Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Meadows Care Center during CMS and state inspections, most recent first.
Glipizide was administered outside the ordered pre-meal timing for a resident with uncontrolled type 2 DM. An LN gave the medication after breakfast had started, despite the order stating it should be given no more than 30 minutes before meals. The CP confirmed glipizide should be given before meals and acknowledged the med was scheduled at 8:00 a.m. and 8:00 p.m., which did not align with mealtimes; the DON also confirmed the timing was not appropriate.
Medication administration errors exceeded the allowed rate when two errors were identified in 30 opportunities. One resident with DM2 received glipizide after breakfast instead of about 30 minutes before a meal as ordered, and another resident with HTN did not receive PRN hydralazine even though the SBP reading met the provider’s parameter for administration. The LPNs involved and the DON acknowledged the orders were not followed.
Failure to Administer PRN Antihypertensive Medication as Ordered: A resident with HTN, AFib, diastolic HF, and CKD stage 3 had an order for hydralazine 50 mg PO q12h PRN for SBP >150 mmHg. LN and DON review found repeated missed doses despite multiple SBP readings above the ordered parameter, and the PRN medication was not administered as prescribed.
Failure to Provide and Document Ongoing Individualized Activities: Two residents with impaired cognition and documented activity preferences did not receive or have records of ongoing activity programs that matched their psychosocial needs. One resident preferred TV, game shows, phone calls, and music, while the other preferred 1:1 visits, artwork, crafting, movies, reading materials, music, and religious activities. Observations found both residents in bed with no activity materials or entertainment present, and the AD confirmed there were no records of ongoing activities provided.
A resident with metabolic encephalopathy, cerebral infarction, left below-knee amputation, and muscle weakness did not receive the ordered restorative nursing program for AROM and bed mobility at the prescribed frequency. Staff confirmed the resident received exercises only intermittently and bed mobility only once, with no documented refusals, despite the care plan and physician orders calling for therapy three times weekly.
Emergency kits were not replaced within the required timeframe, and staff removed medications from previously opened kits. In the medication room, two refrigerated kits were found opened, including one with medication removal logs from prior dates, and the SN confirmed the kits should have been returned to the pharmacy within 72 hours. The DON acknowledged that opened kits needed to be replaced within 3 days and that staff must not access medications from a previously opened kit.
An opened foil pouch of budesonide for a resident was found in a medication cart without the date it was opened, contrary to the manufacturer’s instructions and the facility’s medication labeling policy. An LPN reviewed the pouch, noted the two-week use limit after opening, and said he would discard it because he did not know when it expired; the DON also acknowledged the pouch should have been dated when opened.
Meal tickets were not followed for two residents when an 8 fl oz milk ordered with lunch was not served. One resident had diabetes, severe PCM, and dementia, and the other had hemiplegia, CHF, and dementia; both had severely impaired cognition and required assistance with eating. CNAs confirmed the milk was missing, and the FSD and DON stated resident meal tickets should be followed.
Failure to provide adaptive eating equipment: A resident with Alzheimer's disease, dementia, PCM, muscle weakness, and severely impaired cognition was supposed to receive a scoop plate with meals to support self-feeding. During lunch, staff served the meal on a regular plate instead, and the resident was observed with weak, unsteady hands while trying to scoop food. CNA confirmed the scoop plate was not provided, and the FSD and DON stated adaptive equipment should be provided with meals.
Outside Dumpster Left Open: One of three outside dumpsters was observed with the lid not closed because a piece of a bike from the rehab dept was sticking up and out of the dumpster. The FSD confirmed the lid had not been closed and stated that open dumpsters attract flies, bugs, and rodents. Facility policy stated that outside dumpsters provided by garbage pickup services will be kept closed.
A resident with hemiplegia, CHF, dementia, and severely impaired cognition was on EBP for a MDRO history and wound care, with orders and care plan instructions requiring gown and glove use during high-contact ADL care. During observation, a staff member and later a visiting hospice aide provided hands-on hygiene and incontinence care while wearing only gloves and no gown, and the hospice aide said she was unaware the resident was on EBP and had not been informed by facility staff.
Two residents with moderate cognitive impairment and significant medical needs were found to have non-functioning call light systems in their room and bathroom. Staff, including the DON, DSD, and an RN, confirmed that the call lights did not activate as required, and attempts to repair or use the system were unsuccessful. Both residents reported delays in receiving assistance, and the facility's policy requiring a functional call system at all times was not met.
During a meal service, staff did not follow prescribed menus and portion controls for various therapeutic diets, resulting in residents receiving incorrect portion sizes and meal components. Residents on regular, CCHO, CCHO renal, small portion, fortified, and finger food diets were all affected, with issues such as oversized pasta servings, full desserts instead of half portions, missing fortified margarine, and lack of required garnishes. These discrepancies were confirmed by dietary staff and were not in accordance with facility policies or physician orders.
Surveyors identified multiple deficiencies in food safety and sanitation, including improperly cleaned and stored metal pans, unclean storage areas, a poorly maintained can opener, and dietary staff unable to correctly describe or perform manual dishwashing and sanitizing procedures. Additionally, staff failed to use proper hair restraints and did not consistently label, date, or discard resident food in the refrigerator, which was also found to be unclean. These failures were confirmed through observation, staff interviews, and review of facility policies.
Several residents with cognitive and mobility impairments experienced significant delays in receiving incontinence care or assistance to the bathroom, resulting in episodes of incontinence, emotional distress, and skin discomfort. Documentation showed that individualized care plans for incontinence were lacking for some residents, and staff interviews confirmed that timely care was not consistently provided.
The facility failed to ensure dietary staff were properly trained and competent in food safety procedures, including manual dishwashing, cleaning and sanitizing food contact surfaces, and preparing sanitizer solutions. Two dietary aides lacked required food handler certifications and demonstrated incorrect practices, placing the majority of residents at risk for foodborne illness.
Surveyors found that oxygen and catheter tubing for several residents were in contact with the floor, and enteral feeding tubing was left uncapped and open to air while disconnected. Staff and facility policies confirmed these practices were not in line with infection control standards, as the tubing should not touch the floor or be left open to air due to contamination risks.
A resident with muscle weakness, difficulty walking, and a history of falls did not have their call light within reach on multiple occasions, despite requiring partial to moderate assistance with ADLs. The resident was unable to request help, and staff confirmed the call light was not accessible. Facility policy requires call lights to be within easy reach, but this was not followed.
A resident with a stage 4 pressure ulcer and chronic pain did not receive appropriate pain management during wound care. The nurse did not assess pain using a standardized scale or administer pain medication prior to the procedure, despite the resident expressing significant discomfort. The procedure was further prolonged due to lack of preparation, causing the resident to remain in pain for an extended period. Facility policies and care plan expectations for pain management and wound care preparation were not followed.
A facility failed to follow infection control practices when a nurse did not wear a gown during wound care for a resident with chronic osteomyelitis and bacteremia. Despite Enhanced Barrier Precautions requiring gowns for high-contact care, the nurse confirmed the oversight. Interviews with the Infection Preventionist and DON highlighted the necessity of gowns to prevent infection spread, as per facility policy.
