Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincoln Care And Rehab during CMS and state inspections, most recent first.
A CNA was found to be working without a current and valid certification, as confirmed by a review of personnel files and the Nurse Aide Registry. Administrative staff acknowledged the requirement for current certification, but the facility lacked a policy for CNA certificate renewal.
The facility did not complete required annual performance evaluations for two CNAs, as shown by missing documentation in their personnel files. Administrative staff confirmed that annual evaluations were expected, and facility policy supported this requirement.
Surveyors found that food items, including meat and bread, were not stored or dated properly in the kitchen. Open bags of meat were left unsealed, some food was stored on the floor, and several items lacked required date labeling. Moldy bread was also found past its expiration date, and food debris was present on the freezer floor.
A review of CNA training records found that some staff did not receive required in-service education, including dementia care, and lacked documentation of the mandated annual training hours. Facility policy required at least 12 hours of continuing education per year for nurse aides, but records and interviews confirmed this standard was not met.
Several residents were not invited to participate in their care plan meetings, and there was no documentation of such meetings in their records for the past six months. Staff interviews confirmed that care plan invitations had not been sent since the departure of the Clinical Reimbursement Coordinator, contrary to facility policy requiring resident and family involvement in care planning.
Surveyors observed multiple areas of disrepair and lack of cleanliness, including exposed concrete in a bathroom, missing vent covers, unmade beds stored in a resident's room, and missing tiles and baseboards throughout the facility. Staff interviews confirmed that these issues had persisted for weeks and that maintenance was unable to complete repairs due to shifting priorities and lack of clear direction. The facility did not provide a policy for maintaining a homelike environment.
The facility did not ensure that a CPR-certified staff member was present at all times for residents with Full Code status. A nurse held a CPR certificate without a hands-on component, and a CNA responsible for transporting a resident with Full Code status had an expired CPR card. The facility lacked a system to track and guarantee CPR-certified staff coverage on each shift, despite policy requirements.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during tube feeding care, resident transfers, and peri-care. A nurse and certified nurse aides failed to use gowns and did not disinfect equipment or perform proper hand hygiene between tasks, placing residents at risk for infection.
A resident with severe cognitive impairment and multiple diagnoses had a DNR order in the medical record that was only signed by a physician, lacking the required signature from the resident or their representative. Facility staff confirmed the DNR was incomplete and not valid, and no policy for advance directives was provided.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was given a PRN antianxiety medication repeatedly without a required 14-day stop date or documented physician rationale for extended use. Facility records and staff interviews confirmed the absence of a specified duration for the medication, in violation of facility policy for psychotropic drugs.
The facility did not consistently provide written bed hold policies or timely written notifications of transfer to residents or their representatives during hospitalizations. In several cases, required documentation was missing from the EHR, and staff reported that bed hold forms were sometimes sent unsigned or handled after the transfer, with forms kept outside the EHR.
Three residents had inaccurate MDS assessments, including failure to document CPAP use for a resident with sleep apnea, omission of dental and vision issues for a resident with a history of stroke and dental problems, and incorrect recording of insulin and ventilator use for a resident who did not receive these treatments. These discrepancies were confirmed through care plans, physician orders, staff interviews, and resident observations.
A resident with type 2 diabetes had blood glucose readings above 400 mg/dL on two occasions, but staff did not notify the physician as required by orders and facility policy. Interviews confirmed that nurses were expected to report such results, yet documentation and notification were lacking.
A resident with blindness and a history of schizophrenia did not receive consistent assistance with personal hygiene, specifically facial hair removal, as required by her care plan. Staff interviews revealed inconsistent practices, and documentation of personal hygiene was missing from the EHR. The facility lacked a policy on ADL assistance for dependent residents, resulting in unmet grooming needs.
A resident with a history of stroke and visual impairment did not receive or was not offered vision services, despite a physician's order and her own request for an eye exam. Facility staff could not provide documentation that services were offered or declined, and the resident reported never having received eyeglasses during her stay.
Staff did not properly clean and store respiratory care equipment for two residents, including a nebulizer and a CPAP mask. One resident's nebulizer was left uncleaned and not stored according to policy, while another resident's CPAP mask was left exposed to open air after use. Facility policies and care plans lacked necessary details or were not followed, resulting in unsanitary handling of respiratory devices.
