Health inspection·April 18, 2025

The following reflects the findings of the California Department of Public Health during a recertification survey of Lincoln Glen Skilled Nursing, conducted from 3/17/2025 to 3/24/2025. Survey findings included the investigations of two Facility Reported Incidents, CA00898247 and CA00904624. Event ID: JBV211. The resident census at the time of survey was 51. The total final sample size was 14. An "F" level deficiency was identified (see F700). During the survey, substandard quality of care was cited at F700, which resulted in an extended survey. A "Class B" citation was issued for the following violation: F700 §483.25(n) Bed Rails. The facility must assure ongoing monitoring and supervision: Assuring the correct use of an installed bed rail and maintenance of bed rails is an essential component in reducing the risk of injury. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care to the resident in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to, the following information: • The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring; • The identification of how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene; and • Ongoing assessment to assure that the bed rail is used to meet the resident's needs. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. From 3/17/25 to 3/24/25, an unannounced visit was conducted at the facility for a recertification survey and to investigate two Facility Reported Incidents. Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 22 (Residents 35, 9, 24, 15, 14, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 253, 38, 37, 1, 50 and 11) of 22 residents who used side or bed rails when: 1. Twenty-two (22) of 22 residents who used side or bed rails were without care plans; 2. The risks of entrapment prior to the installation of side or bed rails were not assessed for 22 of 22 residents who used bed rails; and 3. The bed rail assessments were not updated in a timely manner for 18 of 22 residents (Residents 35, 9, 24, 15, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 38, 37 and 11). These failures had the potential to place the residents at risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and injury. Findings: 1a. During the observation of Resident 35, on 3/17/25 at 2:18 p.m., Resident 35 was in bed, confused and could not answer questions. Resident 35's bilateral (both sides) side rails were up. During the concurrent observation of Resident 35 and interview with registered nurse C (RN C), on 3/21/25 at 4:22 p.m., Resident 35 was laying in her bed and her bilateral side rails were up. RN C verified that Resident 35's bilateral side rails were up. Review of Resident 35's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 35 was admitted to the facility on 2/7/23. Review of Resident 35's physician orders indicated, Resident 35's side rails were ordered on 2/6/24. Review of Resident 35's care plans indicated, Resident 35 did not have a care plan for her side rails. 1b. During the observation of Resident 9 on 3/17/25 at 12:44 p.m., Resident 9 was in bed eating his lunch, and he was alert, calm, and verbally responsive. Resident 9's bilateral side rails were up. During the concurrent observation of Resident 9 and interview with RN C, on 3/21/25 at 4:25 p.m., Resident 9 was in his bed and his bilateral side rails were up. RN C verified that Resident 9's bilateral side rails were up, and Resident 9 was using those side rails. Review of Resident 9's admission record, indicated, Resident 9 was admitted to the facility on 8/19/22. Review of Resident 9's physician orders indicated, Resident 9's side rails were ordered on 2/29/24. Review of Resident 9's care plans indicated, Resident 9 did not have a care plan for his side rails. 1c. During the observation of Resident 24 on 3/17/25 at 1:48 p.m., Resident 24 was in her room, alert, comfortable and verbally responsive. Resident 24's bilateral side rails were up. During the concurrent observation of Resident 24 and interview with RN C on 3/21/25 at 4:27 p.m., Resident 24 was in her room and her bilateral side rails were up. RN C verified that Resident 24's bilateral side rails were up, and Resident 24 was using those side rails. Review of Resident 24's admission record, indicated, Resident 24 was initially admitted to the facility on 4/7/21. Review of Resident 24's physician orders indicated, Resident 24's side rails were ordered on 3/14/24. Review of Resident 24's care plans indicated, Resident 24 did not have a care plan for her side rails. 1d. During the observation of Resident 15 on 3/17/25 at 1:48 p.m., Resident 15 was alert, comfortable and verbally responsive. Resident 15's bilateral side rails were up. During the concurrent observation of Resident 15 and interview with RN C on 3/21/25 at 4:30 p.m., Resident 15 was in her room and her bilateral side rails were up. RN C verified that Resident 15's bilateral side rails were up and were used by Resident 15. Review of Resident 15's admission record, indicated, Resident 15 was readmitted to the facility on 8/23/24. Review of Resident 15's physician orders indicated, Resident 15's side rails were ordered on 8/24/24. Review of Resident 15's care plans indicated, Resident 15 did not have a care plan for her side rails. 