A facility failed to report an alleged abuse incident involving a resident with hemiplegia and hemiparesis. The resident reported being disrespected by a CNA, who pushed her fingers into his chest and made demeaning comments. Despite the grievance being documented, staff members did not perceive the incident as abuse and did not report it to the State Survey Agency or local law enforcement, contrary to the facility's policy.
A resident with memory issues and aphasia was transferred to the hospital due to aggressive behavior, but the facility failed to notify the resident's representative as required. The representative only learned of the transfer from the hospital, leading to feelings of astonishment and upset. Documentation discrepancies were noted in the timing of notifications.
The facility failed to provide appropriate respiratory care for three residents. Two residents received incorrect oxygen levels, and one resident was not provided with an incentive spirometer as ordered by the physician. These discrepancies were confirmed by staff and the Director of Nursing, indicating a failure to follow the facility's policies on oxygen administration and physician orders.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). The Director of Nursing confirmed that staff were expected to document on both records, as per facility policy.
The facility had a 10.42% medication error rate during a medication pass for two residents. Errors included not instructing a resident to rinse and spit after using an inhaler, not priming insulin pens, not swabbing a heparin vial, and administering insulin after a meal. The DON confirmed these actions were against the facility's policies.
A resident with left side hemiplegia and muscle weakness was not provided with a rocker knife, as required by her care plan, leading to her inability to cut food and subsequent weight loss. Staff confirmed the absence of the rocker knife and the facility's failure to notify appropriate personnel about its unavailability.
The facility failed to store food in a sanitary manner, with staff not using hair nets and beard guards, and several food items not labeled with open dates or expired. This included expired left-over roast beef that a Dietary Cook was about to reheat.
The facility failed to follow proper infection control practices when a dietary cook did not perform proper hand hygiene in the kitchen and a licensed nurse did not change gloves or perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. These failures had the potential to spread infection within the facility.
A facility failed to ensure that a resident's self-administered albuterol inhaler was reviewed and approved by a physician. The inhaler, brought from the hospital, was found at the resident's bedside without a pharmacy label or physician's order. The Director of Nursing confirmed that a physician's order and proper storage were required for safe self-administration.
A resident with asthma and a left lower limb infection reported being unable to reach the call light while in her wheelchair because it was located on the other side of her bed. The DON confirmed that the call light should have been within reach, as per the facility's policy.
A resident with paraplegia and other medical conditions returned from the hospital to find her room cluttered with personal belongings. Despite her requests for assistance, staff did not help her unpack, leading to an unsafe and disorderly environment. The clutter prevented proper cleaning and created hazards, as the resident could not adjust her bed or use the call light. The facility failed to follow the care plan and policy for a homelike environment.
The facility failed to ensure accurate MDS assessments for three residents. One resident's vision impairment was not documented, another's feeding tube was not recorded, and a third resident's discharge status was incorrectly noted as hospitalization instead of home. These inaccuracies could impact care plans and interventions.
The facility failed to develop and provide a baseline care plan (BCP) and written summary for a resident within 48 hours after admission. The BCP was not completed until several days later, and the summary was not provided to the resident or her representative. The DON confirmed the oversight, which is against the facility's policy.
A facility failed to develop a comprehensive care plan for a resident with COPD, omitting physician's orders for an incentive spirometer and compression stockings. This was confirmed through interviews and record reviews, highlighting a lapse in following the facility's policy for timely care plan development.
A resident received an incorrect dose of heparin when a nurse failed to expel air from the syringe before administration. The nurse acknowledged the error, and the Director of Nursing confirmed that proper medication administration is a staff competency expectation.
The facility failed to assist a resident with the arrangement of an eye doctor consultation, despite the resident's repeated requests and documented need for vision care. The resident, who experienced headaches from provided reading glasses, had not seen an eye doctor since the request was made in August 2023.
A facility failed to follow a physician's treatment order for a stage 4 pressure ulcer on a resident's left posterior leg. The prescribed treatment included cleansing with normal saline, applying collagen, hydroferra blue, triad cream, and a silicone border foam dressing with skin prep. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed. This was confirmed by the nurse and the Director of Nursing.
A facility failed to properly check the functionality of a roam signal device for a resident with paranoid schizophrenia and Alzheimer's disease, leading to an increased risk of elopement. The current method involved taking the resident near the main door, which the DON acknowledged needed improvement for safety.
The facility failed to ensure routine care and dressing changes for a resident's midline catheter, leading to an increased risk of infection. The dressing was not changed for 21 days, and there were no orders or documentation for flushing and locking the catheter. The DON confirmed that nurses did not follow the facility's policies.
A nurse left a med cart unattended in the hallway with a bubble pack containing six hyoscyamine 0.125 mg tablets on top. The facility's policy stated that no medications should be kept on top of the cart.
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically in the cooling down process for turkey and the proper procedures for pureeing food. Dietary Cook 1 did not follow correct procedures, use recipes, or measuring tools, which was confirmed by the Kitchen Dietary Manager and the Food Service Efficiency Consultant.
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, vegetables, and starch. This deficiency was confirmed by the dietary cook and the Food Service Efficiency Consultant, and it had the potential to decrease the nutrients in the food served to five residents on a pureed diet.
The facility failed to post complete daily staffing information at the beginning of each shift for a census of 90 residents. The Staffing Coordinator posted incomplete staffing information in the afternoon, missing the total number and actual hours worked per shift for licensed and unlicensed staff. This was observed on multiple occasions, and the SC confirmed the deficiency.
