas including failure to refund resident funds timely, incomplete care plan revisions, failure to maintain professional standards after falls, inadequate activity programs, and incomplete bed rail entrapment assessments.
Deficiencies (5)
F569 Notice and Conveyance of Personal Funds: Facility failed to refund resident funds within 30 days of discharge for 17 residents and did not notify Medicaid about credit balances.
F657 Care Plan Timing and Revision: Facility staff failed to ensure care plans were reviewed and revised to include fall interventions and side rail use for sampled residents.
F658 Services Provided Meet Professional Standards: Staff failed to maintain professional standards by not completing neurological assessments after unwitnessed falls and not obtaining physician orders for self-administered eye drops.
F679 Activities Meet Interest/Needs Each Resident: Facility staff failed to provide an ongoing program of activities based on resident preferences and needs.
F909 Resident Bed: Facility failed to complete entrapment assessments for bed rails for four residents and did not ensure environment was free of accident hazards.
Report Facts
Residents with delayed refund: 17
Sampled residents: 41
Facility census: 55
Residents with fall care plan issues: 6
Residents with bed rail care plan issues: 1
Residents with neurological assessment failures: 2
Residents with incomplete bed rail entrapment assessments: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Howard | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Census: 55
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident funds refunds, care plan completeness, neurological assessments after falls, medication administration, activity programming, and bed safety entrapment assessments.
Findings
The facility was found deficient in multiple areas including failure to refund resident funds within 30 days of discharge for 17 residents, incomplete care plans lacking fall interventions and side rail documentation, failure to perform neurological assessments after unwitnessed falls for two residents, lack of physician orders for self-administration of eye drops for two residents, inadequate weekend activity programming for three residents, and incomplete entrapment assessments for four residents using side rails.
Deficiencies (5)
Failed to refund resident funds within 30 days of discharge for 17 residents.
Failed to ensure care plans were reviewed and revised to include appropriate fall interventions for six residents and failed to ensure care plans reflected the use of side rails for one resident.
Failed to complete neurological assessments after unwitnessed falls for two residents and failed to get physician orders to self-administer eye drops for two residents.
Failed to provide an ongoing program of activities designed to meet three residents' interests on the weekends.
Failed to complete entrapment assessments for four residents who use side rails to ensure safety and prevent accident hazards.
Report Facts
Residents affected: 17
Facility census: 55
Residents sampled: 41
Residents sampled: 8
Residents sampled: 14
Residents sampled: 14
Residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding resident funds refund and aging reports | |
| Administrator | Interviewed regarding resident funds refund, care plans, neurological assessments, medication administration, activity programming, and entrapment assessments | |
| RN A | Registered Nurse | Interviewed regarding care plans, neurological assessments, and medication administration |
| DON/MDS Coordinator | Interviewed regarding care plans, neurological assessments, medication administration, activity programming, and entrapment assessments | |
| CMT D | Certified Medication Technician | Interviewed regarding medication self-administration |
| CNA B | Certified Nurses Aide | Interviewed regarding weekend activities |
| Activity Director | Interviewed regarding weekend activities | |
| Maintenance Director | Interviewed regarding entrapment assessments |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Oct 3, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to maintain an infection prevention and control program, specifically related to COVID-19 infection control practices and resident placement.
Complaint Details
The visit was complaint-related due to failure to follow infection control practices for COVID-19, including improper rooming of COVID-19 positive and negative residents and failure to notify families. Immediate jeopardy was identified starting 2023-09-23 and removed on 2023-09-30.
Findings
The facility failed to separate residents who tested positive for COVID-19 from those who tested negative, placing residents at increased risk of infection. Staff did not notify families of positive cases, and housekeeping staff shortages and lack of knowledge about deep cleaning procedures contributed to the issue. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (1)
Failure to maintain an infection prevention and control program to prevent the spread of COVID-19, including improper cohorting of COVID-19 positive and negative residents.
