Below 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 Aperion Care Lincoln during CMS and state inspections, most recent first.
Uncovered food was observed on the steam table during lunch service, and a staff member touched a towel, tray tops, serving ware, and her face with gloved hands before plating food without changing gloves, including placing rolls on plates by hand. In a separate dietary pantry observation, the ice scoop for the ice machine was left sitting on top of the machine without a cover.
An RN failed to follow infection control practices during medication administration by touching medication cards with gloved hands, not cleaning an insulin pen's rubber seal, and not cleaning the resident's injection site before giving insulin. A QMA reused a blood pressure cuff between residents without cleaning it, and staff did not follow EBP or glove-change requirements during wound care, including an RN who did not wear a gown for a resident with a chronic wound and an LPN who touched the floor and then the resident's leg with the same gloves.
Missed Scheduled Bathing for Two Residents: The facility failed to provide bathing on scheduled days for two residents who were dependent on bathing. One resident with hemiplegia, anxiety, and depression was observed with greasy hair, an unshaven face, emesis, and dried feces, and the CNA task record showed missed showers despite a set schedule. Another resident with COPD and intact cognition also missed multiple scheduled showers. The DON stated some showers were missed, especially on evenings, and shower documentation could not be found for the missed days.
Surveyors found that one unit was not maintained in a clean, safe, and homelike condition, with debris and dirt buildup on stairs, hallways, and around door frames, cove base pulling away from walls, and soiled carpets in a common room. A kitchenette near the main dining room had debris on the floor and under a storage rack, a large dead bug, a soiled trashcan exterior, a refrigerator interior contaminated with black and red substances, and a freezer with excessive ice buildup. Debris was also present under desks and around walls at two nurses’ stations. Resident Council minutes documented repeated complaints that rooms, bathrooms, toilets, and floor edges and corners were not being cleaned well, despite the housekeeping policy and the Housekeeping Director’s statement that floors were to be mopped daily.
A resident with traumatic brain injury, paraplegia, and a recent history of pressure injuries was admitted with a documented stage 2 right hip ulcer and toe wounds, but the admitting LPN did not perform a head-to-toe skin assessment and relied on verbal handoff instead. Subsequent skin assessment reports recorded only a shoulder surgical incision and no other skin issues, while the MDS documented no pressure ulcers or scars despite prior documentation of a right hip ulcer and toe wounds. A facility-acquired unstageable pressure ulcer on the right great toe was later identified, and treatment orders for toe wounds and a pillow boot were initiated, revealing that required admission skin assessments, ongoing wound documentation, and monitoring per facility policy were not completed.
An LPN was hired and allowed to work independently on multiple units without verification of an active nursing license, contrary to facility policies and job requirements that mandate proof of current licensure and adherence to professional standards and state regulations. Review of the personnel file showed no documentation of a valid license, and the Administrator acknowledged that licensure had not been confirmed before the LPN provided nursing care to residents.
Surveyors found that pharmaceutical services did not ensure timely availability of routine medications, resulting in multiple missed doses for two residents. One resident with depression and anxiety missed scheduled doses of Ativan when the facility ran out and the pharmacy was awaiting a new prescription. Another resident with vitamin deficiency, cerebral palsy, and reduced mobility missed several doses of a multivitamin, a vaginal lubricant, and Chlorzoxazone over multiple days, with nursing notes repeatedly citing medications as on order, pending pharmacy arrival, or not available. An RN reported that nurses are responsible for reordering medications before they run out, and facility policy requires pharmacies to refill prescriptions in time to prevent interruption of drug regimens.
A facility did not report an alleged sexual abuse incident between two residents, one of whom was unable to give consent, to the State Survey Agency. The DON and Administrator were aware of the incident but did not report it, citing lack of awareness of the requirement and absence of a specific reporting policy.
A facility failed to thoroughly investigate and document an alleged incident of sexual abuse between two residents. Although staff were made aware of inappropriate sexual requests and possible exposure, there was no formal documentation or comprehensive investigation as required by facility policy. Interviews confirmed that while the event was discussed and capacity assessments were performed, the necessary investigative steps and documentation were not completed.
A resident with a surgical wound and diabetes had physician orders for a wound vac to be changed every three days, but the wound vac was not changed on two scheduled dates. The DON confirmed the missed treatments, and facility policy required documentation of such treatments, which was not completed.
A resident requiring moderate staff assistance with bathing did not receive scheduled baths or hair shampooing for several weeks, as confirmed by both observation and record review. The resident was noted to have poor hygiene and reported not having had a bath or bed linen change in weeks, despite facility policy requiring bathing to be offered at least twice weekly.
A resident with a history of mental health and behavioral issues made inappropriate sexual advances toward another resident with cognitive impairment. The incident was not documented, care plans were not updated, and there was no evidence of monitoring or follow-up, despite facility policies requiring these actions. Staff interviews revealed a lack of awareness and documentation regarding the event and the residents' behavioral health needs.
Surveyors found that the medication room, treatment cart, and medication refrigerator containing insulin and other medications were left unlocked. A QMA confirmed these areas were supposed to be locked, and facility policy required all medications and biologicals to be securely stored.
Staff did not knock or announce themselves before entering rooms to deliver meal trays, as observed and confirmed by staff and resident council complaints. Facility policy requires staff to protect residents' privacy by knocking and requesting permission before entering.
A resident reported that meals were sometimes served cold, and food temperature checks during a meal revealed that hot foods were below the facility's preferred standard of 120°F. Facility guidelines require monitoring and investigation of food temperature complaints, but observations showed these were not consistently met.