1e. During the observation of Resident 14 on 3/17/25 at 1:54 p.m., Resident 14's bilateral side rails were up. During the concurrent observation of Resident 14 and interview with RN C on 3/21/25 at 4:32 p.m., Resident 14 was in her bed, confused and unable to answer questions. Resident 14's bilateral side rails were up. RN C verified that Resident 14's bilateral side rails were up. Review of Resident 14's admission record, indicated, Resident 14 was admitted to the facility on 2/4/22. Review of Resident 14's physician orders indicated, Resident 14's side rails were ordered on 5/8/22. Review of Resident 14's care plans indicated, Resident 14 did not have a care plan for her side rails. 1f. During the observation of Resident 8 on 3/17/25 at 2:00 p.m., Resident 8's bilateral side rails were up. During the concurrent observation of Resident 8 and interview with RN C on 3/21/25 at 4:35 p.m., Resident 8 was in her bed, alert, calm, comfortable and verbally responsive. Resident 8's bilateral side rails were up. RN C verified that Resident 8's bilateral side rails were up and used by Resident 8. Review of Resident 8's admission record, indicated, Resident 8 was admitted to the facility on 3/24/17. Review of Resident 8's physician orders indicated, Resident 8's side rails were ordered on 2/6/24. Review of Resident 8's care plans indicated, Resident 8 did not have a care plan for her side rails. 1g. During the observation of Resident 19 on 3/17/25 at 2:05 p.m., Resident 19's bilateral side rails were up. During the concurrent observation of Resident 19 and interview with RN C on 3/21/25 at 4:38 p.m., Resident 19 was sitting in the chair, alert, comfortable and verbally responsive. Resident 19's bilateral side rails were up. RN C verified that Resident 19's bilateral side rails were up and used by Resident 19. Review of Resident 19's admission record, indicated, Resident 19 was readmitted to the facility on 2/14/24. Review of Resident 19's physician orders indicated, Resident 19's side rails were ordered on 2/17/24. Review of Resident 19's care plans indicated, Resident 19 did not have a care plan for her side rails. 1h. During the observation of Resident 16 on 3/17/25 at 2:08 p.m., Resident 16's bilateral side rails were up. During the concurrent observation of Resident 16 and interview with RN C on 3/21/25 at 4:42 p.m., Resident 16 was sitting in the chair, alert, comfortable and verbally responsive. Resident 16's bilateral side rails were up, and RN C verified that Resident 16's bilateral side rails were up and used by Resident 16. Review of Resident 16's admission record, indicated, Resident 16 was admitted to the facility on 1/18/23. Review of Resident 16's physician orders indicated, Resident 16's side rails were ordered on 2/6/24. Review of Resident 16's care plans indicated, Resident 16 did not have a care plan for her side rails. 1i. During an observation on 3/17/25 at 9:33 a.m., Resident 10 was seated in a wheelchair, asleep, with bilateral upper bed rails raised. 1j. During an observation on 3/17/25 at 9:43 a.m., Resident 21 was lying in bed, asleep, with both upper bed rails raised. 1k. During an observation on 3/17/25 at 9:44 a.m., Resident 7 was lying in bed, asleep, with both upper bed rails raised. 1l. During an observation on 3/17/25 at 9:57 a.m., Resident 13 was awake, seated in a wheelchair, with both upper bed rails raised. 1m. During an observation on 3/17/25 at 9:58 a.m., Resident 29 was asleep in bed, with both upper bed rails raised. 1n. During an observation on 3/17/25 at 12:28 p.m., Resident 30 was seated in a wheelchair, eating lunch, with bilateral upper bed rails raised. 1o. During an observation on 3/17/25 at 12:30 p.m., Resident 33 was not in the room, but both bilateral upper bed rails were raised. 1p. During an observation on 3/18/25 at 11:16 a.m., Resident 39 was seated in a wheelchair, watching TV, with a caregiver in the room. Both upper bed rails were raised. A review of the clinical records for Residents 10, 21, 7, 13, 29, 30, 33, and 39 indicated that their care plans did not address the use of bed rails. 1q. During an observation on 3/19/25, at 3:09 p.m., Residents 253, 38, 37, 1, 50 and 11 had bilateral (two sides) bed rails. Review of the care plans of Residents 253, 38, 37, 1, 50 and 11 indicated, they did not have the care plans for their bed rails. During the concurrent review of the resident care plans and interview with the director of nursing (DON) on 3/20/25 at 4:00 p.m., DON acknowledged that these 22 of 22 residents who were using side rails, (Residents 35, 9, 24, 15, 14, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 253, 38, 37, 1, 50 and 11), did not have care plans for their side rails and facility will update their care plans. 