A resident with severe dementia, depression, and anxiety exhibited aggressive and disruptive behaviors, required total assistance with daily living, and was prescribed multiple psychotropic medications. Despite these needs, the care plan lacked interventions for dementia care, and there was no documentation of nonpharmacological approaches or a facility policy for dementia care. Staff and administrative interviews confirmed the absence of appropriate care planning and interventions.
A resident with diabetes, end-stage renal disease, and anxiety did not have pharmacist-identified medication regimen irregularities or recommended lab work appropriately addressed. The facility lacked documentation of physician or nurse responses to the pharmacist's reports, and required lab monitoring for diabetes was not completed as ordered. Facility policy for handling medication review irregularities was not followed.
A resident with a history of depression and stroke, dependent on staff for daily care and with documented dental health problems, did not receive or was not offered dental services despite facility policy and care plan directives. Staff interviews and record review confirmed no evidence of dental care being arranged or declined, and the resident reported never being assessed for dental needs, resulting in ongoing dental decay.
A resident with dysphagia and dementia was served cut-up chicken instead of her prescribed mechanical soft diet, leading to a choking incident. Despite care plans and physician orders specifying a ground meat texture, staff failed to provide the correct diet, resulting in the resident being hospitalized for pneumonia and dehydration. Interviews revealed systemic issues in dietary practices and supervision during meals.
A resident with dementia and a history of homelessness was at risk for elopement, but the facility failed to include this risk in the care plan. Despite wearing a Wander Guard initially, the care plan lacked interventions for elopement, and the resident was able to leave the facility without staff knowledge. The facility's policy required a comprehensive care plan based on thorough assessments, which was not followed in this case.
A cognitively impaired resident at moderate risk for elopement exited a facility without staff knowledge when a CNA opened the door for another resident. The resident, who had a history of dementia and depression, refused to wear a Wander Guard, and the care plan lacked interventions for elopement risk. Staff had to retrieve the resident using a vehicle after he left the facility.
Failure to Ensure CNA Maintained Current Certification
Penalty
Summary
The facility failed to ensure that one Certified Nurse Aide (CNA) maintained a current and valid certification. Review of personnel files showed that the CNA was hired in May 2022, but there was no evidence of a current CNA certificate in the file. Further review of the Nurse Aide Registry confirmed that the CNA's status had been inactive since June 2023. During an interview, administrative staff acknowledged the expectation that all CNAs should have current certification. The facility was unable to provide a policy regarding the renewal of CNA certification.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Aides (CNAs) within the required 12-month period. Specifically, a review of personnel files showed that one CNA, hired in May 2022, and another CNA, hired in February 2020, did not have documentation of a performance evaluation conducted in the last 12 months. During an interview, administrative staff confirmed the expectation that all CNA staff should have annual performance evaluations completed. The facility's employee handbook also documented the importance of regular performance reviews as part of their performance management process.
Failure to Store and Date Food Items Properly in Kitchen
Penalty
Summary
Surveyors observed that food items in the facility's kitchen were not stored in a sanitary manner. Specifically, a bag of beef patties was found in the freezer with the plastic bag left open, and two bags of chicken in a store bag were placed on the floor of the refrigerator. The freezer floor had visible food debris, and numerous bags of vegetables and sandwich meat lacked a date received. Additionally, nine loaves of bread with an expiration date of 02/22/25 were found with mold growing on them. The Dietary Manager confirmed that staff were expected to date all food items with the open date, expiration date, and date received, and to rotate stock using the first-in, first-out method, but these procedures were not followed as observed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training, including education on dementia care and abuse prevention, as mandated by facility policy and regulatory requirements. A review of training records for five CNAs revealed that at least two CNAs did not have documentation of dementia training, and one CNA's file lacked evidence of the total number of in-service hours completed. The facility's policy required all nurse aides to participate in at least 12 hours of continuing education annually, including dementia management. During an interview, administrative staff confirmed the expectation for staff to complete the required education and annual training hours.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development and implementation of their person-centered care plans. Multiple residents reported during interviews that they had never been invited to a care plan meeting and were unaware of what such meetings entailed. Review of the electronic health records for these residents confirmed the absence of documentation indicating that care plan meetings had been conducted in the past six months. Further investigation revealed that the staff member responsible for sending care plan meeting invitations had not done so since the departure of the Clinical Reimbursement Coordinator in October 2024. The Social Service Designee acknowledged that no invitations had been sent to residents or their responsible parties since that time. Facility policy requires that residents and their families be encouraged to participate in care planning, but this was not followed, as confirmed by both staff interviews and record review.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness throughout the building. Surveyors noted several patches of white plaster on hallway walls and entrance doors, chipped floor tiles in resident hallways, and holes in the bathroom flooring of a resident's room exposing the concrete underneath. Additionally, a grab bar in the same bathroom was covered with frayed, worn duct tape. In another room, an air conditioning vent cover was missing from the ceiling and was found on a nightstand, and three beds were present, two of which were unmade and had a rolled-up air mattress on them. Staff interviews confirmed that the vent cover had been off for about a month and that the beds had recently been placed in the room for storage due to ongoing repairs elsewhere in the facility. Further observations revealed missing tiles and baseboards in the beauty shop and adjacent hallway, as well as partially painted bathroom floors and missing door trim in other rooms. Maintenance staff acknowledged awareness of these issues but reported difficulty completing repairs due to being redirected to other tasks and uncertainty about required materials. Housekeeping and medication aide staff confirmed the ongoing nature of these environmental concerns. The facility did not provide a policy regarding the maintenance of a homelike environment.