Surveyors found that food items in the kitchen were not consistently labeled or properly sealed after opening, and kitchen floors behind equipment remained soiled despite facility policies requiring daily cleaning. The Dietary Manager and staff described practices that did not align with written procedures, resulting in unsanitary food storage and preparation areas.
A resident with dementia and severe cognitive impairment exhibited wandering and elopement behaviors, but the facility failed to complete and document required elopement risk assessments in the clinical record as per policy. The lack of documentation persisted even after incidents of wandering and an actual elopement, resulting in incomplete and inaccurate records.
A resident with a history of hypertension and hypertensive encephalopathy did not receive prescribed antihypertensive medications on multiple occasions, as documented in the MAR. These medication omissions led to two separate hospitalizations for hypertensive emergencies. Staff interviews revealed a lack of clear policy on blood pressure parameters and adherence to physician orders.
Surveyors found that food items in both dry storage and the reach-in refrigerator were not labeled with open, preparation, or use-by dates. The Dietary Manager confirmed that labeling is required, and facility policy mandates all food items be labeled with the name and consumption date.
The facility did not ensure a certified Infection Preventionist was designated and assigned at least part-time hours to oversee the infection prevention and control program. The DON was responsible for the program in addition to her full-time DON duties, and there was no signed job description confirming assignment of the IP role.
The facility did not complete required quarterly care plan conferences for several residents, including those with cognitive impairment and complex medical conditions. Documentation was missing for recent conferences, and some residents had not had a care plan conference since admission, despite facility policy requiring quarterly participation by residents or their representatives.
Surveyors observed persistent offensive odors, including urine and feces, in hallways, alcoves, and stairwells, as well as unsanitary conditions in two residents' rooms, such as dirty floors and showers and food crumbs. Staff interviews revealed inconsistent cleaning practices and the absence of a daily cleaning list, despite facility policy requiring a clean and odor-free environment.
Multiple residents dependent on staff for ADLs did not receive scheduled showers or hair care as outlined in their care plans, with observations and interviews revealing missed showers, unwashed hair, and inadequate hygiene. Residents with significant medical needs reported infrequent bathing and lack of haircuts, and staff cited ongoing staffing shortages as a contributing factor. The DON confirmed the facility was aware of these ongoing issues, and documentation showed repeated failures to meet residents' bathing preferences.
A meal tray served to a resident included carrots at 115°F, which was below the facility's required holding temperature of 140°F as stated in policy. The Dietary Manager confirmed the expected standard, and the deficiency was identified during a survey in response to a complaint.
A resident who was cognitively intact and dependent on staff for transfers was not consistently able to attend mass as desired due to delays in morning care and insufficient staffing. The resident's care plan documented her preference to get up by a certain time, but staff were unable to consistently meet this preference, resulting in missed opportunities to participate in religious activities.
A resident was not properly informed of her rights and did not receive or sign her admission paperwork, despite documentation indicating otherwise. The resident reported being unaware of her rights and stated the signature on the admission packet was not hers. The Social Services Director confirmed that copies of admission packets are only provided upon request.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss over a short period, but this was not accurately coded on the MDS assessment as required. Clinical records and staff interviews confirmed the weight loss, yet the MDS continued to indicate no weight loss, contrary to facility policy and assessment guidelines.
QMAs administered PRN pain medications and insulin to two residents without obtaining required nurse authorization or following documentation protocols. One resident with diabetes received hydrocodone-acetaminophen from a QMA without nurse approval, while another resident with cerebral palsy and diabetes received insulin and multiple PRN pain medications from QMAs, contrary to facility policy and QMA scope of practice.
Two residents developed facility-acquired heel pressure ulcers due to the facility's failure to identify risk, perform routine skin checks, and consistently follow wound care plans. Both residents were assessed as at risk for pressure ulcers, but comprehensive care planning and monitoring were lacking prior to ulcer development. Multiple wound treatments were missed without documentation of refusal, and physician orders for wound care were not consistently followed, as confirmed by interviews and record review.
Two residents with severe cognitive impairment and repeated falls were not consistently provided with required fall prevention interventions, supervision, or prompt assistance. Numerous falls were not followed by timely care plan updates, IDT reviews, or fall risk assessments, and essential safety measures such as call lights within reach and non-skid footwear were often missing. Documentation and communication lapses further contributed to ongoing fall incidents and injuries.
A resident with dementia, diabetes, and dysphagia experienced a significant, unaddressed weight loss, with no documentation of physician notification, dietitian referral, or nutritional assessment. Despite repeated notes from a mental health NP and the resident's own report of weight loss, the facility failed to re-weigh the resident, update the care plan, or involve the IDT, contrary to facility policy.
A resident with a feeding tube did not consistently receive enteral nutrition as ordered by the physician, with frequent undocumented interruptions in feeding, incomplete documentation of intake, and failure to change feeding equipment daily. Facility staff did not consistently document refusals or notify the physician when the resident did not receive the prescribed amount of nutrition, contrary to facility policy.
Staff failed to follow infection control protocols during care for two residents, including not changing gloves or performing hand hygiene between dirty and clean tasks during incontinence and wound care. Facility policy requires glove changes and hand hygiene, but these steps were not consistently followed by the CNA and RN involved.