Glipizide Given Outside Prescribed Pre-Meal Timing
Penalty
Summary
The facility failed to ensure that glipizide was administered in accordance with manufacturer guidance and prescriber instructions for one resident with uncontrolled type 2 diabetes mellitus. The resident was admitted with diagnoses including primary hypertension and atrial fibrillation, and later had uncontrolled type 2 diabetes mellitus added to the record. Physician orders for glipizide 5 mg oral tablet directed that it be given twice daily and not more than 30 minutes before meals, but the medication was scheduled for 8:00 a.m. and 8:00 p.m. across multiple order periods. During a medication observation, an LN prepared and administered the resident’s oral medications, including glipizide, after breakfast had already started rather than before the meal as ordered. When questioned, the LN acknowledged the medication was not administered before the meal and stated it could be given after eating, describing the 8:00 a.m. dose as having a one-hour before and one-hour after administration window. The Consultant Pharmacist later confirmed that glipizide should be administered 30 minutes before meals, acknowledged the order reflected that requirement, and confirmed the medication had been scheduled at times that were not before mealtimes. The CP also acknowledged he did not make a recommendation to correct the administration times. The DON reviewed the resident’s glipizide orders, MARs, and the facility meal schedule and confirmed that the 8:00 a.m. and 8:00 p.m. administration times were not appropriate for a medication intended to be given before meals. The DON stated that mealtimes were staggered, with breakfast beginning at 7:10 a.m., lunch at 12:10 p.m., and dinner at 5:10 p.m. The DON also confirmed that the Consultant Pharmacist did not identify the medication-timing issue and stated that administering glipizide outside of manufacturer guidelines could lead to uncontrolled blood sugars.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5%, with a reported error rate of 6.67% based on two errors in 30 medication administration opportunities. One error involved a resident with diabetes mellitus type II who had an order for glipizide 5 mg by mouth twice daily, with instructions not to give it more than 30 minutes before a meal and scheduled times of 8 a.m. and 8 p.m. During observation, the resident received the glipizide at the 8 a.m. medication pass after breakfast had already occurred at about 7 a.m., rather than before the meal as ordered. During interview and record review, the nurse who administered the medication acknowledged that the glipizide was not given before breakfast and stated it could be given after eating within a one-hour window before and after the scheduled time. The consultant pharmacist and the DON both reviewed the order and the prescribing information and confirmed that glipizide should be given approximately 30 minutes before a meal. The facility policy on administering medications stated that medications are to be administered in accordance with prescriber orders, including any required time frame. A second error involved a resident with an order for hydralazine 1 tablet by mouth every 12 hours as needed for hypertension when systolic blood pressure is greater than 150 mmHg. The resident’s blood pressure was documented as 164/78 mmHg, which met the ordered parameter for administration, but the PRN hydralazine was not given. The nurse stated the medication was given on the evening shift, then acknowledged after reviewing the order that the resident’s blood pressure met the parameter and the medication should have been administered. The DON also confirmed that the PRN hydralazine was not administered despite the elevated blood pressure reading and the resident was at risk for complications related to untreated elevated blood pressure.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
Resident 16, who had diagnoses including hypertension, atrial fibrillation, diastolic heart failure, and chronic kidney disease stage 3, had a physician order dated 4/28/26 for hydralazine 50 mg by mouth every 12 hours as needed for hypertension, to be given if systolic blood pressure (SBP) was greater than 150 mmHg. During an interview and concurrent record review with LN 2, the nurse initially stated the medication was given on the evening shift, then acknowledged the order required administration as needed when SBP exceeded 150 mmHg. LN 2 confirmed that the resident’s blood pressure earlier that morning was 164/78 mmHg and that the PRN hydralazine was not given as ordered. A review of Resident 16’s blood pressure readings, physician orders, nursing notes, and the May 2026 MAR with the DON identified more than 15 missed opportunities to administer the PRN hydralazine within the ordered 12-hour dosing intervals. On multiple occasions, the resident’s SBP was above the physician-ordered threshold, including readings of 161/78, 160/80, 160/77, 185/75, 177/81, 170/90, 176/89, 158/81, 158/72, 155/87, 161/73, 157/72, 153/73, 168/62, 182/81, 172/80, and 153/74 mmHg, yet the medication was not administered. The DON stated that nursing staff were expected to follow provider orders for PRN blood pressure medications and acknowledged that the PRN hydralazine should have been given when the resident met the SBP threshold, but it was not.
Failure to Provide and Document Ongoing Individualized Activities
Penalty
Summary
The facility failed to ensure that two residents received an ongoing activity program that met their psychosocial needs, and it did not maintain documentation showing that either resident received ongoing activities. Resident 7 was admitted with diagnoses including metabolic encephalopathy, cerebral infarction, dementia, and muscle weakness. His MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition. His care plan and activity assessment identified preferences for watching TV, game shows, talking with family by phone, listening to music, and having books, magazines, radio, or arts and crafts available, with independent leisure activities in his room due to illness. Observations of Resident 7 on multiple occasions showed him lying in bed with the TV off, no music playing, and no books, magazines, radio, or phone noted in the room. During a concurrent interview and record review, the Activities Director confirmed there were no records that Resident 7 was provided with any ongoing activity that met his psychosocial needs and stated that his preferred activities should have been provided to maintain his psychosocial wellbeing. Resident 85 was admitted with diagnoses including Alzheimer's disease, dementia, and muscle weakness. Her MDS showed a BIMS score of 5 out of 15, indicating severely impaired cognition. Her MDS preferences identified books, newspapers, magazines, music, favorite activities, religious services or practices, and being around animals as important. Her care plan included 1:1 in-room visits, reminders for activities, and offering supplies and equipment, and her activity participation review noted she enjoyed artwork, crafting, and watching movies. Observations showed her lying in bed with the TV off and no music, books, magazines, radio, or art or crafting materials in the room. The Activities Director confirmed there were no records that Resident 85 received ongoing activities that met her psychosocial needs, and the DON stated that residents would be at risk for isolation, psychosocial decline, and mental health concerns if an ongoing activity program was not consistently provided.
Failure to Follow Ordered Restorative Nursing Program
Penalty
Summary
The facility failed to provide treatment and services necessary to maintain or improve range of motion (ROM) and mobility for one sampled resident. Resident 10 was admitted with diagnoses including metabolic encephalopathy, cerebral infarction, absence of the left leg below the knee, and muscle weakness. Her MDS showed moderately impaired cognition, dependence for multiple activities of daily living, and substantial to maximal assistance needs for bed mobility and transfers. Her care plan identified her as at risk for decline and/or complications with ROM, decreased mobility and movement, decreased muscle strength, decreased functional use of extremity, pain, deformity, contracture, and/or skin breakdown, and included a restorative nursing ROM program for both upper and lower extremities. Physician orders dated 4/22/26 directed an RNA program for AROM of both upper and lower extremities and a bed mobility program three times weekly or as tolerated. During interview and record review, Resident 10 stated she was upset because she was not receiving the RNA program as ordered and said she had only received one exercise the prior weekend. RNA staff confirmed that over the prior 30 days she received AROM on only several dates and bed mobility exercise only once, with no documented refusals. The RNA, DSD, and DON all stated the ordered RNA frequency should have been followed and that failure to do so placed the resident at risk for decline in ROM, contracture, and mobility.
Emergency Kits Not Replaced or Secured Properly
Penalty
Summary
Emergency kits were not managed within the facility’s required timeframe, and staff removed medications from previously opened emergency kits. During an observation and concurrent interview in the medication room, three refrigerated emergency kits were found in the medication refrigerator on Station 2. Two kits had red plastic ties indicating they had been opened, and one remained sealed. One opened kit contained a log showing it had been opened that morning, while the second opened kit contained logs documenting medication removal on 5/6/26 at 2:00 p.m. and again on 5/17/26 at 4:16 p.m. The Supervisor Nurse confirmed the observations and stated that emergency kits were required to be replaced and returned to the pharmacy within 72 hours of being opened. During a later interview, the DON stated that emergency kits needed to be replaced within 3 days of being opened and acknowledged that medication might not be available to residents in need when opened kits were not returned to the pharmacy in a timely manner. The DON also acknowledged that staff must not access or obtain medications from a previously opened emergency kit. The facility policy titled Emergency Kits stated that when a medication is needed, the nurse breaks the seal, removes the required medication, notifies the pharmacy for replacement, and that opened kits are placed with sealed kits within 72 hours of opening.
Undated Opened Budesonide Pouch in Medication Cart
Penalty
Summary
The facility failed to ensure that an opened foil medication pouch containing budesonide ampules for Resident 28 was labeled with the date it was opened, as required by the manufacturer’s instructions and the facility’s medication storage and labeling policy. During inspection of the 2B Medication Cart, an opened and undated foil pouch of budesonide prescribed for Resident 28 was observed stored in the cart. The Licensed Nurse reviewing the pouch noted the manufacturer’s instruction that, once the foil envelope is opened, the ampules are to be used within two weeks, and stated he would discard the medication because he did not know when it expired. The Director of Nursing reviewed photographs of the opened pouch and the manufacturer’s labeling instructions and acknowledged that the medication pouch should have been dated when it was opened. The facility policy titled Medication Storage and Labeling stated that medications are labeled in accordance with applicable federal and state requirements and currently accepted pharmacy practices. The prescribing instructions for budesonide also stated that the foil envelope should be dated when opened and that the vials can be stored for 2 weeks after opening the protective aluminum foil envelope.