Failure to Ensure Presence of CPR-Certified Staff for Full Code Residents
Penalty
Summary
The facility failed to ensure that at least one staff member certified in cardiopulmonary resuscitation (CPR) was present at all times for residents who had chosen Full Code status. Review of staff records showed that one licensed nurse held a CPR certification from an online provider that did not include a hands-on skills component, contrary to facility policy. Additionally, the staff schedule did not identify which staff were CPR-certified for each shift, and there was no system in place to guarantee that a CPR-certified staff member was always present. A certified nurse aide responsible for transporting a resident with Full Code status to and from dialysis appointments did not have a current CPR certification, as her card had expired. Interviews with administrative staff confirmed that the facility did not track or ensure the presence of CPR-certified staff on each shift, and that some staff may not have completed the required hands-on component of CPR training. The facility's policy required staff to maintain current CPR certifications with a hands-on session and to have CPR-certified staff available 24 hours a day.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
Staff failed to maintain effective infection control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene. During tube feeding care for a resident who had pulled out their feeding tube, a licensed nurse did not wear a gown as required by EBP protocols. In another instance, two certified nurse aides transferred a resident using a mechanical lift and provided a shower without donning gowns for EBP. After using the Hoyer lift, staff did not disinfect the equipment before moving it into the hallway. Additionally, a certified nurse aide provided peri-care to a resident and changed their brief while wearing the same soiled gloves, then handled the bedpan and continued care without performing hand hygiene between glove changes. The aide later acknowledged that handwashing should have occurred after glove removal and before continuing care. The facility's policy required appropriate precautions for residents with multidrug-resistant organisms (MDROs) and adherence to EBP, but these protocols were not consistently followed during observed care activities.
Incomplete DNR Documentation for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically a Do Not Resuscitate (DNR) order, was thoroughly completed and valid. The resident in question had diagnoses of dementia, depression, and anxiety, with severely impaired cognition as documented by low BIMS scores on multiple Minimum Data Set (MDS) assessments. The resident was dependent on staff for all activities of daily living and was receiving hospice services. The resident's care plan and physician orders documented a DNR, but the only DNR form available in the electronic health record was a hospice-based form signed solely by the physician, lacking the required signature from the resident or the resident's representative. Interviews with facility staff confirmed that the DNR form in the record was incomplete and not valid, as it did not include the necessary signature from the resident or their durable power of attorney (DPOA), nor was it witnessed. The facility was unable to provide a policy for advance directives. This incomplete documentation resulted in the resident's advance directive not being properly honored according to regulatory requirements.
Failure to Ensure Required Stop Date for PRN Antianxiety Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses of dementia, depression, and anxiety was administered a PRN (as-needed) antianxiety medication without a required 14-day stop date or a specified duration, and without documentation of the physician's rationale for extended use. The resident's electronic health record showed severely impaired cognition and dependence on staff for activities of daily living. The resident's care plan included directions for medication administration and monitoring, but the PRN order for Ativan lacked a stop date as required by facility policy. Review of the resident's records revealed that the PRN Ativan was ordered and administered multiple times over a period exceeding 14 days, with no evidence in the electronic health record of a specified duration or physician's rationale for continued use. The medication regimen review initially did not identify irregularities, but a subsequent review noted the missing stop date. Despite this, the medication continued to be administered without the required documentation. Interviews with nursing staff indicated a lack of clarity regarding which PRN medications required stop dates. The facility's policies specified that as-needed psychotropic medications should be limited to 14 days unless a longer duration is justified and documented by the physician. The failure to include a stop date or physician's rationale for the extended use of the PRN antianxiety medication constituted the deficiency.