Report Facts
Facility census: 50
COVID-19 positive residents: 4
COVID-19 negative residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Notified of immediate jeopardy and provided explanations about resident placement and staffing issues | |
| Assistant Administrator | Provided information about housekeeping staff shortages and deep cleaning procedures | |
| Licensed Practical Nurse (LPN) A | Reported on resident COVID-19 status and room sharing |
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding infection prevention and control practices related to COVID-19 at Lincoln Community Care Center.
Complaint Details
The complaint investigation found the violation to be at immediate jeopardy level K initially, but corrective actions lowered the severity to level E. The facility had implemented corrective actions to address and lower the violation at the time of exit.
Findings
The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, including improper cohorting of residents and failure to notify families of positive cases. The deficiency was initially at immediate jeopardy level but was lowered to a less severe level after corrective actions.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, including failure to properly isolate residents and follow infection control practices.
A4086 Infection Control/Communicable Disease: The facility did not meet Missouri state regulations for infection control related to communicable diseases, specifically failing to prevent the spread of infection and timely reporting.
Report Facts
Facility census: 50
Deficiency tags: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Temme | Surveyor | Named in infection prevention and control deficiency observation |
| Jacob Baker | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 3
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to regulatory compliance at Lincoln Community Care Center and to review the facility's plan of correction for those deficiencies.
Findings
The facility was found deficient in assuring financial security of resident funds, developing and implementing comprehensive person-centered care plans, and food safety practices including storage and sanitation. Several residents' care plans lacked necessary interventions and documentation, and food storage areas contained unlabeled, undated, or improperly stored items.
Deficiencies (3)
F570 Surety Bond-Security of Personal Funds: The facility failed to purchase a surety bond in an amount sufficient to assure security of all resident funds held by the facility.
F656 Develop/Implement Comprehensive Care Plan: Facility staff failed to develop and implement a comprehensive person-centered care plan for four residents, lacking measurable objectives and interventions for medical, psychosocial, and behavioral needs.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility staff failed to store food to protect from contamination and out-dated use, including reuse of single-service containers and improper hand hygiene during food handling.
Report Facts
Facility census: 48
Surety bond amount required: 64500
Surety bond amount approved: 60000
Number of residents with deficient care plans: 4
Number of undated or improperly stored food items observed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Bobsaw | Administrator | Named in plan of correction approval signature |
| Babs Cunningham | RN Consultant for Professional Healthcare Consultants | Named in plan of correction for comprehensive care plan |
| Crystal Plank | QIPMO Nurse | Named in plan of correction for in-service training |
Inspection Report
Life Safety
Census: 48
Capacity: 66
Deficiencies: 18
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness requirements at Lincoln Community Care Center.
Findings
The facility was found deficient in maintaining an up-to-date emergency preparedness plan, training and testing programs, fire alarm system maintenance, fire watch policy, egress door functionality, sprinkler system maintenance, and electrical system safety. Several deficiencies were cited related to fire safety and emergency preparedness that could affect all facility occupants.
Deficiencies (18)
E004: The facility failed to review and update their emergency preparedness plan at least annually, potentially delaying effective emergency response. The facility census was 48 residents with a capacity of 66.
E006: The facility failed to develop and maintain a complete, up-to-date emergency preparedness program including risk assessments and policies, with outdated information and lack of annual review. The census was 48 with a capacity of 66.
E036: The facility failed to develop and maintain an emergency preparedness training and testing program, with no documentation of training or testing provided to staff. The census was 48 with a capacity of 66.
E037: The facility failed to provide training on emergency preparedness policies and procedures to all staff annually and upon hire, with no documentation of training provided. The census was 48 with a capacity of 66.
K222: Egress doors were found with a portion of a door knob removed preventing proper opening, and delayed-egress locking devices requiring two actions to open. The facility census was 48 with a capacity of 66.
K321: Hazardous areas were not protected by self-closing doors or fire barriers, with doors held open by wedges or boxes, and gaps allowing passage of smoke. The facility census was 48 with a capacity of 66.
K345: Fire alarm system testing and maintenance records were incomplete, with failure to secure the fire alarm control panel and monthly testing not documented. The census was 48 with a capacity of 66.
K346: Fire alarm system was out of service for more than four hours without complete interim fire watch policies and procedures. The census was 48 with a capacity of 66.
