Summerset Lincoln Assisted Living and Memory Care

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, facility staff observed R1’s health declining on 12/18/2024. Although facility staff reached out to R1’s responsible party, facility staff did not reach out to R1’s primary physician until 12/24/2024 resulting in a delay in R1 obtaining proper medical care.

Comply with all admission agreement terms

87507 Admission Agreements(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: facility billing for care services which were not rendered between the days of 7/8/2024 and 7/9/2024 including frequent checks (16 per shift) and redirecting regarding exit seeking behavior. This posed an indirect threat to the health and safety of resident in care.

87705(c) (4) Care of Persons with Dementia. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by R1 eloping from facility without staff knowledge. This posed a direct threat to the health and safety of resident in care.

Prohibit false or misleading facility statements

87207 False ClaimsNo licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirement was not met as evidenced by S2 signing the MAR regarding R2's insulin when they were not the one to administer the injection. This poses an indirect threat to the health and safety of residents in care.

Maintain cleanliness and prevent incontinence odors

87625 Managed Incontinence(b) . . .the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by R1 having repeated incontinence in clothing documented by nursing notes and photographs. This poses an indirect threat to the health and safety of residents in care.

87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety. . . This requirement was not met as evidenced by R1 having a Dx of seizures and having repeated falls and wandering. This poses a direct threat to the health and safety of residents in care.

87629 Injections(b) . . . the licensees who admit or retain residents who require injections shall be responsible for the following:(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by allowing an employee who did not have their nursing license administer insulin injections. This poses a direct threat to the health and safety of residents in care.

Protection from punishment and intimidation

Personal Rights of Residents in All Facilities(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by S2 forcefully grabbing R1's hands while performing ADLs. This poses an immediate risk to the health and safety of resident in care.

Regular observation and documentation of resident changes

Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical. . . . the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by R1's POA and doctor not being notified of their catheter not draining. This poses an immediate risk to the health and safety of residents in care.

Basic services requirements(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by R1 sustaining multiple falls. This poses a direct risk to the health and safety of resident in care.

87623 Indwelling Urinary Catheter(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed. This requirement was not met as evidenced by no documentation of staff training related to R1 and their catheter care. This poses an indirect threat to the health and safety of resident in care.

Theft and Loss(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. . . This requirement was not met as evidenced by R1's glasses and lower dentures were lost and R1's POA has not received reimbursement for the items. This poses a potential risk to the health and safety of resident in care.

Limit staff assistance with self-administered drugs

Incidental Medical and Dental CareThe licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:based on interview and MAR document review, resident was not given medication as prescribed. This poses a direct risk to the health and safety of resident in care.

Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports . . (1) A written report shall be submitted to the licensing agency at (D) Any incident which threatens the welfare, safety or health of any resident . . . This requirement was not met as evidnced by no SOC341 or LIC624 submitted to the Ombudsman or Licensing. This poses a potential risk to the health and safety of resident in care.

Regular observation and documentation of resident changes

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes. . . changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by no communication between the facility and R1 regarding R1’s weight loss. This poses a direct threat to the health and safety of resident in care.

Incidental Medical and Dental Care(e) For every prescription and nonprescription PRN medication . . . physician's order and the label shall contain at least all of the following information (2) The exact dosage.This requirement was not met as evidenced by R1’s PRN medication stating to take ½ tablet (25mg) to 1 tablet (50mg) by mouth as needed for insomnia. This poses a direct threat to the health and safety of resident in care.

Incidental Medical and Dental Care(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, (1) Facility staff shall contact the resident's physician prior to each dose This requirement was not met as evidenced by no communication with R1’s physician prior to dispensing the PRN medication to R1. This poses a direct threat to the health and safety of resident in care.

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation of staff, the facility staff are not wearing masks while inside of the facility, which poses a potential health and safety risk to residents in care.