Legend Ddd Services - Lincoln Nsgh

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's (admitted 2024) medical record did not include documentation of evidence of freedom from infectious TB for Compliance Officer review. 3. A review of R2's (admitted 2024) medical record did not include documentation of evidence of freedom from infectious TB for Compliance Officer review. 4. In an interview, E6 acknowledged R1's, and R2's medical records did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on documentation review and interview, the administrator did not ensure policies and procedures for medication administration covered the documentation of a resident’s refusal to take prescribed medication in the resident’s medical record. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication Administration.” However, the policy did not include documentation of a resident’s refusal to take prescribed medication. 2. In an interview, E6 acknowledged the policies and procedures for medication administration did not cover the documentation of a resident’s refusal to take prescribed medication in the resident’s medical record.

Based on record review, observation and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication list dated March 18, 2025 including an order for the following medication: - Atorvastatin Calcium 10 milligram (MG) Tabs - Take One Tab By Mouth Every - Schedule: Daily At 20:00. 3. A review of R1's medication administration record (MAR) for March 2025 revealed R1 received the following medication from March 18. 2025 to March 31, 2025: - Atorvastatin Calcium 10 milligram (MG) Tabs - Take One Tab By Mouth Every - Schedule: Daily At 20:00. 4. An observation of R1's medications revealed a bubble pack of "Atorvastatin 20MG - Take One Tablet By Mouth Every Day" with a fill date of February 25, 2025. 5. In an interview. E5 reported that R1 had been administered the Atorvastatin from the remainder of a previous order since the dose was the same. E5 reported the medication had not been changed in the medication drawer when the new medication was received. 6. In an interview, E6 acknowledged medication administered to R1 was not administered in compliance with a medication order.

Based on documentation review and interview, the administrator did not ensure the disaster plan is reviewed at least once every 12 months. Findings include: 1 . A review of the facility’s documentation revealed a disaster plan that appeared to meet rule. However, no documentation of the disaster plan being reviewed at least once every 12 months was available for Compliance Officer review. 2 . In an interview, E6 reported a review of the disaster plan is being conducted each year. E6 acknowledged documentation of the disaster plan having been reviewed at least once every 12 months was not available.

Based on documentation review and interview, the administrator did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility’s documentation revealed no documentation of disaster drills for employees being conducted was available for review. 2. In an interview, E6 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for residents was conducted at least once a year on each shift and documented. Findings include: 1. In an interview E5 reported the following shifts: Direct Support Personnel - 9AM to 9PM and 9PM to 9AM; and Nursing Personnel - 7AM to 7PM and 7PM to 7AM. 2. A review of the facility's documentation revealed an "Evacuation Drill Report" dated December 9, 2024 conducted at 4:40PM. However, no other documented Evacuation Drill Reports were available for review. 3. In an interview, E6 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.

Based on observation and interview, the administrator did not ensure bathtubs and showers contain slip-resistant strips, rubber bath mats, or slip-resistant surfaces. Findings include: 1. During an environmental inspection, the Compliance Officer observed two showers which appeared not to be slip-resistant surfaces and did not contain rubber bath mats, or slip-resistant strips. 2. During an interview, E6 acknowledged showers did not contain slip-resistant strips, rubber bath mats, or slip-resistant surfaces.