A resident with cerebral palsy and other conditions was injured during a transfer using a Hoyer lift due to improper use and inadequate staffing. The lift tipped over because the resident's weight was not centered, and the procedure for safe transfers was not followed, resulting in the resident sustaining knee and back injuries.
Uncovered food and improper glove use during meal service
Penalty
Summary
Food was not served under sanitary conditions during lunch service in the first-floor dining room and dietary pantry. During a continuous observation, staff placed food trays in the steam table with the food left uncovered from 11:58 A.M. until 12:10 P.M. The food included chicken, potatoes, carrots, mashed potatoes, gravy, rolls, hot dogs, and cheeseburgers. At 12:16 P.M., [NAME] 7 put on gloves and touched a towel, tray tops, serving ware, and her face, then began plating food at 12:19 P.M. without changing gloves. She placed rolls onto plates using her hand until 12:33 P.M., when she began using tongs. During a separate observation of the dietary pantry, the ice scoop for the facility ice machine was found sitting on top of the machine without an appropriate cover. The DON stated that staff should not touch food while serving and that proper kitchen tools should be used, and also stated that ice scoops should be covered when not in use. The Administrator provided policies stating scoops are to be stored in a protected manner and that utensils only should be used when serving food, with gloves changed anytime a contaminated surface is touched.
Infection Control Practices Not Followed During Medication Administration and Wound Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for four residents and during wound care for two residents. During medication preparation for one resident, an RN wore gloves, touched the medication cart, computer, and water jug, and then removed tablets from medication cards into her hand without changing gloves. The DON stated that medications should be popped directly into the medication cup and never touched with a bare or gloved hand. During insulin administration for another resident, an RN prepared a Basaglar Kwikpen without cleaning the rubber seal with an alcohol swab before attaching the needle, then administered 12 units of insulin glargine to the resident's left arm without cleaning the injection site with alcohol first. The resident's record showed diagnoses including peripheral vascular disease, and the insulin pen insert and facility policy both indicated that the rubber seal should be wiped with alcohol and the skin should be wiped with alcohol before injection. The DON stated that staff should clean the rubber seal port and the injection site prior to administering insulin. During vital sign checks, a QMA used the same wrist blood pressure cuff on two residents without cleaning it between uses. During wound care, an RN provided care to a resident with a venous stasis ulcer and an EBP order without wearing a gown, even though the resident's record showed chronic wound care needs and the facility's EBP policy required gown and glove use for wound care. In another wound dressing change, an LPN touched the floor while wearing gloves and then touched the resident's leg without changing gloves. The DON stated that staff should clean vital sign equipment between residents and change gloves between dirty and clean tasks.
Missed Scheduled Bathing for Two Residents
Penalty
Summary
The facility failed to ensure bathing was provided on scheduled days for 2 of 5 residents reviewed for bathing, identified as Resident F and Resident T. Resident F had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, anxiety, and depression. The current Quarterly MDS indicated Resident F was cognitively impaired and dependent on bathing. Observation on 5/20/26 found Resident F sitting in a wheelchair with greasy hair, an unshaven face, and a dark substance coming out of the nose. Observation on 5/21/26 found Resident F lying in bed with greasy hair, an unshaven face, emesis in the bed and floor, and dried feces in the sheets. The CNA POC task showed showers were scheduled for Monday, Wednesday, and Friday nights per the resident's preference, but showers were not received on 5/13/26 and 5/18/26, and the resident was sent to the hospital on 5/15/26. Resident T had a diagnosis of chronic obstructive pulmonary disease. The current Annual MDS indicated Resident T was cognitively intact and dependent on bathing. The CNA POC tasks showed showers were scheduled for Tuesday, Thursday, and Saturday evenings per the resident's preference, but showers were missed on 5/2/26, 5/9/26, and 5/12/26. During interview, the DON stated that some showers were missed, especially on the evening shift, and later could not find shower documents for the days that were not documented in the CNA tasks reviewed. The facility policy stated that a shower, tub bath, or bed/sponge bath would be offered according to resident preference two times a week or according to preferred frequency and as needed or requested, and that bathing tasks and assistance provided would be documented in the electronic record.
Failure to Maintain Clean, Safe, and Homelike Environment on One Unit
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, sanitary, and homelike environment on one of two units (the 100 Unit). On multiple observations, debris buildup was noted on the stairs leading to the unit, including a folded band-aid on the steps. Walls in common areas, including by the stairwell and across from a room marked medical suite, had cove base coming off. Dirt was built up under water fountains, around double fire doors, and in the corners and around door frames in the hallways and resident room entrances. A room containing a fireplace and piano had soiled, stained carpets. A kitchenette near the main dining room had debris on the floor and under a metal storage rack, a large dead bug under the rack, a soiled exterior trashcan, a refrigerator interior soiled with a black and red substance, and a freezer with ice buildup. The two nurses’ stations on the unit had debris buildup on the floor under the desks and around the walls. Resident Council meeting minutes further documented concerns about inadequate cleaning. On one date, residents reported that rooms were not being cleaned well, bathrooms were being left dirty, and toilets were not being cleaned. On another date, residents reported that floors were not being cleaned well, especially along the edges and in the corners. The Housekeeping Director stated that floors were supposed to be mopped daily in resident rooms and throughout the units. The Administrator provided a housekeeping services policy stating the facility was to maintain a clean, odor-free, comfortable, and orderly environment in all health care and public areas. These observations and resident reports showed that the facility did not follow its own policy and did not maintain the required environmental standards on the 100 Unit.