Meal Tickets Not Followed for Ordered Milk
Penalty
Summary
The facility failed to follow prepared meal tickets and did not provide an 8 fl oz milk with lunch to two sampled residents. Resident 21 had diagnoses including diabetes, severe protein-calorie malnutrition, and dementia, with a BIMS score of 7 out of 15 indicating severely impaired cognition. Resident 21’s physician order called for a regular diet with minced and moist texture and thin liquids, and the nutritional risk review and care plan identified nutritional imbalance and malnutrition concerns related to limited intake, weight loss history, and altered nutrition needs. During a concurrent observation and interview in the dining room, Resident 21’s lunch tray included a beverage, and the meal ticket showed standing orders for an 8 fl oz beverage and an 8 fl oz milk. Resident 21 stated that milk was not received and that she wanted it. CNA 2 confirmed that Resident 21 was not served the 8 fl oz milk and stated that if it was on the meal ticket, it should have been provided from the kitchen. Resident 5 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, congestive heart failure, and dementia, with a BIMS score of 4 out of 15 indicating severely impaired cognition. Resident 5’s physician order called for a regular diet with pureed texture and thin liquids, and the nutritional risk review and care plan addressed nutritional risk and malnutrition. During a concurrent observation and interview in Resident 5’s room, the lunch tray included a beverage, the meal ticket showed standing orders for an 8 fl oz beverage and an 8 fl oz milk, and Resident 5 stated that milk was not received. CNA 3 confirmed the milk was not served and stated the meal ticket should have been followed. The FSD and DON both stated that resident meal tickets should be followed and that incomplete meal contents could affect residents’ nutritional intake.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide the appropriate assistive eating utensil to Resident 85 during the lunch meal on 5/18/26. Resident 85 had diagnoses including Alzheimer's disease, dementia, moderate protein-calorie malnutrition, and muscle weakness. The MDS dated 1/8/26 indicated a BIMS score of 5 out of 15, showing severely impaired cognition, and also indicated the resident needed supervision or touching assistance with eating. The care plan identified malnutrition risk related to dementia and malnutrition, and the active physician's order called for a fortified regular diet with thin liquids. The resident's nutritional risk review dated 4/9/26 directed that a scoop plate be provided during all meals to support independence with self-feeding. During observation, staff served the lunch meal on a regular white dinner plate, and Resident 85 was seen with weak and unsteady hands while trying to scoop food. Resident 85 stated the scoop plate was not provided and that it would have helped with scooping food and prevented the tray from becoming cluttered. CNA 3 confirmed the scoop plate was not provided and stated the resident should have received one with every meal. The FSD and DON stated that adaptive eating equipment should be provided with meals to support independence, and the facility policy stated adaptive devices will be provided for residents who need or request them.
Outside Dumpster Left Open
Penalty
Summary
Garbage and refuse were not properly contained when one of three outside dumpsters was observed with its lid not closed. During a concurrent observation and interview, the Food Services Director confirmed that a piece of a bike from the rehab department was sticking up and out of the dumpster, which prevented the dumpster from being properly closed. In a later interview, the Food Services Director confirmed that garbage dumpsters not being closed attracted flies, bugs, and rodents, and also confirmed that the lid had not been closed. Review of the facility policy titled Garbage and Refuse Disposal, dated September 2025, stated that garbage and refuse containing food wastes will be stored in a manner that prevents pests and that outside dumpsters provided by garbage pickup services will be kept closed.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility did not follow and maintain an effective infection prevention and control program for one sampled resident who was on enhanced barrier precautions (EBP). Resident 5 was admitted in December 2025 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction, congestive heart failure, and dementia. The resident’s MDS dated 4/11/26 showed a BIMS score of 4 out of 15, indicating severely impaired cognition. The care plan dated 2/9/26 identified the resident as requiring EBP during high-contact care activities because of a history of infection or colonization with a MDRO, and the care plan intervention dated 4/10/26 directed staff to use PPE, including gown and gloves, during dressing, bathing/showering, transferring, hygiene, brief changes, and toileting assistance. Active physician orders also directed staff to use EBP for ADLs, hygiene, toileting, and transferring/repositioning, and to treat excoriation on the left buttocks with daily wound care. During observation on 5/18/26, a staff member provided ADL and hygiene care to Resident 5 while wearing only gloves and not a gown, despite EBP signage posted at the room indicating gown and glove use for high-contact care activities. In a later interview, the visiting hospice aide confirmed that she wore only gloves while providing a partial bed bath, washing the resident’s face, providing incontinence care, applying cream to the resident’s bottom, and changing the resident’s gown. The hospice aide stated she was not aware the resident was on EBP and said no facility staff informed her of it. The Infection Preventionist stated that staff and visiting hospice staff caring for residents on EBP were expected to wear the required PPE during high-contact care, and the DON stated staff should follow EBP and wear both gloves and gown to prevent cross contamination and possible infection.
Non-Functioning Call Light System in Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents residing in the same room. Both residents had moderate cognitive impairment and required assistance due to their medical conditions, including a displaced comminuted fracture of the left patella and surgical aftercare following digestive system surgery. Observations and interviews revealed that the call light in their room did not activate the light above the door or register at the nurse's station, and one resident reported not being given a call bell. Both residents described significant delays in receiving assistance, with one stating she had to call out for help and the other reporting waits of up to two hours. Multiple staff members, including the DON, DSD, and an RN, confirmed through direct observation that the call light system was not working as intended. Attempts to replace the call light cord and activate the system were unsuccessful, and the emergency call light in the bathroom required excessive force to activate. The facility's policy required the call system to remain functional at all times, but this was not maintained, as confirmed by staff interviews and direct testing of the system.
Failure to Follow Therapeutic Diet Menus and Portion Controls
Penalty
Summary
The facility failed to ensure that planned menus were followed for therapeutic diets during a lunch meal service. Observations revealed that residents received incorrect portion sizes and meal components that did not align with their prescribed diets. Specifically, residents on regular diets received larger portions of pasta than indicated, those on consistent carbohydrate (CCHO) and CCHO renal diets received full servings of dessert and larger pasta portions instead of the prescribed reduced amounts, and residents on small portion diets were served full portions of dessert, pasta, and chicken rather than the smaller amounts required. Additionally, residents on fortified diets did not receive the extra margarine intended to increase caloric intake, and those on finger food diets did not have their desserts appropriately portioned for ease of handling. All residents who received meals from the facility kitchen did not receive the required garnish, which was specified in the menu to enhance meal presentation and potentially stimulate appetite. The discrepancies were confirmed through interviews with kitchen staff, the dietary manager, and the registered dietitian, who all acknowledged that the menu and portion guidelines were not followed during meal preparation and service. The facility's own menu spreadsheets and diet guidelines clearly outlined the correct portions and meal components for each therapeutic diet, but these were not adhered to during the observed meal service. A review of facility policies and job descriptions further confirmed that staff were expected to follow prepared menus, portion control guides, and special diet requirements accurately. The failure to do so resulted in residents receiving meals that did not meet their individualized nutritional needs as prescribed by their physicians and outlined in the facility's diet manual. These actions and inactions directly led to the deficiency cited in the report.