K353: Sprinkler system maintenance and testing were deficient, with accumulation of lint and debris on sprinklers and unsealed gaps allowing smoke passage. The census was 48 with a capacity of 66.
K354: Sprinkler system was out of service for more than 10 hours without adequate fire watch procedures. The census was 48 with a capacity of 66.
K712: Fire drills were not conducted quarterly on all shifts, and simulated resident evacuation drills were not conducted annually. The census was 48 with a capacity of 66.
K761: Facility failed to inspect and maintain fire doors and smoke barrier doors, including electronically controlled locking mechanisms, monthly. The census was 48 with a capacity of 66.
K911: Electrical panels were unsecured and accessible, with keys removed from locked electrical panel boxes. The census was 48 with a capacity of 66.
K918: Facility failed to conduct monthly inspections and testing of emergency generators and electrical systems, and failed to maintain documentation of inspections. The census was 48 with a capacity of 66.
K926: Facility failed to provide annual training on medical gas safety and oxygen storage to staff, and failed to maintain proper storage of oxygen cylinders. The census was 48 with a capacity of 66.
E0006: Maintenance Director was not in service on hazard/risk assessments, and the facility failed to update emergency preparedness policies and training as required. The census was 48 with a capacity of 66.
E00036: Facility failed to provide emergency preparedness training and testing to staff on a yearly basis, and failed to audit new staff packets and training compliance. The census was 48 with a capacity of 66.
E0037: Facility failed to train all staff on emergency procedures annually and upon hire, with no documentation of training provided. The census was 48 with a capacity of 66.
Report Facts
Facility census: 48
Total capacity: 66
Deficiency counts: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to emergency preparedness, fire safety, and maintenance deficiencies | |
| Business Office Manager/assistant administrator | Named in interviews regarding emergency preparedness and fire safety policies |
Inspection Report
Routine
Census: 48
Deficiencies: 5
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident fund security, care planning, food safety, hand hygiene, and dishwashing procedures at Lincoln Community Care Center.
Findings
The facility failed to maintain a sufficient surety bond for resident funds, did not develop comprehensive care plans for several residents, and had multiple food safety violations including improper food storage, reuse of single-service containers, and failure to perform proper hand hygiene. Additionally, sanitized dishes were not allowed to air dry before storage.
Deficiencies (5)
Failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds.
Failed to develop and implement a comprehensive person-centered care plan for four residents, lacking measurable timetables and interventions for dental care, pressure ulcer prevention, falls, and antipsychotic medication use.
Failed to store food properly to prevent contamination and out-dated use, including storing food on the floor, unlabeled and undated opened food items, reuse of single-service containers, and improper storage of raw foods above ready-to-eat foods.
Failed to perform hand hygiene as often as necessary using approved techniques, including improper glove use and inadequate handwashing duration.
Failed to allow sanitized dishes to air dry prior to stacking and storage, leading to potential growth of food-borne pathogens and cross-contamination.
Report Facts
Facility census: 48
Average monthly resident trust fund balance: 43373.99
Required surety bond amount: 64500
Current ledger amount: 49567.63
Escrow Agreement Account amount: 60000
Number of residents with deficient care plans: 4
Number of Haldol administrations documented: 7
Dates of opened food items found expired or undated: Multiple food items with expired or missing dates observed
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Responsible for ensuring surety bond sufficiency and food storage monitoring | |
| Social Services Designee (SSD) | Responsible for making dental appointments and resident communication | |
| MDS Coordinator | Responsible for completing and updating care plans | |
| LPN M | Licensed Practical Nurse | Provided information on care plan expectations and interventions |
| Director of Nursing (DON) | Oversight of care plan updates and staff communication | |
| Dietary Manager (DM) | Responsible for monitoring food storage, hand hygiene, and dishwashing procedures | |
| DA C | Dietary Aide | Observed failing to perform proper hand hygiene and dishwashing procedures |
| DA H | Dietary Aide | Observed performing hand hygiene inconsistently and improper dishwashing practices |
| [NAME] A | Cook | Observed improper handwashing and glove use |
| [NAME] D | Cook | Observed improper handwashing and glove use |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 1, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 6
Date: Nov 20, 2020
Visit Reason
The document is a Plan of Correction submitted by Lincoln Community Care Center following a survey conducted from 11/09/20 to 11/13/20 with an exit date of 11/20/20. The plan addresses deficiencies cited during the inspection.