Failure to Complete Admission Skin Assessment and Monitor Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and skin assessment for a resident admitted with existing pressure areas and at risk for pressure injuries. The resident, who had traumatic brain injury, paraplegia, a lower leg amputation, and a cognitive communication deficit, had been hospitalized shortly before admission and received specialty bed support and wound care for pressure injuries. Hospital information and the facility’s admission/readmission observation on the day of admission documented a stage 2 pressure ulcer on the right trochanter (hip), and an admission checklist the following day noted wound care to the right great and second toes with betadine. However, the admission MDS completed shortly after admission indicated the resident had no pressure ulcer/injury, no scar over a bony prominence, and no non-removable dressing or device. Skin assessment reports completed on two dates after admission documented only a right shoulder surgical incision and no other skin impairments. The admitting LPN reported she completed the admission/readmission form based on hospital report of a right hip stage 2 pressure ulcer but did not perform a head-to-toe skin assessment because the resident did not want to get into bed, and she relied on passing the need for a skin assessment to the night nurse. The DON later acknowledged that the admission checklist comments about buttock and toe skin areas were not followed up on and that the right hip should have been documented on skin assessments. A facility-acquired unstageable pressure ulcer on the right first toe was identified on a wound assessment dated approximately two weeks after admission, and subsequent physician orders were written for pillow boot use and iodine treatment to the right great and second toe wounds. At the time of survey observation, the right hip showed pink scar tissue with a dry callous and no open area, and the resident stated he had this area for a long time. Facility policies required a head-to-toe skin condition assessment and pressure ulcer risk assessment at admission/readmission, completion of a skin condition report with any wound or skin breakdown, and weekly assessment and documentation of pressure and other ulcers, but these processes were not carried out as required for this resident.
Unverified LPN Licensure Resulting in Unqualified Nursing Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by qualified personnel in accordance with each resident’s written plan of care. During review of an employee file for an LPN hired in late September and terminated in early November, surveyors found no documentation of an active LPN license. The Administrator reported that the LPN had been hired without verification of licensure and that the facility was unable to confirm that this individual ever held an active nursing license. The Administrator further indicated that the LPN worked on all units in the facility and provided dates on which the LPN worked independently after an initial orientation period. The facility’s own documents required proof of current licensure upon application for employment and at least annually thereafter, and the LPN job description specified that the position required a current, unencumbered state LPN license. Additional policies and role descriptions referenced that an LPN must accept assignments consistent with education, training, and competency, and adhere to professional standards, facility policies, and applicable state laws and regulations. Despite these written requirements, the LPN’s personnel file lacked evidence of a valid license, and the Administrator acknowledged that licensure had not been verified before the LPN was allowed to work and provide nursing care to residents on multiple units.
Failure to Ensure Timely Availability of Routine Medications
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided physician-prescribed routine medications as ordered, resulting in missed doses for two residents. One resident with diagnoses including depression and anxiety had a physician order for Ativan 1 mg three times daily starting in December. Review of the January Medication Administration Record (MAR) showed that the 2:00 p.m. and 8:00 p.m. doses on one day were not documented as administered. Nursing progress notes for that day documented that the pharmacy was waiting on a new prescription and that the pharmacy was aware of the need for the medication, and the resident reported she had recently not received her routine antianxiety medication because the facility had run out. Another resident, with diagnoses including vitamin deficiency, cerebral palsy, and reduced mobility, had physician orders for a daily multivitamin, daily vaginal lubricant (Replens gel), and Chlorzoxazone 500 mg four times daily. The January MAR showed multiple days when these medications were not administered. The multivitamin was not given on one day; Replens gel was not given on four separate days; and Chlorzoxazone was not given on multiple consecutive and nonconsecutive days. Nursing notes repeatedly documented that these medications were pending pharmacy arrival, on order, not available, or waiting on pharmacy delivery, and that the facility was out of Replens and had reordered it. An RN stated it was the nurse’s responsibility to reorder medications before they ran out. The facility’s pharmaceutical services policy stated that residents may use a pharmacy of their choice as long as the pharmacy refills prescription drugs when needed to prevent interruption of drug regimens.
Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents to the State Survey Agency. According to interviews, a CNA informed the DON that one resident entered another resident's room, asked inappropriate sexual questions, and requested to be her boyfriend. The resident who was approached was not capable of giving consent. The DON also learned that the resident exposed her breasts to the other resident. Both the DON and the Administrator were aware of the incident but did not report it to the State Survey Agency, as they were unaware of the reporting requirement. The Administrator also stated that the facility did not have a policy related to reporting alleged violations and instead followed state regulations.
Failure to Investigate and Document Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving two residents. According to interviews and record review, a CNA reported to the DON that one resident entered another resident's room and made inappropriate sexual requests. The DON completed a capacity for sexual consent assessment for both residents and instructed the resident not to ask such questions again. However, there was no documentation of the incident or the investigation, despite the facility's policy requiring such documentation. Further, it was reported that the resident who was approached may have exposed herself, but this was also not documented or investigated thoroughly. Interviews with the DON, Administrator, and Regional President of Operations revealed that while the incident was discussed among staff and both residents were interviewed, there was no formal documentation or evidence of a comprehensive investigation. The facility's policy mandates that any suspicion of non-consensual sexual relations or questions about a resident's capacity to consent should trigger an investigation, with findings documented in the resident's record. In this case, the required documentation and investigative steps were not completed.