Multiple Food Safety and Sanitation Deficiencies Identified in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards, as evidenced by multiple deficiencies observed during survey. Metal pans in the clean and ready-to-use storage areas were found stacked while still wet and with food particles present, indicating improper cleaning and drying procedures. The storage areas themselves were not clean, with food debris noted on surfaces. Additionally, the blade of the can opener was discolored and chipped, and the dietary staff did not consistently demonstrate or verbalize correct procedures for manual dishwashing, cleaning, sanitizing, or preparing and testing sanitizer solutions. For example, one dietary aide was unable to describe the full manual dishwashing process, omitting the sanitizing step, and another did not follow correct procedures for cleaning food contact surfaces or using sanitizer test strips. Further observations revealed that dietary staff did not always use proper hair restraints, with one aide's hair not fully covered by a cap or hairnet. The resident food refrigerator located at the nurse station was found to be unclean, with dry liquid spills and improperly labeled or outdated food items present in the freezer. Food items lacked resident names, received dates, or were past their expiration dates, and there was no set schedule for cleaning the refrigerator. Interviews with nursing and housekeeping staff revealed confusion over responsibilities for monitoring and cleaning the refrigerator, with inconsistent practices regarding labeling, dating, and discarding perishable foods. Facility policies and procedures reviewed during the survey supported the need for proper dishwashing, sanitation, maintenance of equipment, labeling and dating of resident food, and regular cleaning of storage and refrigeration areas. However, staff interviews and direct observations confirmed that these procedures were not consistently followed, leading to unsanitary conditions and potential food safety risks for all residents receiving food from the facility kitchen.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four residents who required varying levels of support for toileting hygiene. Documentation and interviews revealed that these residents experienced delays in receiving help, resulting in episodes of incontinence and emotional distress. For example, one resident with a history of left femur fracture and moderate cognitive impairment reported being unable to access the restroom due to physical barriers and lack of staff response, leading to an incontinence episode. Another resident with spinal stenosis and impaired mobility stated that staff took a long time to assist her to the bathroom, despite her preference to use a commode or toilet rather than remain in a brief. Care plan reviews showed that some residents who were always or frequently incontinent did not have individualized care plans addressing their incontinence needs. For instance, residents with documented incontinence episodes throughout all shifts lacked specific interventions in their care plans to manage bladder incontinence. One resident with enterocolitis due to C. difficile, who was always incontinent with bowel movements, reported significant discomfort and skin irritation due to delays in incontinence care, stating it took hours to receive assistance after an episode of diarrhea. Staff interviews confirmed that the expectation was to provide incontinence care as soon as possible to maintain skin integrity and prevent irritation or infection. However, multiple residents described long wait times for assistance, leading to feelings of anger, distress, and being unvalued. Observations and interviews corroborated that the facility did not consistently provide timely and appropriate care for residents who were continent or incontinent of bowel/bladder, as required by facility policy.
Deficient Food and Nutrition Service Staff Training and Competency
Penalty
Summary
The facility failed to ensure that dietary staff had the appropriate skills and knowledge to safely perform food and nutrition service operations. Dietary Aide 1 was unable to correctly verbalize the manual dishwashing process using a 2-compartment sink, omitting the sanitizing step and not knowing the required sanitizer concentration. Facility policy required washing, rinsing, sanitizing at 200-400 ppm for at least 1 minute, and air drying, but DA 1 could not state these requirements. Additionally, DA 1 did not possess the required food handler's certificate as per the job description. Dietary Aide 2 was observed cleaning soiled food contact surfaces incorrectly by using a towel from a sanitizer bucket without first cleaning with soap and water, contrary to facility policy which mandates a two-step process of cleaning and then sanitizing. DA 2 also demonstrated improper technique in preparing and testing the sanitizer solution, including incorrect use of test strips and not adhering to the required solution temperature for accurate testing. The sanitizer solution was found to be below the recommended temperature range, and DA 2 did not have the required food handler's certificate, despite being listed as a cook in her employee file. Both DA 1 and DA 2 had documentation indicating competency in relevant procedures, and records showed they attended in-service trainings. However, there were no individualized lesson plans for the competency topics, and the Director of Food and Nutrition was responsible for training and ensuring compliance with infection control policies. These failures had the potential to place 88 out of 92 residents at risk for foodborne illness due to improper food handling and sanitation practices.
Infection Control Lapses: Tubing and Enteral Feeding Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Oxygen tubing for three residents with respiratory conditions, including chronic obstructive pulmonary disease, acute respiratory failure, and asthma, was found lying on the floor while in use. Licensed nurses and the Director of Nursing confirmed during interviews that the tubing should not be in contact with the floor due to infection control and safety concerns. Facility policy requires respiratory therapy equipment to be free from all microorganisms, and staff acknowledged the tubing's improper placement. A resident with a Foley catheter for urinary drainage was seen wheeling herself in a wheelchair with the catheter tubing dragging on the floor. Both a licensed nurse and the Director of Nursing confirmed the tubing was in contact with the floor and stated this was against infection control expectations. The facility's policy on indwelling catheters specifies that catheter tubing and drainage bags must be kept off the floor, and the Infection Preventionist reiterated that floor contact increases the risk of contamination. Additionally, a resident receiving continuous enteral feeding via a feeding tube was observed returning from physical therapy with the feeding formula and tubing left uncapped and open to air while disconnected. A licensed nurse confirmed that the uncapped tubing could lead to contamination, especially for vulnerable residents. Facility policies on enteral feedings and cleaning of resident-care items require aseptic technique and prevention of contamination, which were not followed in this instance.