Findings
The facility was cited for multiple deficiencies including failure to purchase a sufficient surety bond for resident funds, failure to post required telephone numbers and complaint information, failure to maintain professional standards in care plans, failure to complete neurological assessments after falls, inadequate medication storage and labeling, and food safety violations.
Deficiencies (6)
F570 Surety Bond-Security of Personal Funds. Facility staff failed to purchase a surety bond sufficient to assure security of all resident funds. The facility census was 56.
F575 Required Postings. Facility failed to post the required telephone number to the Department of Health and Senior Services hotline and a list of names, addresses, and phone numbers of the State Survey Agency in a prominent location for residents and visitors.
F658 Services Provided Meet Professional Standards. Staff failed to maintain professional standards by not completing neurological assessments for residents after unwitnessed falls and failed to document assessments for pressure ulcers and skin issues.
F732 Posted Nurse Staffing Information. Facility failed to accurately post nurse staffing data daily in a prominent place accessible to residents and visitors. The facility census was 56.
F761 Label/Store Drugs and Biologicals. Facility failed to store and label medications properly, including expired medications and medication labeling and disposal procedures.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. Facility failed to store food in a safe and sanitary manner, including failure to date opened food items and failure to maintain proper hygiene and food handling procedures.
Report Facts
Facility census: 56
Surety bond amount required: 43500
Surety bond amount approved: 30000
Surety bond penalty amount: 60000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl LaFavor | Administrator | Named as signing the Plan of Correction and referenced in interviews |
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: Nov 20, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident fund security, posting of state agency contact information, professional standards of care, medication storage and labeling, nurse staffing information posting, and food safety and sanitation practices.
Findings
The facility was found deficient in multiple areas including failure to maintain sufficient surety bond for resident funds, failure to post required hotline information, failure to complete neurological assessments after resident falls, failure to document and notify physician of skin conditions, inaccurate nurse staffing postings, improper medication storage and labeling, and unsafe food handling and sanitation practices.
Deficiencies (6)
Facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds.
Facility failed to post the required telephone number to the Department of Health and Senior Services hotline and State Survey Agency contact information in a prominent and accessible location.
Staff failed to complete required neurological assessments following unwitnessed falls and falls with head injury for multiple residents, and failed to document assessments of pressure ulcers, blisters, and cellulitis or notify physicians accordingly.
Facility staff failed to accurately post nurse staffing information including number of certified nursing assistants and their hours worked, and failed to post staffing data in a location accessible to residents and visitors.
Facility staff failed to store and label medications properly, including use of undated and expired medications, and failure to label opened medications with date opened.
Facility failed to store food safely and sanitary, including undated and expired food items, failure to thaw food properly, failure to perform hand hygiene between tasks, and failure to allow sanitized kitchenware to air dry before stacking.