Missed Wound Vac Changes for Resident with Surgical Wound
Penalty
Summary
The facility failed to ensure that wound treatments were completed as ordered for a resident with a surgical wound and a diagnosis of type 2 diabetes mellitus. The resident had a physician's order for a wound vac to be changed every three days, starting from a specified date. Review of the electronic treatment administration record showed that the wound vac was not changed on two scheduled dates in September, as required by the physician's order. During interviews, the DON confirmed that the wound vac changes were missed on those dates. Facility policy required that physician-ordered treatments be documented by staff after each administration, but this was not done for the missed treatments.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and personal hygiene for a resident who required moderate staff help. The resident, who was cognitively intact and diagnosed with type 2 diabetes mellitus, reported not having received a bath or had bed linens changed in weeks. During observation, the resident exhibited a strong sour odor, greasy hair, and long, soiled fingernails. Review of both paper and electronic records confirmed that the resident had not received or refused a bath or shower on multiple documented dates over the past month, and had not had their hair shampooed during that period. Facility policy required that showers, tub baths, or bed/sponge baths be offered according to resident preference at least twice weekly, but this was not followed for the resident in question.
Failure to Document and Address Sexual Behaviors and Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of mental health disorders, substance use, and behavioral issues. An incident occurred in which the resident made inappropriate sexual advances toward another resident who had moderate cognitive impairment. The incident was not documented in the clinical record, and there was no evidence that the care plan was updated to address sexual behaviors or that the resident was monitored for such behaviors following the event. Interviews revealed that staff, including the Social Services Director and Certified Nurse Aides, were either unaware of the incident or did not document the behaviors and follow-up actions. The Director of Nursing acknowledged that a report was made about the incident and that capacity for sexual consent assessments were completed for both residents, but there was no documentation of the incident, investigation, or subsequent monitoring in the clinical records. Additionally, the family of the resident with cognitive impairment was not notified of the incident, despite claims to the contrary. The facility's documentation systems, including progress notes and care plans, lacked information about the sexual incident, the behaviors exhibited, and the interventions or monitoring implemented. The facility's policies required investigation, documentation, and care plan updates in response to such incidents, but these procedures were not followed. As a result, the necessary behavioral health services and protections were not provided to the residents involved.
Failure to Secure Medication Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of medications in the first floor medication room. On observation, the medication room containing the Emergency Drug Kit (EDK) was found unlocked, and within the room, both the treatment cart and the medication refrigerator, which contained insulin, suppositories, and other cold medications, were also unlocked. During the observation, a Qualified Medication Aide (QMA) confirmed that the medication room, treatment cart, and medication refrigerator were all supposed to be locked. Review of the facility's current Medication Storage policy indicated that all medications and biologicals, including treatment items, should be securely stored in locked compartments or rooms inaccessible to residents and visitors.
Failure to Knock or Announce Before Entering Resident Rooms During Meal Delivery
Penalty
Summary
Staff failed to honor residents' rights to dignity and respect by not knocking or announcing themselves before entering resident rooms during meal tray delivery. This was observed when a CNA delivered lunch trays to multiple rooms without knocking or introducing herself. Resident council minutes also documented a complaint regarding staff not knocking or introducing themselves prior to entering rooms. Another CNA confirmed that the expected practice is to knock and inform residents before entering with food. The facility's policy requires staff to protect and value residents' private space, including knocking and requesting permission before entering rooms.
Failure to Serve Food at Appetizing and Safe Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature for residents, as evidenced by observations and interviews on unit 200. One resident reported that food was not always served hot and was sometimes ice cold depending on delivery time. During a meal service, food temperatures were measured and found to be below the facility's preferred standard, with the pork loin at 115°F, stuffing at 85°F, and peas at 79°F. The facility's guidelines require hot foods on room trays to be at 120°F or greater to promote palatability, and complaints about food temperature are to be documented and investigated. However, the observed temperatures and resident complaint indicate that these procedures were not consistently followed.
Failure to Maintain Sanitary Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to serve food in a sanitary manner according to professional standards during two separate kitchen inspections. In the walk-in freezer, partially used bags of breaded chicken, mixed vegetables, and garlic bread were found unlabeled, and later, an open box of fish squares was left unsealed and exposed to air. The kitchen floor behind the stove, deep fryer, and under a stainless steel table with a sink had visible soil buildup and debris, and these areas remained soiled several days later. The Dietary Manager stated that floors under equipment are typically cleaned once a week, while facility policy requires daily cleaning. Additionally, although the facility's policy mandates labeling and dating opened food items, this was not consistently followed, as evidenced by the unlabeled and improperly stored food items.
Failure to Maintain Accurate Elopement Risk Assessments and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a history of dementia and cognitive impairment. Although the care plan identified the resident as being at risk for elopement and required quarterly reassessment, there was no documentation of elopement risk assessments in the clinical record except for one completed after an actual elopement event. The facility's policy required new assessments after any actual or attempted elopement or when exit-seeking behaviors were identified, but these were not documented as required. The resident exhibited wandering behaviors, including an incident where the resident left the floor, exited the building, and was found outside by a staff member. Despite these behaviors and the facility's policy, the required elopement risk assessments were not completed or documented in the clinical record prior to the elopement event. The administrator confirmed that paper assessments could not be located and that the assessments were not transcribed into the clinical record, resulting in incomplete and inaccurate documentation.
