Above 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 Glen Skilled Nursing during CMS and state inspections, most recent first.
The facility did not develop care plans, assess entrapment risks prior to bed rail installation, or update bed rail assessments quarterly for 22 residents using bed rails. Observations and record reviews confirmed that residents, some of whom were confused or unable to respond, were using bilateral side rails without required documentation or individualized planning. Staff interviews and policy reviews further verified these deficiencies.
Surveyors found that the exterior of the kitchen's ice machine was covered in dust, with clean plates placed nearby. The Food Service Manager and Director of Support Services confirmed the dust and acknowledged that staff were responsible for cleaning the machine's exterior according to facility policy and manufacturer guidelines.
Surveyors found that opened medications in two medication carts were missing open dates, and an expired medication was present. Additionally, an LVN left a medication cart unlocked and unattended while responding to a resident, contrary to facility policy requiring medication storage to be locked and secure.
Staff failed to follow infection control protocols, including not sanitizing hands before delivering meal trays, improper hand hygiene during wound care and after resident contact, using a paper towel instead of a cotton ball for a fingerstick glucose check, placing employee food on a resident's overbed table, and not maintaining oxygen equipment as required. These actions were observed and acknowledged by staff as not meeting facility policy.
A resident with a Foley catheter was observed with an uncovered urine drainage bag at the bedside, contrary to facility policy requiring catheter bags to be covered to maintain dignity. An LVN confirmed the expectation for the bag to be covered, and the facility's policy prohibits practices that compromise resident dignity.
A resident receiving daily treatment for a sacral pressure injury was not accurately coded for this condition on the MDS, despite clinical records and the TAR documenting the ongoing treatment. The MDS Coordinator confirmed the omission during review, which was inconsistent with facility policy requiring accurate reflection of clinical information.
Four residents with diagnoses such as COPD, Parkinson's disease, and Alzheimer's disease did not have their activity care plans reviewed and updated quarterly as required. Despite physician orders allowing participation in activities, the care plans were not updated in accordance with facility policy, a fact confirmed by the AD, SSD, and DON during interviews and record reviews.
A resident with skin discoloration on both forearms did not have a physician order or care plan addressing the condition. The DON confirmed the omission after reviewing the clinical record, despite facility policy requiring prompt notification and care planning for changes in a resident's condition.
A resident with a stage 2 pressure ulcer did not have wound measurements documented during three wound assessments, despite facility policy and professional standards requiring this information. Both the LVN and DON confirmed the omission, and the facility's wound care documentation policy specifies that wound size must be recorded during each assessment.
A resident with anemia received ferrous sulfate and Calcium+D3 at the same time, despite orders and known drug-drug interactions that reduce iron absorption. The facility did not ensure medication administration times were separated as required by policy and standard drug information resources.
Failure to Assess, Care Plan, and Update Bed Rail Use for Multiple Residents
Penalty
Summary
The facility failed to ensure the proper use of bed rails for 22 residents who were using side or bed rails. All 22 residents lacked care plans addressing the use of bed rails, as confirmed by both record review and interviews with facility staff, including the DON. Observations showed that residents were using bilateral side rails, and in several cases, residents were confused or unable to answer questions, while others were alert and responsive. Despite physician orders for bed rails, there was no evidence that individualized care plans were developed to address the use of these devices for any of the residents involved. Additionally, the facility did not assess the risks of entrapment prior to the installation of bed rails for any of the 22 residents. Clinical records lacked documentation of such assessments, and this was verified by the DON. The absence of these assessments was consistent across all residents observed with bed rails, regardless of their cognitive or physical status at the time of observation. The facility's own policy required risk assessments to be completed before bed rail use, but this was not followed. Furthermore, bed rail assessments were not updated in a timely manner for 18 of the 22 residents. Review of records indicated that the last bed rail assessments for these residents were not completed quarterly as required by facility policy. In some cases, the most recent assessments were several months old, and in others, only a single assessment was present in the record. Staff interviews confirmed that these assessments were not kept current. The facility's policies specified that bed rail assessments should be performed quarterly and that care plans should be comprehensive and person-centered, but these requirements were not met.
