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Complaint Investigation

Lincoln County Nursing & Rehab

Inspection Date: November 17, 2025
Total Violations 1
Facility ID 265433
Location TROY, MO
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Inspection Findings

F-Tag F0744

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident would calm down and let NA J provide care;-NA J did not have access to the resident's care plan;-NA J had to ask during report how to care for the residents. During an interview on 9/23/25 at 1:26 P.M. and 3:46 P.M. CNA K said the following:-The resident was often combative; -If two aides of the opposite gender provided care it was best, and the resident did not act out as much; -CNA K did not think

the resident liked staff of the same gender to care for him/her;-CNA K frequently got report from CNA I, who was the same gender as the resident, who said Resident #1 was combative, aggressive, or cursed when CNA I provided care;-The resident was changed from a two person assist with a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair and assist with sitting and standing) for transfers to a sit to stand lift;-Once the resident was in the standing position in

the sit to stand lift, he/she would let go of the handles and flail his/her arms almost every time;-CNA K did not have any kind of dementia training. During an interview on 10/1/25 at 11:29 A.M. CNA I (who is the same gender as the resident) said the following:-Resident #1 had been very combative and yelled out. The resident had hit CNA I many times before, bit and scratched him/her;-Staff could not redirect the resident when he/she was angry. The resident continued to be upset for about 45 minutes once he/she was upset and then calmed down. During an interview on 9/24/25 at 4:22 the MDS/Care Plan Coordinator said the following:-It was her responsibility to update resident care plans;-She should have updated the resident care plan after the incident with the resident on 9/18/25;-Not all CNAs knew how to access a resident's care plan on the computer. During an interview on 9/24/25 at 4:15 P.M. the Director of Nursing (DON) said the following:-She expected staff to notify her if a resident had behaviors. CNAs should notify nurses, and the nurses should notify the DON;-All staff know non-pharmacological interventions to use if a resident had behaviors; leave the resident and go back later and try again, redirect the resident, and figure out what triggered the resident;-The care plan should have been updated by the MDS/Care Plan Coordinator;-Staff received dementia care training upon hire. During an interview on 9/24/25 at 4:30 P.M. the Administrator said the following:-Staff received dementia care training upon hire;-She expected staff to step away from Resident #1 if he/she had behaviors or resisted cares and then go back later and try again;-She did not know the resident did not like or had a problem with CNA B until the incident on 9/18/25. None of the staff let her know;-She also did not know the resident did not like or had a problem with CNA I and had behaviors when CNA I provided care to the resident. During an interview on 9/30/25 at 9:57 A.M. the resident's Psychiatric Nurse Practitioner said the following:-He/She was not aware the resident had behaviors. This was the first time she heard Resident #1 exhibited behaviors of any kind;-He/She was at the facility on 9/25/25 and spent time with the resident with the SSD in the room. The SSD said the resident was doing fine and had no problems;-He/She expected staff to let him/her know if the resident exhibited behaviors. Just because a problem appeared to be resolved, it did not mean the behavior was over or wouldn't occur again; -The Psychiatric Nurse Practitioner expected staff to have dementia care training; -A staff member's approach with dementia residents was very important;-If staff haven't been trained properly or don't have access to care plans to know how to care for residents, it could be hard for both the staff and

the resident. 26241422621418

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📋 Inspection Summary

LINCOLN COUNTY NURSING & REHAB in TROY, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TROY, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LINCOLN COUNTY NURSING & REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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