Failure to Provide Timely Bed Hold Policy and Transfer Notification
Penalty
Summary
The facility failed to provide written bed hold policies and timely written notifications of transfers for three residents who were hospitalized. Review of the electronic health records (EHR) for these residents showed no evidence that bed hold notices or written notifications of transfer were provided to the residents or their representatives at the time of transfer. Specifically, one resident was transferred to the hospital on multiple occasions without documentation of the required notifications, and another resident's transfer lacked a signed bed hold form for one of the hospitalizations. Staff interviews revealed that, in practice, bed hold forms were sometimes sent unsigned with residents during emergency transfers, and follow-up for signatures was handled later, with forms kept in a separate folder rather than uploaded to the EHR. The facility's policy required informing residents of the bed hold policy upon admission and prior to transfer, including any charges and Medicaid time limits. However, the process described by staff did not consistently ensure that residents or their representatives received or signed the bed hold forms at the time of transfer, particularly during emergencies. Additionally, the required information was not always documented in the EHR as expected by facility leadership, resulting in incomplete records of notification and policy provision.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual care needs and what was documented. For one resident with a diagnosis of obstructive sleep apnea, the MDS did not indicate the use of a CPAP machine, despite physician orders, care plan documentation, and staff confirmation that the resident used a CPAP at night. The facility did not provide a policy on accurate MDS assessment. Another resident with major depressive disorder and a history of stroke had inconsistencies in the MDS regarding oral and vision care. The MDS documented no dental or vision issues, while the care plan and resident interview revealed significant dental problems, a need for mouth care assistance, and a visual deficit. The resident reported never being assessed by a dentist and not having eyeglasses, despite needing them, and observations confirmed broken teeth and visual impairment. A third resident with schizophrenia and anxiety was incorrectly documented in the MDS as receiving insulin, hypoglycemic medication, and using a non-invasive mechanical ventilator. However, the care plan, physician orders, and resident interview confirmed that the resident had never received insulin, was not diabetic, and had only used oxygen via nasal cannula. The facility did not provide a policy on accurate MDS assessment for any of the cases.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
Staff failed to follow physician orders and facility policy regarding the notification of blood glucose levels for a resident with type 2 diabetes mellitus. The resident's care plan and physician orders required staff to notify the physician if blood sugar readings were greater than 400 mg/dL or less than 60 mg/dL. Despite this, the electronic medical record showed that on two separate occasions, the resident's blood glucose levels exceeded 400 mg/dL (418 mg/dL and 409 mg/dL), and there was no documentation that the physician was notified as required. Interviews with licensed nurses and the administrative nurse confirmed that the standard practice and expectation was to contact the physician for blood sugars above 400 mg/dL, in accordance with the orders. The facility's policy also emphasized timely and effective communication of significant changes in resident status to the medical staff. However, the lack of documentation and notification in these instances demonstrated a failure to meet professional standards of care for the resident.
Failure to Provide Consistent ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically grooming of facial hair, for a resident who was blind and required help with personal care. The resident had diagnoses including blindness in both eyes and paranoid schizophrenia, and her care plan directed staff to provide cueing and set-up assistance with personal hygiene. Observations over several days revealed that the resident had prominent beard stubble and yellow crusty drainage on her eyes, and she reported that staff only cleaned her face during showers. Documentation of personal hygiene tasks was missing from the electronic health record. Interviews with staff indicated inconsistent practices regarding facial hair removal, with some staff performing the task and others not. Staff reported that facial hair should be removed on shower days or when requested, but the resident, due to her blindness, did not typically request this care. The facility did not provide a policy on ADL assistance for dependent residents. These actions and omissions resulted in the resident not receiving grooming care in accordance with her needs and preferences.