Failure to Maintain Cleanliness of Kitchen Ice Machine Exterior
Penalty
Summary
Surveyors observed that the exterior side panel of the kitchen's ice machine was covered in dust, with clean plates placed next to the dusty area. The Food Service Manager confirmed the presence of dust and acknowledged that staff were responsible for cleaning the exterior of the ice machine, as indicated on the facility's Cleaning Assignments Checklist. The checklist specified that kitchen staff were to clean the exterior of the ice machine every evening shift. The Director of Support Services also acknowledged the dust during the observation. A review of the ice machine manufacturer's manual stated that the exterior should be cleaned as often as necessary to maintain cleanliness. This lapse in cleaning practices resulted in the failure to keep the exterior of the kitchen's ice machine free of dust.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that medications in two medication carts were not stored according to facility policy and professional standards. Specifically, opened bottles of docusate sodium, guaifenesin, ibuprofen, acetaminophen, Vitamin B-12, Melatonin, and Vitamin C did not have open dates recorded on their labels. Additionally, an expired container of hyoscyamine sulfate was found in one cart. Staff interviews confirmed that opened medications should be dated and expired medications should not be present in the carts. The facility's policy requires that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions. In a separate incident, a medication cart containing medications was left unlocked and unattended by an LVN, who left the cart to respond to a resident's call light. The LVN acknowledged that the cart should have been locked before leaving it unattended. Facility policy states that medication rooms, cabinets, and supplies must remain locked when not in use or when not attended by authorized personnel.
Infection Control Lapses in Hand Hygiene, Clinical Procedures, and Environmental Maintenance
Penalty
Summary
Multiple staff members failed to follow established infection prevention and control procedures during routine care and meal service. Certified nursing assistants and an activities leader delivered meal trays to three residents without sanitizing their hands, despite acknowledging during interviews that hand hygiene was required before tray delivery. Additionally, a home health aide exited a resident's room after preparing for a bed bath without performing hand hygiene, and a licensed vocational nurse did not sanitize hands after removing gloves or when moving from dirty to clean areas during a wound dressing change. These actions were observed and confirmed by staff interviews, and were not in accordance with the facility's hand hygiene policies. Further deficiencies were observed in clinical procedures and environmental cleanliness. A licensed vocational nurse used a paper towel, rather than a cotton ball, to wipe away the first drop of blood during a fingerstick glucose check, contrary to facility policy. In another instance, employee food was found placed on a resident's overbed table, which staff confirmed should have been stored in the employee break room and not in a resident's room. These actions were acknowledged by the staff involved as not following proper protocol. Environmental infection control lapses were also identified. One resident's oxygen concentrator filter was found to be dusty and the humidifier bottle had not been changed within the required five-day interval, as confirmed by staff and facility policy. These failures in infection prevention and control practices were observed directly by surveyors and acknowledged by staff during interviews, with facility policies reviewed to confirm the required standards were not met.
Uncovered Urine Drainage Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of urinary retention and an indwelling Foley catheter was observed lying in bed with her urine drainage bag uncovered and hung at the bedside. During the observation, a licensed vocational nurse confirmed that the urine drainage bag should have been placed in a cover bag, in accordance with facility policy. The facility's dignity policy specifically prohibits demeaning practices and requires staff to assist residents in maintaining dignity, including keeping urinary catheter bags covered. The failure to cover the urine drainage bag was directly observed and acknowledged by staff, and was not in compliance with the facility's stated standards of care.
Failure to Accurately Code MDS for Pressure Injury
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was receiving daily treatment for a pressure injury on the sacrum. Review of the Treatment Administration Record (TAR) for two separate months showed ongoing treatment for the pressure injury, but Section M of the MDS for the same periods did not reflect the presence of the pressure injury. During an interview and record review, the MDS Coordinator confirmed that the pressure injury was not coded correctly on the MDS assessments during the relevant look-back periods, despite documentation in the clinical records and TAR. The facility's policy requires that MDS assessments consistently reflect information in progress notes, care plans, and resident observations or interviews.