Failure to Administer Antihypertensive Medications Leads to Hospitalizations
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident not receiving prescribed blood pressure medications on multiple occasions. The resident, who had a diagnosis of hypertensive encephalopathy and was moderately cognitively intact, had physician orders for several antihypertensive medications, including Carvedilol, Isosorbide Mononitrate, Lisinopril, and later Hydralazine. On at least two documented occasions, the resident did not receive these medications as ordered, with the electronic medication administration record (MAR) showing missed doses and a lack of blood pressure recordings. Following these missed doses, the resident experienced hypertensive emergencies that required hospitalization. On one occasion, the resident was found on the floor complaining of pain, and his blood pressure was significantly elevated upon hospital admission. On another occasion, after missed medication doses and absent blood pressure documentation, the resident developed chest pain and was again hospitalized for a hypertensive emergency. Interviews with facility staff revealed that there was no policy provided regarding blood pressure parameters and following physician orders, and the DON stated that staff should use nursing judgment and follow physician orders.
Failure to Label and Date Food Containers in Storage and Refrigeration
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner during kitchen inspections. In the dry storage area, a bag of noodles and a bag of marshmallows were found without open dates. In the reach-in refrigerator, multiple containers of juices and fluids were present without labels, preparation dates, or use-by dates. The Dietary Manager confirmed during an interview that containers should be labeled with preparation and use-by dates. The facility's food storage policy, provided by the Director of Nursing, also requires all food items to be labeled with the name of the food and the date it should be consumed by.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified and certified Infection Preventionist (IP) responsible for the infection prevention and control program. Review of the Director of Nursing's (DON) employee file revealed the absence of a signed job description for the IP role. The DON confirmed she was currently responsible for the infection prevention and control program while also working full time as the DON. Although a current IP job description was available, it was not signed or assigned, and the DON's job description did not reflect the IP responsibilities. This resulted in the lack of a dedicated staff member with at least part-time hours assigned specifically to the IP role, as required.
Failure to Hold Quarterly Care Plan Conferences for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for six out of seven residents reviewed. For several residents, including those with diagnoses such as cerebral palsy, diabetes mellitus, major depressive disorder, dementia, repeated falls, wedge compression fracture, hypertensive encephalopathy, and hypertension, the most recent care plan conferences were either not held within the required quarterly timeframe or had not been conducted since admission. Clinical records showed that some residents had not had a care plan conference for several months, and in two cases, no care plan conference had been held since the residents were admitted. Interviews and record reviews confirmed that the facility's policy required residents and/or their representatives to be invited to participate in care plan conferences at least quarterly, either in person, by phone, or via video conference. However, documentation for recent care plan conferences was missing for multiple residents, and the Director of Nursing acknowledged that these conferences were supposed to be held quarterly. Requests for records of care plan conferences for certain residents could not be fulfilled, further confirming the deficiency.
Failure to Maintain a Safe, Clean, and Odor-Free Environment
Penalty
Summary
The facility failed to provide a safe, clean, and odor-free environment for residents, staff, and the public, as evidenced by multiple observations of offensive odors and unsanitary conditions over a five-day period. Strong smells of urine were repeatedly detected in public hallways, alcoves, stairwells, and near the chapel, as well as outside specific resident rooms and the Holy Family Nurses Station. Additionally, the smell of feces was noted in alcoves on the second floor. These conditions were observed on several occasions, indicating a persistent issue rather than isolated incidents. Further, interviews and direct observations revealed that resident rooms and bathrooms were not being cleaned adequately. One resident reported that her room was not cleaned daily, and brown dried mud and dirty shower floors were observed in her room on separate days. Another resident's family member reported finding food crumbs behind drawers, and subsequent inspection confirmed the presence of food crumbs, a sticky bathroom floor, and a dirty shower floor. A housekeeper stated there was no daily cleaning list and described inconsistent cleaning practices. The DON confirmed that there should be no offensive smells in the building and provided a policy stating the facility's intent to maintain a clean, odor-free environment, which was not being met.
Failure to Provide Scheduled Showers and Hair Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs), specifically bathing and hair care, for 9 out of 10 residents reviewed. Multiple residents who were dependent on staff for bathing and personal hygiene did not receive showers or hair shampooing according to their care plans and preferences. Observations and interviews revealed that residents often received bed baths without hair washing, and some residents' hair appeared oily, unkempt, or unwashed. Several residents and family members reported infrequent showers, lack of haircuts, and inadequate hygiene, with some residents expressing dissatisfaction with the timing and quality of care provided. Clinical record reviews indicated that these residents had significant medical conditions such as cerebral palsy, diabetes mellitus, dementia, depression, hypertensive encephalopathy, and malignant neoplasm, and required varying levels of staff assistance for ADLs. Documentation showed missed showers on multiple scheduled days for each resident, and in some cases, no documentation of hair washing since admission. Care plans consistently indicated a preference for showers two times per week, but these preferences were not met. Staff interviews confirmed ongoing issues with staffing shortages, which contributed to the inability to complete all required ADL care. The Director of Nursing acknowledged that the facility was aware of the ongoing problem with missed ADL care, including showers, and that there was no designated staff member responsible for ensuring showers were given. Facility policy required that residents be offered showers or baths according to their preferences at least twice weekly, but this was not consistently implemented. The deficiency was cited under 3.1-38(a)(3) and related to specific complaints.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by an observation of a meal tray on the 200 Unit where the carrots measured 115 degrees F. According to the Dietary Manager, the expected holding temperature on the steam table should be 145 degrees F or higher. The facility's policy on Monitoring Food Temperatures for Meal Service requires serving/holding temperatures to be at least 140 degrees F prior to meal service, and hot foods on room trays should be at 120 degrees F or greater for palatability. The deficiency was identified during a survey and relates to a specific complaint.