Report Facts
Facility census: 56
Resident trust fund average monthly balance: 29267.14
Required surety bond amount: 43500
Current ledger amount: 53138.91
Number of residents affected by neurological assessment deficiencies: 5
Number of CNAs scheduled vs worked: Discrepancies noted in staffing reports and schedules for November 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Provided details on neurological assessment procedures and deficiencies |
| CNA C | Certified Nursing Assistant | Provided information on hotline posting and fall reporting |
| Administrator | Responsible for bond sufficiency and nurse staffing postings | |
| Business Office Manager | BOM | Interviewed regarding surety bond responsibility |
| Social Service Designee | SSD | Unaware of hotline posting requirements |
| DON | Director of Nursing | Provided information on neurological assessment expectations and medication labeling |
| RN B | Registered Nurse | Involved in resident skin assessments and medication observations |
| ADON | Assistant Director of Nursing | Informed about resident blister and physician notification |
| DM | Dietary Manager | Provided information on food safety and sanitation deficiencies |
| DA E | Dietary Aide | Observed failing to change gloves and perform hand hygiene |
| DA H | Dietary Aide | Observed failing to perform hand hygiene before handling food |
| CMT D | Certified Medication Technician | Provided information on medication labeling and disposal |
| [NAME] F | Dietary Staff | Observed stirring food with bare hands and improper food handling |
| [NAME] G | Dietary Staff | Observed failing to change gloves and perform hand hygiene |
Inspection Report
Life Safety
Census: 56
Capacity: 66
Deficiencies: 14
Date: Nov 12, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain unobstructed means of egress, install a complete fire alarm system including manual pull stations, maintain the sprinkler system free of corrosion and obstructions, maintain smoke barrier walls, and conduct fire drills as required. Several deficiencies were noted related to blocked exits, missing fire alarm pull stations, sprinkler system maintenance, smoke barrier wall integrity, and fire drill scheduling.
Deficiencies (14)
K211 Means of Egress - General: Facility staff failed to maintain exit locations free of obstructions, including blocked exit doors and furniture obstructing egress paths.
K341 Fire Alarm System - Installation: Facility staff failed to install a complete fire alarm system including manual fire alarm pull stations at the nurse's station.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain the sprinkler system free of corrosion, dirt, and obstructions, and failed to inspect and clean sprinklers regularly.
K372 Subdivision of Building Spaces - Smoke Barrier: Facility staff failed to maintain smoke barrier walls free of openings and penetrations, including unsealed holes and damaged walls.
K712 Fire Drills: Facility staff failed to conduct fire drills quarterly on each shift and at varying times, and failed to maintain proper documentation of fire drills.
A1047 Nurses' Work Station Requirements: Facility staff failed to install a work counter and storage space for charts at the front nurse's station.
A1048 Medication Room Requirements: Facility staff failed to provide a medication preparation room next to each nurse's station as required.
A1131 Nurses' Call System Requirements: Facility staff failed to install an electrically-powered nurses' call system with indicator lights and audible signals at each nurse's station.
A1132 Night-lights-Required Locations: Facility staff failed to maintain functional night-lights in resident rooms, common toilet rooms, and shower rooms.
A2018 Complete Fire Alarm System Requirements: Facility staff failed to install a complete fire alarm system that transmits alarms to the fire department or central monitoring.
A2034 Sprinkler System-Test/Maintain: Facility staff failed to inspect, maintain, and test sprinkler systems in accordance with regulations.
A2037 Exit Requirements: Facility staff failed to maintain unobstructed exits remote from each other as required by code.
A2054 Smoke Section Walls/Doors: Facility staff failed to maintain smoke section walls and doors with required fire resistance ratings and self-closing mechanisms.
A2061 Fire Drill Requirements, Evacuation: Facility staff failed to conduct required fire drills quarterly on each shift and maintain proper documentation.
Report Facts
Facility census: 56
Facility capacity: 66
Deficiencies cited: 14
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 2
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess the facility's compliance with infection prevention and control requirements related to COVID-19.
Findings
The facility was found to be out of compliance with infection control requirements, specifically failing to ensure staff wore facemasks, promote social distancing, properly wash hands, screen residents for COVID-19 symptoms, and restrict non-essential personnel. Multiple observations and interviews confirmed these deficiencies.
Deficiencies (2)
F880 Infection Control: Facility staff failed to ensure all staff wore facemasks, promote social distancing, wash hands properly, screen residents for COVID-19 symptoms, and restrict non-essential healthcare personnel.
A4085 Infection Control/Communicable Disease: Facility failed to use acceptable infection control procedures to prevent the spread of infection and failed to report communicable diseases within seven days.
Report Facts
Facility census: 58
Deficiency count: 2
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 10
Date: Jun 6, 2019
Visit Reason
The inspection was conducted as an annual survey of Lincoln Community Care Center to assess compliance with Medicare and Medicaid regulations, including review of resident care, environment, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide proper Medicaid/Medicare notices, maintain a safe and homelike environment, complete comprehensive assessments after significant changes, develop baseline care plans timely, and ensure free of accident hazards. Several residents' records and care practices did not meet regulatory requirements.
