Lincoln County Care Center

Based on observation, resident and staff interview, and food test tray evaluation, it was determined the facility failed to ensure resident meals were palatable and maintained safe and appetizing temperatures to the residents. This had the potential to affect the 26 residents who resided in the facility who consumed meals prepared in the facility's kitchen. This failed practice had the potential to negatively affect the residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F or above and cold food will be maintained at 41 degrees F or below. On 4/13/26 at 10:42 AM, during the Resident Council meeting, 6 of 6 residents stated the food served was often cold, tasteless, and not nutritious. The residents stated there are no condiments on the meal tray, especially when trays are delivered to their room, and the dinner meal is usually the worst meal of the day. On 4/14/26 at 11:27 AM, observed the lunch meal service with the following observations: - The menu documented the main entree was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the FDA Food Code, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled, and cleaning logs were properly documented. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination of food and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code 2022, 3-501.17 documented, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 4/12/26 at 9:41 AM, observed the following:- the walk-in refrigerator contained one large, opened package of provolone cheese with no use by date. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Handwashing/Hand Hygiene Policy Revised date March 2022, documented use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after eating or handling food.The facility's Homelike Environment policy revision date February 2021, documented the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.The following was observed for hand hygiene:On 4/12/26 at 12:04 PM, observed 14 residents served their meals in the dining room. The residents were not offered hand hygiene…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure all components of the baseline (initial) care plan were included upon resident's admission. This was true for 1 of 14 residents (Resident #129) reviewed for baseline care plan. This failure created the potential for harm when the baseline care plan failed to provide directions for care. Findings include: Resident #129 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) and diabetes. Resident #129's baseline care plan had not documented or addressed her mobility assistance needs. Resident #129's nursing progress note dated 4/9/25, documented resident is able to ambulate around facility using her walker. Resident #129's nursing progress note dated 4/10/25, documented resident is a stand by assist with some assistance into bed. Resident using a wheelchair in facility assist X 1 for mobility, she also uses a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure resident's discharge summary included a reconciliation of medications (an accurate list of pre-discharge medications to post-discharge medications by creating an accurate list to prevent unintended changes or omissions at transition points in care). This was true for 1 of 1 resident (Resident #27) reviewed for discharge. This failure created the potential for the receiving facility to not provide appropriate and timely care. Findings include: Resident #27 was admitted to the facility on [DATE], for neuroleptic induced parkinsonism (movement disorder with symptoms like Parkinson's disease as a side effect of taking certain medications) and major depression. On 4/15/25 at 4:02 PM, a record review of Resident #27's Nurse Progress Note, dated 1/15/25, documented resident was here for long term care and decided to move to a different facility. On 4/15/25 at 4:04 PM, Resident #27's Discharge Summary/Recap of Stay documented No -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to employ a certified Activities Director (AD). This failure had the potential to affect residents' quality of life when design of activities appropriate for residents was not implemented. Findings include: During resident council meeting on 4/14/25, residents stated the AD left about a month ago and one of the CNA's stepped in to help with activities. On 4/14/25 at 1:00 PM, the Administrator stated they had not been able to hire a certified AD, so one of the CNA's had been assigned as an interim AD.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined the facility failed to ensure professional standards of care were followed. This was true for 1 of 14 residents (Resident #18) whose records were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status. Findings include: Resident #18 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including left side hemiplegia and hemiparesis following stroke (weakness or the inability to move one side of the body, rather than complete paralysis) and chronic respiratory failure with hypercapnia (caused by an imbalance in the load-capacity-drive relationship of the respiratory muscle pump). A) On 4/13/25 at 12:15 PM, observed Resident #18's left arm had a Lidocaine patch without date or initials of the nurse that applied the patch. On 4/15/25 at 2:20 PM, the DON stated the Lidocaine patch should have be labeled with the date applied and initials of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: On 4/15/25, during review of nurse staffing hours, observed the scheduled and actual hours worked were documented with the number 1 instead of the hours worked on the following dates: - 10/1/24 - 12/9/24 - 12/10/24 - 12/11/24 - 3/15/25 On 4/15/25 at 3:15 PM, the DON stated the hours listed on the nurse staffing hours were both the scheduled and actual worked hours and the use of number 1 on these sheets was done in error.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 4/13/25 at 1:47 PM, during [NAME] hall medication cart audit, observed the narcotic accountability record, dated 4/1/25 to 4/13/25, with nine licensed nurse signatures not documented. On 4/13/25 at 1:54 PM, the DON stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 4/13/25 at 2:03 PM, during East hall medication cart audit, observed the narcotic accountability record, dated 4/1/25 to 4/13/25, with two licensed nurse signatures not documented. On 4/13/25 at 2:05 PM, the DON stated two nurses should have signed the narcotic accountability sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Drugs.com review, Federal Drug Administration review, and staff interview, it was determined the facility failed to ensure residents were monitored appropriately for medication use. This was true for 1 of 5 residents (Resident #2) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring. Findings include: Drugs.com documented Seroquel is an antipsychotic/antimanic agent that has a black box warning related to those with dementia. Seroquel may increase the risk of death in older adults with mental health problems related to dementia. The FDA requires manufacturers to place a black box warning on Seroquel and other antipsychotic drugs, highlighting the increased risk of death in elderly patients with dementia and that these drugs are not approved for the treatment of behavioral symptoms in elderly patients with dementia. Resident #2 was admitted to the facility on [DATE], with multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, policy review, and record review it was determined the facility failed to ensure medications were properly stored in a locked compartment, and controlled medications were stored and kept secure from potential theft and/or diversion. This was true for 1 of 14 residents (Resident #26) and the facility. These deficient practices created the potential for undetected misuse of medications and/or diversion of controlled medications and had the potential to affect all residents who receive medication in the facility. Findings include: The facility Administering Medications policy dated 3/25, documented under Policy Interpretation and Implementation #17, during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. 