Failure to Review and Update Activity Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that activity care plans for four sampled residents were reviewed and updated quarterly for effectiveness, as required by facility policy and federal regulations. Observations, interviews, and record reviews revealed that the activity care plans for these residents were not updated in accordance with the required schedule. The deficiency was identified through direct observation of the residents, review of their admission records, physician orders, and care plans, as well as interviews with the activity director, social service director, and director of nursing, all of whom confirmed the lack of quarterly review and updates. The residents involved had various primary diagnoses, including chronic obstructive pulmonary disease, Parkinson's disease with dyskinesia, and Alzheimer's disease. At the time of observation, their conditions ranged from being alert and verbally responsive to being confused and unable to answer questions. Physician orders for each resident indicated that participation in activities was permitted if not in conflict with treatment or the plan of care. Despite these orders, the activity care plans for each resident had not been reviewed or updated on a quarterly basis as required. Facility policy states that comprehensive, person-centered care plans must be developed and implemented for each resident, with ongoing assessments and revisions as the resident's condition changes. The policy specifically requires that care plans be reviewed and updated at least quarterly, in conjunction with the required quarterly MDS assessment. The failure to adhere to this policy was acknowledged by facility staff during interviews and was evident in the documentation reviewed for each of the four residents.
Lack of Physician Order and Care Plan for Skin Discoloration
Penalty
Summary
The facility failed to provide necessary care and services for one resident who exhibited skin discoloration on both forearms. Observations on two separate occasions confirmed the presence of the discoloration, yet there was no corresponding physician order or care plan documented in the resident's clinical record. The director of nursing reviewed the record and confirmed the absence of both a physician order and a care plan for the skin condition. According to the facility's policy, changes in a resident's condition should prompt notification of the physician and the development of a care plan, but this process was not followed in this case.
Failure to Document Wound Measurements During Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide care and services related to pressure ulcers in accordance with professional standards of practice for one resident. Specifically, a resident with a stage 2 pressure ulcer on the coccyx did not have wound measurements documented during three separate wound assessments. The wound assessments dated 11/26/24, 12/10/24, and 12/11/24 lacked the required wound measurements, despite facility policy and professional standards mandating that such measurements be recorded during each assessment. During interviews, both the LVN and the DON confirmed that wound measurements should have been completed and documented weekly or as needed, and acknowledged the absence of these measurements in the resident's clinical records. The facility's own policy on wound care documentation requires that all assessment data, including wound size, be recorded in the resident's medical record. The resident involved was admitted with multiple diagnoses, including Parkinson's disease with dyskinesia, unspecified dysphagia, and a stage 2 pressure ulcer, and was observed to be awake but confused and unable to answer questions at the time of the survey.
Failure to Separate Administration Times for Iron and Calcium Supplements
Penalty
Summary
The facility failed to ensure the effective use of medications for a resident diagnosed with anemia by administering ferrous sulfate and Calcium+D3 at the same time. The resident had physician orders for ferrous sulfate every other day at 9 a.m. and Calcium+D3 twice daily at 9 a.m. and 6 p.m. Since the initiation of the Calcium+D3 order, both medications were given concurrently at 9 a.m. every other day. This practice was confirmed through record review and interview with the clinical pharmacist consultant. According to a nationally recognized drug information resource, the concurrent administration of calcium and ferrous sulfate results in a significant drug-drug interaction, with calcium decreasing the absorption of iron by an average of 60%. The facility's policy requires that the consultant pharmacist, nurses, and physician review medications for potential interactions, but this was not effectively implemented, leading to the deficiency.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Herman Health Care Center | 0.4 mi | ★★★★★ | 31 | 0 |
| The Redwoods Post-acute | 1.8 mi | ★★★★★ | 1 | 0 |
| Empress Care Center, Llc | 2.4 mi | ★★★★★ | 0 | 0 |
| Camden Postacute Care, Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| White Blossom Care Center | 2.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.