Deficiencies (10)
F582 Medicaid/Medicare Coverage/Liability Notice: Facility staff failed to provide required Medicare and Medicaid notices to residents discharging from Medicare Part A services. The facility census was 56.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to maintain a safe, clean, comfortable, and homelike environment, including damaged wallpaper, paint chips, and gouges in resident rooms #206, #208, and #210.
F623 Notice Requirements Before Transfer/Discharge: Facility staff failed to notify residents or their representatives in writing about transfers or discharges for two sampled residents. The facility census was 56.
F637 Comprehensive Assessment After Significant Change: Facility staff failed to complete significant change assessments for four residents with significant changes. The facility census was 56.
F655 Baseline Care Plan: Facility staff failed to develop and implement baseline care plans within 48 hours of admission for multiple residents. The facility census was 56.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure safe techniques to lift and move four residents, increasing risk of injury. The facility census was 56.
F700 Bedrails: Facility staff failed to perform entrapment risk assessments and ensure safe use of bed rails for multiple residents. The facility census was 56.
A4073 Protective Oversight, Voluntary Leave: Facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave.
A4074 Nursing Care per Resident Condition: Facility failed to provide personal attention and nursing care consistent with residents' conditions and current acceptable nursing practice.
A6015 Walls/Ceilings/Doors/Windows Clean: Facility failed to maintain walls, ceilings, doors, and windows in clean and good repair.
Report Facts
Facility census: 56
Deficiencies cited: 10
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 6, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility met the applicable provisions of the Life Safety Code. No deficiencies or state licensure deficiencies were cited during this inspection.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 9
Date: Jun 8, 2018
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and exploitation involving multiple residents at Lincoln Community Care Center.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect involving multiple residents. The facility was found responsible for failure to prevent and report abuse, inadequate staff training, and deficient care practices.
Findings
The investigation found multiple instances of abuse and neglect, including verbal and physical abuse by staff towards residents, failure to report incidents timely, and inadequate care practices. The facility failed to ensure resident safety and comply with abuse prevention policies.
Deficiencies (9)
F600: The facility failed to prevent abuse, neglect, and exploitation of residents, including verbal and physical abuse by staff and failure to report incidents promptly.
F609: The facility failed to implement abuse prevention policies and procedures, including staff training and timely reporting of abuse allegations.
F610: The facility failed to investigate and report alleged abuse and neglect in accordance with regulatory requirements.
F641: The facility failed to accurately assess and monitor residents' conditions, including cognitive status and weight changes.
F645: The facility failed to ensure proper admission screening and care planning for residents with mental health diagnoses.
F657: The facility failed to develop and implement comprehensive care plans addressing residents' needs and changes.
F686: The facility failed to provide adequate care to prevent pressure ulcers and manage wounds.
F758: The facility failed to ensure proper use and monitoring of psychotropic medications.
F781: The facility failed to ensure proper storage and administration of medications, including vaccines.
Report Facts
Facility census: 58
Deficiency tags cited: 9
Inspection Report
Life Safety
Census: 58
Capacity: 66
Deficiencies: 2
Date: Jun 8, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with NFPA 101 standards regarding egress doors and locking arrangements.
Findings
The facility failed to maintain doors in a means of egress readily accessible at all times, specifically failing to post codes to unlock delayed egress magnetic locking devices. Staff were unaware of the requirement to post these codes, affecting the safety of residents and visitors.
Deficiencies (2)
K222 Egress Doors: Facility staff failed to maintain doors in a means of egress readily accessible at all times and did not post codes to unlock doors equipped with delayed egress magnetic locking devices. This failure affected all occupants and posed a potential safety risk.
A2041 Door Locks: Door locks must be operable from the inside by turning a knob or operating a simple device to release the lock. Only one lock is permitted on any one door. This regulation was not met as evidenced by the referenced deficiency K222.
Report Facts
Facility census: 58
Total capacity: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Engles | Administrator | Named in signature on inspection and plan of correction documents |
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