Call Light Not Within Reach for Resident Requiring Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including muscle weakness, difficulty walking, and a history of falls, did not have their call light within reach on multiple occasions. The resident required partial to moderate assistance with activities of daily living, as documented in their Minimum Data Set. During observations, the call light was found on the floor behind the bed and later dangling off the side of the bed, both times out of the resident's reach. The resident expressed frustration about not being able to use the call light to request assistance, such as lowering the television volume, and noted that the privacy curtain was usually drawn, making it difficult to see staff passing by. The resident also mentioned that their roommate kept the television volume high, making it unlikely that staff would hear them if they called out. Staff interviews confirmed the call light was not within reach during these observations. A licensed nurse and a certified nurse assistant both acknowledged the issue when it was pointed out. The Director of Nursing stated that the expectation was for all call lights to be within reach of residents. A review of the facility's policy on answering call lights indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
A resident with a history of chronic pain and a stage 4 sacral pressure ulcer was admitted to the facility and was under hospice care. The resident had physician orders for pain assessment every shift using a standardized pain scale and for administration of morphine or oxycodone as needed for moderate to severe pain. The resident's care plan specified that pain should be managed to a tolerable level, with relief expected after comfort measures or medication. During wound care, the resident expressed significant pain, stating her pain was 'a lot,' and was observed moaning and crying throughout the procedure. The nurse performing the wound care did not use a pain scale to assess the resident's pain, nor was there documentation of pain medication being administered prior to the treatment, despite the resident's clear expressions of discomfort. The nurse also prolonged the resident's pain episode by not having all necessary supplies at hand, resulting in multiple trips to the treatment cart and extending the time the resident had to remain in a painful position. The Director of Nursing confirmed that the facility's expectation was for nurses to pre-medicate residents for pain prior to wound care and to use a pain scale for assessment. Facility policies required pain assessment using a standardized approach and for wound care supplies to be prepared in advance and within reach. These protocols were not followed, resulting in unmanaged pain for the resident during wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident diagnosed with chronic osteomyelitis and bacteremia. The resident was under Enhanced Barrier Precautions (EBP) for activities such as wound care, which required the use of personal protective equipment (PPE) including gowns. However, during an observation, a licensed nurse performed wound care on the resident without donning a gown, which was confirmed by the nurse as a deviation from the required protocol. Interviews with the Infection Preventionist and the Director of Nursing further confirmed that gowns are mandatory during high-contact care activities like wound care under EBP. The facility's policy, effective April 2024, mandates the use of gowns and gloves during such activities to mitigate infection risks. The failure to follow these guidelines had the potential to increase the spread of infection, as noted in the report.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency and local law enforcement, and did not report the results of the investigation within the required five working days. The incident involved a resident who was admitted with medical diagnoses including hemiplegia and hemiparesis following a cerebral infarction. The resident, who had an intact cognitive status, reported that a Certified Nursing Assistant (CNA) disrespected him by pushing her fingers into his chest and making demeaning comments. This grievance was documented, but the facility did not follow through with the necessary reporting procedures. Interviews with various staff members revealed a lack of consensus on the severity of the incident. The Director of Staff Development acknowledged receiving the grievance but did not report it further, considering it a customer service issue rather than abuse. Similarly, other staff members, including a Licensed Nurse and the Social Services Director, did not perceive the incident as abuse and did not take further action. The facility's policy on abuse prevention requires investigation and reporting of all possible incidents of abuse, but this protocol was not followed in this case.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in condition and emergency hospital transfer for one of the sampled residents. The resident, who had a history of memory problems with agitation and aphasia, exhibited aggressive and combative behaviors, prompting a transfer to the emergency department. Despite the facility's policy requiring notification of the RR in such situations, the RR was not informed until contacted by the hospital the following day, leading to feelings of astonishment and upset. The clinical record indicated that the physician was notified and an order for hospital transfer was obtained, but the documentation showed discrepancies in the timing of the RR notification. The Licensed Nurse (LN) involved acknowledged these discrepancies and the lack of documentation regarding the RR's response. The Director of Nursing (DON) confirmed that the RR should have been notified after the physician, as per facility policy, and recognized the RR's reaction upon learning of the transfer from the hospital.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards of quality for three residents. Resident 39 and Resident 240 were administered oxygen at rates inconsistent with their physician's orders and care plans. Resident 39 was observed receiving four liters of oxygen per minute instead of the prescribed two liters, and Resident 240 was observed receiving five liters per minute instead of the prescribed two liters. Both discrepancies were confirmed by licensed nurses and the Director of Nursing, who acknowledged that the incorrect oxygen administration could lead to carbon dioxide retention due to their diagnoses of COPD and acute respiratory failure. The facility's policy on oxygen administration was not followed, as it requires verification of physician's orders for oxygen administration. Resident 5 was not provided with an incentive spirometer as ordered by the physician. Despite a physician's order for the use of an incentive spirometer three times a day to improve lung function, the device was not available in Resident 5's room, and the resident had never seen or used it. Licensed Nurse 3 confirmed the absence of the device and admitted to not instructing Resident 5 on its use. The Director of Nursing stated that nursing staff are expected to follow physician's orders accurately and ensure that residents receive the prescribed treatments. The facility's policies on carrying out physician orders and incentive spirometry were not adhered to in this case.
Failure to Ensure Accurate Accountability and Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three out of four residents. Specifically, the controlled medications for Residents 6, 189, and 190 did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For Resident 6, tramadol was signed out on the CDR but not documented on the MAR for specific dates in February and March 2024. Similarly, for Resident 189, hydrocodone/APAP was signed out on the CDR but not documented on the MAR for a specific date in March 2024. For Resident 190, oxycodone was signed out on the CDR but not documented on the MAR for multiple dates in March 2024. During an interview, the Director of Nursing (DON) confirmed that nursing staff were expected to document on both the MAR and CDR whenever a controlled medication was administered. The facility's policy and procedure for controlled medications, dated May 2022, also indicated that the licensed nurse administering the medication should immediately enter the date, time, amount administered, and their signature on both the accountability record and the MAR. The failure to follow these procedures resulted in inaccurate accountability of controlled medications and potential for abuse or misuse.
Medication Administration Errors
Penalty
Summary
The facility had a 10.42% medication error rate when five medication errors out of 48 opportunities were observed during a medication pass for two residents. Licensed Nurse 1 (LN 1) administered Trelegy Ellipta to Resident 5 without instructing the resident to rinse and spit after use, contrary to the manufacturer's specifications. LN 1 acknowledged that she normally instructs residents to rinse and spit to prevent fungal infections but failed to do so in this instance. Licensed Nurse 4 (LN 4) made several errors while administering medications to Resident 189. LN 4 did not prime the insulin glargine and insulin lispro pens before administration, did not swab the rubber cap of the heparin vial with an alcohol pad, and administered heparin with a large air bubble in the syringe. Additionally, LN 4 administered insulin lispro after Resident 189 had eaten breakfast, contrary to the physician's order to administer it before meals. LN 4 also prepared a multivitamin with minerals instead of the prescribed plain multivitamin. The Director of Nursing (DON) confirmed that the correct administration of injectable medications is expected and part of the nursing staff's competency. The facility's policies and procedures for administering medications and subcutaneous medication administration were reviewed, indicating that medications should be administered safely, timely, and as prescribed, including verifying the right dosage and expelling air from syringes.
Failure to Provide Adaptive Eating Utensil
Penalty
Summary
The facility failed to provide a special eating utensil, specifically a rocker knife, for a resident with left side hemiplegia, muscle weakness, and lack of coordination. Despite the resident's meal ticket indicating the need for a rocker knife, the resident was observed without it during meals. The resident was unable to cut her food using a regular knife, which led to her not eating her lunch. This was confirmed by multiple staff members, including a Restorative Nurse Assistant and Central Supply, who acknowledged the absence of the rocker knife and the resident's inability to cut her food with a regular knife. Further review of the resident's records, including the Minimum Data Set, Order Summary Report, and Nutrition Care Plan, indicated that the resident required a rocker knife as adaptive equipment to promote self-feeding independence. Interviews with the Kitchen Dietary Manager and the Director of Nursing revealed that the facility never had a rocker knife available, and staff failed to notify the appropriate personnel about the unavailability of the utensil. This oversight contributed to the resident's weight loss and increased dependence on staff for feeding assistance.
Failure to Maintain Sanitary Food Storage and Handling
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a survey. Dietary staff were found not using hair nets and beard guards while in the kitchen, which is against the facility's dress code policy. Specifically, a Dietary Aid and the Kitchen Dietary Manager were observed without the required hair restraints. The Kitchen Dietary Manager confirmed that hair nets and beard guards are mandatory while in the kitchen. Additionally, several food items in the reach-in refrigerator and dry storage were not labeled with their open dates, and some were expired. This included two loaves of bread and heads of lettuce without date labels, expired left-over beef puree, and six opened bread bags without open date labeling. Furthermore, a Dietary Cook was about to reheat expired left-over roast beef, unaware of its expiration. The facility's policies on labeling, dating, and handling leftover foods were not followed, as confirmed by the Food Service Efficiency Consultant.
Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to follow proper infection control practices in two observed instances. First, a dietary cook did not perform proper hand hygiene while in the kitchen. The cook was observed washing her hands without using soap and scrubbing for less than 20 seconds, and pat drying her hands using her clothes. This was confirmed by the Food Service Efficiency Consultant, who stated that staff must perform hand washing before providing food services. The facility's policy on hand washing, dated 2023, indicated that hands need to be washed with soap and water for at least 20 seconds before starting work in the kitchen. Second, a licensed nurse did not change gloves and perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. The nurse was observed removing the old dressing, cleaning the wound, and applying a new dressing without changing gloves or performing hand hygiene between these steps. This was confirmed by the Director of Nursing, who stated that staff are required to change gloves from dirty to clean during the wound care process. These failures had the potential to spread infection within the facility.
Failure to Ensure Physician Approval for Self-Administered Medications
Penalty
Summary
The facility failed to ensure that self-administered medications kept at the bedside for one resident were reviewed and approved by a physician. During an observation, a Licensed Nurse (LN) was seen administering medications to a resident who had an albuterol inhaler on their bedside table without a pharmacy label. The resident mentioned that the inhaler was brought from the hospital and was not providing relief. Upon review, it was confirmed that there was no physician's order for the albuterol inhaler or for the resident to self-administer medications. The LN acknowledged that a physician's order was necessary for safe self-administration and that the medication should have been stored in a lockbox. The Director of Nursing (DON) stated that medications brought in by residents should be given to family members or securely stored with the DON. A resident assessment and a physician's order are required to allow self-administration of medication, and the medication should be stored in the medication cart. The facility's policies and procedures were reviewed, indicating that medications brought in by residents must be identified and approved by a physician or pharmacist, and residents may self-administer medications only if deemed safe by the attending physician and the Interdisciplinary Care Planning Team.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident 62's respect and quality of care were maintained when the resident was unable to reach the call light. Resident 62, who was admitted in 2024 with diagnoses including asthma and a left lower limb infection, reported during an observation and interview that she could not reach the call light while in her wheelchair because it was located on the other side of her bed. The Director of Nursing confirmed that the call light should have been within reach of the resident. The facility's policy, dated December 2022, indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide a Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident 37, who had a history of urinary tract infection, major depressive disorder, and paraplegia. Upon readmission from the hospital, Resident 37's room was cluttered with multiple personal belongings, including bags and boxes, which had not been unpacked since her return. Despite Resident 37's requests for assistance, the Social Services Assistant (SSA) and other staff members did not help her unpack, leading to a disorderly and cluttered room. This clutter prevented housekeepers from properly cleaning the area and created an unsafe environment for Resident 37, who was unable to adjust her bed or use the call light due to the clutter. The Director of Staff Development (DSD) and Licensed Nurse 1 (LN 1) acknowledged Resident 37's requests but failed to communicate them to the appropriate personnel, resulting in the continued disarray of her room. Resident 37's care plan indicated a need for a safe environment free from clutter due to her risk of falls related to paraplegia and gait/balance problems. However, the facility did not adhere to this care plan, as evidenced by the cluttered state of her room and the lack of assistance provided to unpack her belongings. The Director of Nursing (DON) confirmed that the SSA should have filed a grievance form or resident concern form and followed up until the problem was resolved. The facility's policy on providing a homelike environment was not followed, leading to Resident 37's increased anxiety and discomfort due to the disorderly state of her room and the inability to access her personal items.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for three residents. Resident 70's most recent quarterly MDS assessment did not reflect his impaired vision, despite observations and interviews indicating he had vision issues and had requested to see an eye doctor. The Activities Director and Social Services Assistant confirmed that Resident 70 used eyeglasses and had been requesting an optometrist visit, which had not been arranged yet. The Director of Nursing acknowledged that the MDS assessment should accurately reflect the resident's condition to develop an appropriate care plan. Resident 64's MDS inaccurately indicated that she had no feeding tube, despite her being observed with a feeding tube and her medical records confirming the need for enteral feeding due to gastrointestinal dysfunction. The MDS Coordinator and Director of Nursing confirmed the inaccuracy, noting that it could impact data collection, billing, and the delivery of specific care areas. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, which was not adhered to in this case. Resident 88's MDS inaccurately indicated that he was discharged to a hospital, while records and interviews confirmed he was discharged home with his daughter. The MDS Coordinator and Director of Nursing verified the discrepancy, acknowledging that the discharge status in the MDS was incorrect. These inaccuracies in the MDS assessments had the potential to affect the residents' care and interventions, as the assessments guide the development of care plans and other critical aspects of resident management.
Failure to Develop and Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and provide a baseline care plan (BCP) and written summary for one of 23 sampled residents (Resident 240) within 48 hours after admission. Resident 240 was admitted to the facility on [DATE], but the BCP was not completed until 3/19/24, and a printed summary was not provided to the resident or her representative. During an interview on 3/26/24, the Director of Nursing (DON) confirmed that the BCP was not completed within the required timeframe and acknowledged that the summary was not provided in writing. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a diagnosis of pulmonary dysfunction due to COPD exacerbation. The resident had physician's orders for the use of an incentive spirometer three times a day for 10 days and for the use of compression stockings for 10 hours daily. However, these orders were not included in the resident's care plan, which had the potential for the orders to be missed and not implemented. This was confirmed during interviews and record reviews with the licensed nurse, medical records director, and director of nursing, who all acknowledged the absence of the required care plans. The deficiency was identified during a review of the resident's medical records and order summary reports, which showed the specific orders for the incentive spirometer and compression stockings. Despite the facility's policy and procedure requiring comprehensive care plans to be developed and implemented for each resident within seven days, the care plans for these orders were not found. The director of nursing stated that she expects her staff to develop and revise care plans as necessary, but this was not done in this case.
Failure to Expel Air from Syringe Resulting in Incorrect Heparin Dose
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for Resident 189 when nursing staff did not expel air from a syringe, resulting in an incorrect dose of heparin being administered. During a medication pass observation, Licensed Nurse 4 (LN 4) was seen preparing ten medications for Resident 189, including heparin 5000 units/milliliter. LN 4 withdrew the medication and pulled the plunger back to the 1 milliliter measurement marker, but a large bubble was observed in the syringe, causing the heparin to be at the 0.88 milliliter measurement marker. LN 4 confirmed she had finished preparing the dose and administered the heparin into Resident 189's left lower abdomen without expelling the air from the syringe. A review of Resident 189's medical record indicated a physician's order for heparin 5,000 units/milliliter, to be injected 1 milliliter subcutaneously every 24 hours for deep venous thrombosis. During an interview, LN 4 acknowledged that she was unable to remove the bubble from the syringe and agreed that Resident 189 did not receive the correct dosage of heparin. The Director of Nursing confirmed that correctly administering injectable medications was an expectation and part of nursing staff's competency. The facility's policy and procedure for administering medications and subcutaneous medication administration both indicated that air should be expelled from the syringe before administering the medication.