2a. Review of Resident 35's admission record indicated, Resident 35 was admitted to the facility on 2/7/23. Review of Resident 35's physician orders indicated, Resident 35's side rail was ordered on 2/6/24. Review of Resident 35's clinical records indicated, there was no documentation that Resident 35 was assessed for the risks of entrapment prior to the installation of her bed rails. 2b. Review of Resident 9's admission record, indicated, Resident 9 was admitted to the facility on 8/19/22. Review of Resident 9's physician orders indicated, Resident 9's side rail was ordered on 2/29/24. Review of Resident 9's clinical records indicated, there was no documentation that Resident 9 was assessed for the risks of entrapment prior to the installation of his bed rails. 2c. Review of Resident 24's admission record, indicated, Resident 24 was initially admitted to the facility on 4/7/21. Review of Resident 24's physician orders indicated, Resident 24's side rail was ordered on 3/14/24. Review of Resident 24's clinical records indicated, there was no documentation that Resident 24 was assessed for the risks of entrapment prior to the installation of her bed rails. 2d. Review of Resident 15's admission record, indicated, Resident 15 was readmitted to the facility on 8/23/24. Review of Resident 15's physician orders indicated, Resident 15's side rail was ordered on 8/24/24. Review of Resident 15's clinical records indicated, there was no documentation that Resident 15 was assessed for the risks of entrapment prior to the installation of her bed rails. 2e. Review of Resident 14's admission record, indicated, Resident 14 was admitted to the facility on 2/4/22. Review of Resident 14's physician orders indicated, Resident 14's side rail was ordered on 5/8/22. Review of Resident 14's clinical records indicated, there was no documentation that Resident 14 was assessed for the risks of entrapment prior to the installation of her bed rails. 2f. Review of Resident 8's admission record, indicated, Resident 8 was admitted to the facility on 3/24/17. Review of Resident 8's physician orders indicated, Resident 8's side rail was ordered on 2/6/24. Review of Resident 8's clinical records indicated, there was no documentation that Resident 8 was assessed for the risks of entrapment prior to the installation of her bed rails. 2g. Review of Resident 19's admission record, indicated, Resident 19 was readmitted to the facility on 2/14/24. Review of Resident 19's physician orders indicated, Resident 19's side rail was ordered on 2/17/24. Review of Resident 19's clinical records indicated, there was no documentation that Resident 19 was assessed for the risks of entrapment prior to the installation of her bed rails. 2h. Review of Resident 16's admission record, indicated, Resident 16 was admitted to the facility on 1/18/23. Review of Resident 16's physician orders indicated, Resident 16's side rail was ordered on 2/6/24. Review of Resident 16's clinical records indicated, there was no documentation that Resident 16 was assessed for the risks of entrapment prior to the installation of her bed rails. 2i. During an observation on 3/17/25 at 9:33 a.m., Resident 10 was seated in a wheelchair, asleep, with bilateral upper bed rails raised. 2j. During an observation on 3/17/25 at 9:43 a.m., Resident 21 was lying in bed, asleep, with both upper bed rails raised. 2k. During an observation on 3/17/25 at 9:44 a.m., Resident 7 was lying in bed, asleep, with both upper bed rails raised. 2l. During an observation on 3/17/25 at 9:57 a.m., Resident 13 was awake, seated in a wheelchair, with both upper bed rails raised. 2m. During an observation on 3/17/25 at 9:58 a.m., Resident 29 was asleep in bed, with both upper bed rails raised. 2n. During an observation on 3/17/25 at 12:28 p.m., Resident 30 was seated in a wheelchair, eating lunch, with bilateral upper bed rails raised. 2o. During an observation on 3/17/25 at 12:30 p.m., Resident 33 was not in the room, but both bilateral upper bed rails were raised. 2p. During an observation on 3/18/25 at 11:16 a.m., Resident 39 was seated in a wheelchair, watching TV, with a caregiver in the room. Both upper bed rails were raised. A review of the clinical records for Residents 10, 21, 7, 13, 29, 30, 33, and 39 showed that the facility did not assess the risk of entrapment before installing bed rails. 2q. During an observation on 3/19/25, at 3:09 p.m., Residents 253, 38, 37, 1, 50 and 11 had bilateral (two sides) bed rails. Review of the clinical records of Residents 253, 38, 37, 1, 50 and 11 indicated, there was no documentation that they were assessed for the risks of entrapment prior to the installation of their bed rails. During the concurrent review of the clinical records of the residents and interview with the DON on 3/21/25 at 4:47 p.m., DON verified that these 22 of 22 residents who were using side rails, (Residents 35, 9, 24, 15, 14, 8, 19, 16, 7, 21, 33, 30, 10, 29, 13, 39, 253, 38, 37, 1, 50 and 11), were not assessed for the risks of entrapment prior to the installation of side or bed rails. 3a. Review of Resident 35's admission record indicated, Resident 35 was admitted to the facility on 2/7/23. Review of