Failure to Facilitate Access to Vision Services for Resident with Visual Impairment
Penalty
Summary
A deficiency was identified when the facility failed to provide or facilitate access to visual services for a resident with impaired visual function. The resident had a history of major depressive disorder and cerebrovascular accident, resulting in a left-sided visual deficit. Despite having a physician's order allowing for specialist visits, including an eye doctor, there was no evidence in the electronic health record (EHR) that visual services were offered or facilitated, nor was there documentation that the resident declined such services. The resident reported requesting an eye exam and stated she could not read without glasses, yet had never received eyeglasses during her stay at the facility. Interviews with facility staff revealed that when a resident requested vision services, the process involved documenting the request in the EHR or informing the Social Services Designee (SSD). However, the SSD could not locate any documentation of a declined consent or progress note regarding visual services for this resident. The facility's policy required the provision of necessary care and services, including assistance with making vision appointments, but this was not followed in the resident's case. The lack of action placed the resident at risk for further deterioration of vision.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
Staff failed to provide sanitary respiratory care for two residents requiring respiratory devices. For one resident with a history of pneumonia and moderate cognitive impairment, the nebulizer was observed attached to tubing on the bedside table with liquid remaining in the chamber and had not been separated or rinsed after use. Staff interviews confirmed that the nebulizer should have been cleaned after each treatment, and facility policy required washing, rinsing, disinfecting, and proper storage of the nebulizer equipment after each use. However, these procedures were not followed, and the resident's care plan did not include information regarding nebulizer use. For another resident diagnosed with obstructive sleep apnea and using a CPAP device, the CPAP mask was observed left attached to the tubing and exposed to open air on the bedside table after use on multiple occasions. The resident's care plan documented CPAP use, but the facility's policy did not address cleaning and storage procedures for the CPAP mask. Staff interviews indicated that the expectation was for the mask to be cleaned and stored in a bag after each use, but this was not done.
Failure to Provide Nonpharmacological Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate nonpharmacological dementia care and services to a resident diagnosed with dementia, depression, and anxiety. The resident had severely impaired cognition, as evidenced by low BIMS scores, and required total dependence for activities of daily living such as toileting, personal hygiene, and footwear. The resident also exhibited fluctuating behaviors, disorganized thinking, and frequent rejection of care. Despite these needs, the resident's care plan lacked specific interventions to address dementia care, and there was no facility policy provided for dementia care. The resident was prescribed multiple psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents, and was monitored for behavioral symptoms. However, the Medication Administration Records for April and May did not document occurrences of behavioral symptoms or the use of nonpharmacological interventions, despite the resident displaying frequent crying, repetitive movements, yelling, aggression, and resistance to care. Progress notes indicated that the resident had difficulty participating in activities, was not easily redirected, and sometimes became aggressive during care, requiring staff intervention and medication administration. Observations and staff interviews confirmed that the resident engaged in aggressive and disruptive behaviors, such as attempting to slap a surveyor, grabbing another resident's walker, and self-transferring, which required frequent staff redirection. Staff reported that care plans typically guide interventions, but in this case, the care plan did not address the resident's dementia needs. Administrative staff acknowledged the omission, and the facility did not provide a policy for dementia care when requested.
Failure to Act on Pharmacist Medication Review and Lab Orders
Penalty
Summary
The facility failed to act upon the pharmacist's monthly medication regimen review (MRR) for a resident with diagnoses including diabetes mellitus, end-stage renal disease, and anxiety. The resident's care plan included the use of antidepressant and antianxiety medications, but lacked documentation of non-pharmacological interventions. The MRRs for multiple months indicated irregularities and referenced reports, but the electronic health record (EHR) did not contain the actual reports or any documented responses from the physician or nursing staff. Additionally, the pharmacist requested a hemoglobin A1c (HbA1c) lab draw to monitor diabetes management, but the lab was not completed as ordered, and the last available result was outdated. Interviews with administrative nursing staff revealed that the resident refused lab draws at the facility, expecting them to be completed at the dialysis center, which did not occur. The administrative nurse was unable to locate the missing MRRs and confirmed that follow-up on the pharmacist's recommendations was not documented. Facility policy required that irregularity reports be provided to the physician for review and that any actions or rationale for no change be documented, but this process was not followed for the resident in question.