Failure to Arrange Eye Doctor Consultation for Resident
Penalty
Summary
The facility failed to assist Resident 70 with the arrangement of an eye doctor consultation, which had the potential to delay the delivery of care to improve the resident's vision. Resident 70, who was admitted in June 2023 with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was observed squinting while watching television and reported that the reading glasses provided by the Activities Director caused headaches. Despite requesting to see an eye doctor, no consultation had been arranged by the time of the survey in March 2024. The Social Services Assistant (SSA) acknowledged that the last follow-up on Resident 70's request was documented in August 2023, with no further updates. The Director of Nursing (DON) confirmed that staff are expected to assess and identify residents' needs, including vision impairments, and assist in obtaining necessary services promptly. The facility's policies and procedures stipulate that staff should refer visually impaired residents for vision evaluations and provide medically-related social services to maintain or improve residents' abilities to meet everyday physical needs.
Failure to Follow Physician's Treatment Order for Pressure Ulcer
Penalty
Summary
The facility failed to follow a physician's treatment order for a stage 4 pressure ulcer for one resident. The resident, who was admitted in 2024 with diagnoses including diabetes and a stage 4 pressure ulcer, had a specific treatment order for the ulcer on the left posterior leg. The order required cleansing with normal saline, patting dry, applying collagen, hydroferra blue, triad cream to the margin, and a silicone border foam dressing with skin prep every Monday, Wednesday, and Friday during the day shift. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed while performing the dressing change. This was confirmed by the nurse during the observation and later by the Director of Nursing, who stated that staff are expected to follow physician orders for wound care. The resident's care plan, dated 3/25/24, indicated the presence of a pressure ulcer on the left leg and required the administration of treatment as ordered. The facility's policy on pressure ulcers, dated 4/2022, also indicated that the physician or nurse practitioner would order pertinent wound treatment, including wound cleaning and the application of topical agents. The failure to follow the prescribed treatment order had the potential to worsen the resident's current pressure ulcers.
Improper Checking of Roam Signal Device
Penalty
Summary
The facility failed to properly check the functionality of a roam signal device for a resident diagnosed with paranoid schizophrenia and Alzheimer's disease. The resident, who exhibited exit-seeking behavior, was observed wearing the device and propelling himself towards the dining room. The order summary indicated that the device should be checked for placement every shift and functionality every afternoon shift. However, the Licensed Nurse interviewed was unsure how to check the functionality and which staff was responsible for this task. The Director of Nursing confirmed that the device was checked by taking the resident near the main door, but acknowledged the need for a proper method to ensure the resident's safety. The facility's policy on assistive devices and equipment indicated that the facility provides, maintains, trains, and supervises the use of such devices for residents. Despite this policy, the improper checking method placed the resident at an increased risk for elopement. The Director of Nursing admitted awareness of the current checking method and recognized the necessity for a safer procedure. The failure to implement a proper checking method for the roam signal device led to the deficiency noted in the report.
Failure to Ensure Routine Midline Catheter Care
Penalty
Summary
The facility failed to ensure the routine care and dressing change of a midline catheter for one resident. During an observation and interview, it was noted that the dressing on the resident's midline catheter was dated 21 days prior, indicating it had not been changed as required. The Licensed Nurse confirmed that the dressing should have been changed. A review of the resident's physician's orders and medical records revealed no orders for flushing and locking the midline catheter or for changing the dressing. The Director of Nursing acknowledged that the nurses failed to add preset orders to the active orders, leading to the omission of necessary midline catheter care until the catheter was removed. This failure increased the risk of central line-associated bloodstream infections for the resident. The facility's policies and procedures for central venous catheter care and dressing changes were reviewed and indicated specific guidelines for flushing, locking, and changing dressings. These guidelines were not followed, as evidenced by the lack of documentation in the resident's medical records regarding the midline catheter care. The Director of Nursing confirmed that the nurses did not follow the facility's policies, resulting in the missed care and increased risk of infection for the resident.
Unattended Medications on Med Cart
Penalty
Summary
The facility failed to ensure medications were not stored on top of medication carts when left unattended. During an observation, a Licensed Nurse (LN 7) was seen preparing medications at a med cart in the hallway. LN 7 left the med cart unattended to locate a missing medication, leaving a bubble pack containing six hyoscyamine 0.125 mg tablets on top of the cart. LN 7 confirmed that the bubble pack was left unattended and not securely stored. The facility's policy and procedure for administering medication, dated April 2023, explicitly stated that no medications are to be kept on top of the cart.
Failure to Ensure Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically Dietary Cook 1 (DC1), in two critical areas. First, DC1 did not correctly follow the cooling down process for turkey, as evidenced by the cooling log being documented as complete while the turkey was still cooking in the oven. This was confirmed by both the Kitchen Dietary Manager (KDM) and the Food Service Efficiency Consultant (FSEC). Additionally, there was no cooling down process training or in-service provided to DC1 in 2023, as confirmed by the KDM. Second, DC1 demonstrated a lack of knowledge and adherence to proper procedures for pureeing food. During observations, DC1 did not use recipes, measuring tools, or utensils while pureeing beef, vegetables, starch, and bread biscuits. DC1 confirmed not knowing the correct puree consistency and not using any measurable tools or recipes. This was further corroborated by the FSEC, who stated that dietary staff should use recipes and measuring utensils when pureeing food. The facility's policy requires Food and Nutrition Services employees to demonstrate competency in food safety principles and job skills, which was not adhered to in this case.
Failure to Use Recipes and Measuring Tools for Pureed Diets
Penalty
Summary
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, pureed vegetable, and pureed starch. This deficiency was observed during the preparation of lunch, where the dietary cook used unmeasured amounts of ingredients and did not follow any recipes for pureeing beef, vegetables, sweet potatoes, and bread biscuits. The dietary cook confirmed that no measuring tools or recipes were used during the preparation process. The Food Service Efficiency Consultant confirmed that dietary staff should have used recipes and measuring utensils to maintain the nutritive value of the food. The facility's policy on food preparation, dated May 2023, indicated that food should be prepared by methods that conserve nutritive value, flavor, and appearance. This failure had the potential to decrease the nutrients in the food served and decrease food intake for five residents who received a pureed diet out of a facility census of 90.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was complete and posted on a daily basis at the beginning of each shift for a census of 90 residents. The Staffing Coordinator (SC) posted staffing information in the afternoon without including the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was observed on multiple occasions, including when the staffing information for the current date was not posted in the morning. The SC confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) forms for several dates did not include the required information and that staffing information was not posted on one of the dates. The facility's policy required daily posting of nurse staffing data for each shift, but this was not adhered to, as confirmed by the SC.
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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.
Illustrative
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Illustrative
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Ridge Healthcare Center | 10.3 mi | ★★★★★ | 20 | 0 |
| Roseville Point Health & Wellness Center | 10.7 mi | ★★★★★ | 9 | 0 |
| Roseville Care Center | 11.2 mi | ★★★★★ | 2 | 0 |
| Pine Creek Care Center | 11.2 mi | ★★★★★ | 1 | 0 |
| Auburn Oaks Care Center | 11.4 mi | ★★★★★ | 9 | 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.