1. On 4/13/25 at 10:27 AM, observed a bottle labeled Tylenol arthritis at Resident #26's bedside. Bottle contained multiple tablets of medication. On 4/13/25 at 3:30 PM, Resident #26's medical record review had not documented an assessment for self-administration of medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility's Food Receiving and Storage policy dated 3/1/25, under Dry Food Storage documented dry foods and goods are handled and stored in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 1 of 1 residents (Resident #4) reviewed for infection control when staff failed to perform effective hand hygiene during resident cares, and Hoyer lift cleaning between resident use. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The following was observed for hand hygiene. Resident #4 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including epilepsy and neurogenic bladder ( bladder control problems caused by brain, spinal cord, or nerve problems). On 4/15/25 at 11:52 AM, the following was observed in Resident #4's room: - Resident #4 was observed lying in bed, - LPN #1 and DON put on a protective gown and gloves and entered Resident #4's room to change her soiled brief, top, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents receiving a psychotropic medication had resident-specific target behaviors identified and monitored. This was true for 3 of 5 residents (#7, #19 and 34) who were reviewed for unnecessary medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include: 1. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including depression and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Resident #7's quarterly MDS assessment, dated 11/30/19, documented he had severe cognitive impairment, and received anti-depressant medication on 7 of the last 7 days. Resident #7's physician's orders included Fluoxetine Hydrochloride (anti-depressant) 40 mg once a day for depression, ordered on 4/2/18. Resident #7's Behavior care plan documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, policy review, and record review, it was determined facility failed to ensure medications were stored at appropriate temperatures and medications were appropriately labeled. This deficient practice created the potential for harm if residents received medications or vaccinations which had reduced efficacy from improper storage. Findings include: The facility's policy for Medication Storage in the Facility, dated 3/18, documented medications were maintained within the refrigerator temperature ranges of 36 degrees F (Fahrenheit) to 46 degrees F as recommended by the United States Pharmacopoeia (USP) and the Centers for Disease Control (CDC). The policy also documented the facility should maintain a temperature log in the storage area to record temperatures at least once a day. The facility's policy for Storage of Medications, dated 4/07, documented The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On 2/19/20 at 8:59 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to administration of medication for 1 of 5 residents (Resident #34) who was reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the risks and benefits associated with the medications and the right to refuse the medications. Findings include: Resident #34 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses including dementia. Resident #34's physician's order included Donezepil (used to treat confusion related to dementia) HCl (hydrochloride) 10 mg at bedtime, started on 2/12/20. Resident #34's record did not include documentation she consented to the Donezepil, or was informed about beneficial effects and possible side effects of the medication. On 2/20/20 at 11:00 AM, the Administrator said the facility did not obtain consent for Donezepil. Resident #34's record did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure the comprehensive resident-centered care plan included the use of oxygen and smoking. This was true for 2 of 12 residents (#7 and #34) whose comprehensive care plans were reviewed. This failure created the potential for residents to receive inappropriate or inadequate care with subsequent decline in health. Findings include: 1. The facility's Smoking policy, undated, documented any smoking related privileges, restrictions and concerns, such as a need for close monitoring, were noted on the care plan. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including COPD (progressive lung disease characterized by increasing breathlessness). Resident #7's quarterly MDS assessment, dated 11/30/19, documented he had severe cognitive impairment. Resident #7's record included a Smoking Safety Evaluation, dated 4/24/19, which documented he had smoked cigars and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, andresident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 12 residents (#16) reviewed for quality of care. This created the potential for adverse effects or worsening of health status if residents did not receive care and services as ordered by the physician. Findings include: Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus and dementia. Resident #16's quarterly MDS assessment, dated 12/30/19, documented she was cognitively intact. Resident #16's physician's order, dated 2/5/20, directed staff to cleanse her wound on her gluteal cleft with normal saline, pat dry, apply calcium alginate (type of wound dressing) and cover with Allevyn (a border dressing) every two days and as needed. Resident #16's 2/2020 TAR, documented her wound dressing was completed on 2/15/20, 2/17/20, and 2/19/20. On 2/19/20 at 10:05 AM, CNA #2 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations,staff interviews, policy review, and record review, the facility failed to follow current professional standards of nursing practice for 1 of 1 resident (Resident # 5) who had a feeding tube. This deficient practice had the potential to affect resident care and a potential for a negative outcome in the provision of resident care. Findings include: The facility's policy for Maintaining Patency of a Feeding Tube (Flushing), dated 3/15, documented .6. Attach sixty ml catheter tip syringe with 10 to 30 ml (milliliters) of air to tube. Unclamp tube. 7. Verify placement of tube by aspiration. 8. Clamp tube and remove empty syringe. 9. Attach 60 ml catheter tip syringe without plunger to tube. Unclamp tube and unless otherwise ordered, pour 30 ml warm water into syringe. Allow water to flow by gravity into syringe. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (paralysis [loss of the ability to move] of all four limbs) and persistent vegetative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control guidelines during the administration of multi-dose medications and blood sugar monitoring for 2 of 6 residents (Resident # 5 and Resident #21) whose medication administration were observed. This deficient practice created the potential for the spread of infectious organisms from cross contamination. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (paralysis of both arms and legs) and persistent vegetative state (a chronic state in which a person shows no signs of awareness) after a motor-vehicle accident. Resident #5's physician's order, included Lotemax (eye drops) 0.5% to both eyes two times daily for eye pain, ordered on 2/20/20. On 2/19/20 at 9:43 AM, during the medication pass RN #2 opened the multi-dose bottle of Lotemax and placed the open bottle and the lid directly on the resident's bed covers while she administered the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.