Failure to Provide or Facilitate Dental Services for Resident with Dental Decay
Penalty
Summary
The facility failed to provide or facilitate access to dental services for a resident with widespread dental decay. The resident had a history of major depressive disorder, cerebrovascular accident, and was dependent on staff for several activities of daily living, including requiring set-up assistance for oral care. Despite care plan documentation indicating oral and dental health problems and directing staff to coordinate dental care, there was no evidence in the electronic health record that dental services were offered or facilitated, nor that the resident had declined such services. The resident reported that no staff had asked about dental assessment since admission and described having several broken teeth, which was confirmed by observation. Interviews with facility staff revealed that the process for arranging dental appointments involved documentation in the EHR or verbal communication with social services, but there was no record of this occurring for the resident in question. The social services designee stated that residents must sign a consent or declination for dental services, but no such documentation could be found for this resident. The facility's policy required an initial dental evaluation upon admission, but this was not completed for the resident, resulting in a lack of dental care despite clear need.
Failure to Provide Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide a cognitively impaired resident, identified as R2, with her prescribed mechanical soft diet, which led to a choking incident. R2, who had diagnoses of dysphagia and dementia, was served cut-up chicken instead of the required ground meat texture. This error occurred despite R2's care plan and physician orders specifying a mechanical soft diet with ground meat due to her swallowing difficulties. On the day of the incident, R2 began to cough and choke on her food, requiring staff intervention to clear her airway. The resident was subsequently transferred to the hospital and admitted for fever, pneumonia, and dehydration. Interviews with staff revealed that dietary and nursing staff were not consistently present in the dining room to ensure residents received the correct diet consistency. Dietary Staff F and Dietary Staff I admitted to serving R2 cut-up meat instead of ground meat, as they were instructed to do so based on previous practices. It was noted that R2 had been receiving chopped meat for her meals many times prior to the choking episode, indicating a systemic issue in adhering to prescribed dietary orders. The facility's policies on therapeutic diets and tray identification were not followed, as nursing staff failed to verify the correct diet before serving the resident. The lack of oversight and communication between dietary and nursing staff contributed to the incident, placing R2 and potentially other residents at risk. The deficiency was identified as an immediate jeopardy situation, highlighting the critical need for adherence to dietary orders and proper supervision during meal times.
Failure to Develop Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R3, who was at risk for elopement. R3 had a history of dementia and depression, with a moderately impaired cognition score. Despite wearing a Wander Guard initially, the care plan did not include interventions for elopement risk, and there were no physician orders for the Wander Guard at the time of R3's elopement. The resident had previously expressed a desire to leave the facility and had a history of homelessness, which was documented in the progress notes. The facility's records showed that R3's Wander Guard was discontinued after he was no longer exit-seeking, but later progress notes indicated that R3 expressed a desire to leave again. Despite these indications, the care plan was not updated to reflect the elopement risk until after R3 had already left the facility. Staff interviews revealed that the care plan lacked documentation of elopement risk and Wander Guard use until after the incident occurred. The facility's policy required a comprehensive care plan based on thorough assessments, including the MDS and physician orders, but this was not adhered to in R3's case. The failure to include elopement risk in the care plan placed R3 at risk for inadequate care and services, as evidenced by the resident's ability to leave the facility without staff knowledge or supervision.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired, independently mobile resident identified as a moderate risk for elopement. The resident, who had a history of dementia and depression, exited the facility without staff knowledge when a Certified Nurse Aide (CNA) opened the exit door for another resident. The resident was previously assessed as having a low risk for elopement, and the care plan lacked interventions related to the resident's elopement risk. The resident had a history of refusing to wear a Wander Guard, a bracelet that sets off an alarm when residents attempt to exit the building without an escort. Despite previous incidents where the resident expressed a desire to leave the facility, the Wander Guard was not consistently used or documented in the resident's care plan. On the day of the incident, the resident exited the facility, and staff had to retrieve him using a vehicle. Interviews with staff revealed that the resident had made comments about wanting to leave the facility and had previously removed the Wander Guard. The facility's policy on elopement was not effectively implemented, as the resident's risk was not adequately assessed or documented, and the necessary precautions were not taken to prevent the elopement.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount St Mary | 0.3 mi | ★★★★★ | 0 | 0 |
| Orchard Gardens | 1.5 mi | ★★★★★ | 7 | 0 |
| Life Care Center Of Wichita | 1.9 mi | ★★★★★ | 0 | 0 |
| Medicalodges Wichita | 2 mi | ★★★★★ | 21 | 0 |
| Legacy At College Hill | 3.6 mi | ★★★★★ | 17 | 1 |
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