Failure to Accommodate Resident's Choice to Attend Religious Activity
Penalty
Summary
A resident with diagnoses including cerebral palsy and major depressive disorder, who was cognitively intact and dependent on staff for toileting and bathing, was not accommodated in her choice to attend mass due to delays in morning care. The resident expressed that staff did not always get her up in time for mass, which was scheduled daily at 11:00 A.M. Observations confirmed that on one occasion, the resident was still in bed waiting for staff to use a mechanical lift to transfer her, despite her care having just been completed. The resident's care plan indicated a preference to get up for the day at 10:00 A.M. or as desired, and that she required assistance from two staff members and a mechanical lift for transfers. Staff interviews revealed that there was insufficient staffing to complete all required tasks in a timely manner. The facility's Resident Rights policy stated that residents have the right to self-determination, including the right to choose activities and schedules consistent with their interests, such as participating in religious activities. The failure to accommodate the resident's choice to attend mass was attributed to staffing limitations and delays in providing necessary morning care and transfers.
Failure to Provide and Verify Resident Rights and Admission Paperwork
Penalty
Summary
The facility failed to ensure that a resident was properly informed of her rights and provided with the required admission paperwork. During interviews, the resident stated she was unaware of her rights and had not received or signed an admission packet. Review of the clinical record showed an admission packet was signed electronically by both the Social Services Director and the resident, but the resident later stated the signature was not hers. The Social Services Director confirmed that residents sign admission packets electronically and are only given a copy if they request it. The facility's policy requires healthcare professionals to make prompt, factual, and complete documentation entries.
Failure to Accurately Code Significant Weight Loss on MDS Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was completed accurately for a resident with significant weight loss. The resident, who had diagnoses including dementia, diabetes mellitus, and dysphagia, was documented as having severe cognitive impairment and requiring setup assistance for eating. The Annual MDS Assessment recorded the resident's weight as 179 pounds with no weight loss, while the subsequent Quarterly MDS Assessment listed the weight as 132 pounds, also indicating no weight loss. However, clinical records showed the resident's weight dropped from 179.3 pounds to 131.7 pounds between assessments, representing a 26.55% loss, and further decreased to 123.3 pounds, totaling a 31.23% loss since the initial weight. Staff interviews confirmed the weight loss should have been coded on the MDS, but it was not, despite facility policy to follow the Resident Assessment Instrument (RAI) Manual for MDS coding.
QMAs Administered PRN Medications and Insulin Outside Scope of Practice
Penalty
Summary
The facility failed to ensure that Qualified Medication Aides (QMAs) practiced within their defined scope of practice for two residents who were reviewed for unnecessary medications. For one resident with type 2 diabetes mellitus, a QMA administered hydrocodone-acetaminophen, a pain medication, on multiple occasions without prior authorization from a nurse, as required by policy and the QMA scope of practice. The resident was noted to be moderately cognitively intact, and the medication was ordered to be given as needed for pain. For another resident with cerebral palsy, diabetes mellitus, and pain, QMAs administered both insulin and various PRN pain medications, including hydrocodone-acetaminophen, Tylenol, and Excedrin, without obtaining prior authorization from a nurse. The facility's policy did not permit QMAs to administer insulin, even if they were insulin certified. The QMA scope of practice and job description both required that PRN medications only be administered with nurse authorization, and that such administration be properly documented and cosigned by a licensed nurse. These requirements were not followed, as evidenced by the medication administration records and interviews with facility staff.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address the risk of pressure ulcer development, perform routine skin checks, and follow care plans to promote wound healing for two residents who developed facility-acquired heel wounds. In the first case, a resident admitted for therapy after fracture surgery, with diagnoses including diabetes mellitus with polyneuropathy, was assessed as at risk for pressure ulcers but had no comprehensive care plan addressing this risk. The clinical record lacked weekly skin observations for over a month, and a new pressure injury to the right heel was only documented after this period, by which time the wound had progressed and required advanced interventions, including a wound vac and surgical procedures. In the second case, another resident admitted for therapy after an accident was also assessed as at risk for pressure ulcers but did not have monitoring for skin breakdown prior to the development of a pressure injury. The resident developed a deep tissue injury to the left heel, and although a care plan was created after the ulcer appeared, there were multiple documented instances where prescribed wound treatments were not administered as ordered and not refused by the resident. This included several missed dressing changes over multiple months, as evidenced by gaps in the treatment administration record. Observations and interviews confirmed that wound care orders were not consistently followed, and dressings were not changed as scheduled. The facility's policy required regular skin inspections and adherence to physician orders for wound care, but these were not implemented as documented. The Director of Nursing acknowledged that staff should be following physician's orders as written, but the records and observations indicated otherwise.
Failure to Implement and Document Fall Prevention Protocols for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls were adequately supervised and protected from accident hazards, as evidenced by repeated failures to follow fall protocols, update care plans, and implement or maintain fall prevention interventions. Both residents had extensive histories of falls, with one resident experiencing 23 falls and the other 34 falls within a year. Despite documented high fall risk and multiple interventions listed in their care plans, there were numerous instances where interventions were not in place, such as call lights not being within reach, lack of non-skid footwear, and absence of required safety equipment like dycem or non-skid strips. Observations also revealed that residents were left unattended in their rooms, contrary to care plan instructions. The clinical records for both residents showed significant gaps in documentation and follow-through after falls. Many falls lacked Interdisciplinary Team (IDT) notes, timely updates to care plans with new interventions, and completion of fall risk assessments. In several cases, there was no evidence that the physician or responsible party was notified after a fall, and some falls were only referenced in 72-hour charting notes without details on the circumstances or follow-up. Additionally, some interventions added to care plans after IDT reviews were not observed to be implemented during surveyor observations. Both residents had complex medical histories, including dementia, muscle weakness, repeated falls, and other comorbidities that increased their vulnerability. Despite these risks, the facility did not consistently anticipate or meet their needs, failed to ensure prompt response to call lights, and did not always provide appropriate supervision or assistance with toileting and transfers. The lack of consistent documentation, communication, and implementation of fall prevention strategies contributed to ongoing falls and injuries for these residents.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident with multiple diagnoses, including dementia, diabetes mellitus, and dysphagia. The resident experienced a significant and unaddressed weight loss, dropping from 179 pounds to 131.7 pounds within a short period, representing a 26.55% decrease. Despite this substantial weight loss, there was no documentation of physician notification, referral to the dietitian, or a nutritional assessment by the dietitian. The care plan identified the resident as being at risk for altered nutritional status, but no updated interventions or reviews were documented in response to the weight loss. The clinical record lacked evidence that the resident was re-weighed after the initial significant weight loss was identified, despite repeated notes from the mental health nurse practitioner highlighting the issue and requesting re-weighs. There was also no documentation of review by the Interdisciplinary Team (IDT) regarding the weight loss. The resident herself reported noticeable weight loss and ill-fitting clothes, yet no action was documented to address her nutritional needs or investigate the cause of the weight loss. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the weight loss was not properly identified or coded, and that the dietitian did not follow up as required. The facility's own policy required reporting significant weight changes to the physician and dietitian, as well as obtaining re-weights for discrepancies, but these steps were not taken for this resident. The deficiency was identified during a complaint investigation.
Failure to Follow Physician Orders and Document Enteral Nutrition Administration
Penalty
Summary
The facility failed to ensure that physician orders for enteral nutrition were followed and that appropriate documentation and care were provided for a resident receiving tube feedings. Observations over several days revealed that the resident's enteral nutrition was frequently turned off outside of the physician-ordered two-hour break, and feeding equipment, such as syringes, was not changed daily as required. The feeding formula and equipment were observed to be dated from previous days, and the feeding tube was found uncapped and wrapped around the pole when not in use. The resident in question had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and dementia, and was dependent on staff for transfers. The care plan required monitoring of caloric intake, and physician orders specified a continuous enteral feeding regimen with specific amounts and times, as well as regular flushing and equipment changes. However, the Medication Administration Record (MAR) showed inconsistent documentation of the amounts of formula administered, with several days lacking complete records or showing significant deviations from the ordered volume. There was also a lack of documentation regarding when the enteral nutrition was turned off or when the resident refused nutrition, except for two documented refusals with physician notification. Facility policies required close monitoring of tube feeding tolerance, intake and output, and prompt documentation of changes in the resident's condition, including refusals and notifications to the physician. Despite these policies, the clinical record did not consistently reflect refusals, changes in feeding administration, or timely notifications to the physician when the resident did not receive the prescribed amount of nutrition. Interviews with the DON and Regional Nurse confirmed that documentation and adherence to physician orders were expected but not consistently followed in this case.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during care for two of three residents observed. In one instance, during incontinence care, a CNA sanitized hands and donned gloves, while an RN only donned gloves. The CNA then gathered supplies with gloved hands, provided care, and applied barrier cream without changing gloves or performing hand hygiene between tasks. The same gloves were used to place barrier cream and to put on a clean incontinence brief, with the CNA wiping the gloved hands inside the clean brief. The RN removed soiled gloves and washed hands after care, but the CNA did not change gloves or perform hand hygiene as required by facility policy. In another instance, during wound care, an RN applied hand sanitizer, donned a gown and gloves, and performed wound care procedures. After removing the gown and gloves, the RN put on a new pair of gloves to apply a heel boot but did not perform hand hygiene during or after the procedure. The facility's policy requires gloves to be changed and hand hygiene to be performed when moving from dirty to clean tasks and after glove removal, which was not followed in these observed cases.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate safety measures during the transfer of a resident, resulting in an accident. Resident B, who has a history of cerebral palsy, knee pain, osteoarthritis, and asthma, was being transferred from her bed to a shower chair using a Hoyer lift. During the transfer, the lift tipped over due to uneven weight distribution, causing the resident to sustain injuries, including a bruised knee and back pain. The incident occurred with only one staff member initially assisting, despite the resident's care plan indicating the need for two staff members for transfers. The incident was further complicated by the improper use of the Hoyer lift. The CNAs involved in the transfer did not follow the correct procedure, which requires the resident's weight to be centered over the base of the lift's legs and the resident to face the attendant operating the lift. Instead, the lift was brought in sideways, and the shower chair was tilted, leading to the lift tipping over. The CNAs attempted to stabilize the situation, but the resident still ended up on the floor, although she did not hit her head. The facility's Director of Nursing confirmed that staff receive training on Hoyer lift use during orientation and at quarterly skills fairs. However, the incident revealed a lapse in following the established procedures for safe transfers. The facility's procedure guide emphasizes the importance of keeping the lift's base spread to its widest position for stability and ensuring the resident faces the attendant, which was not adhered to in this case.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 293 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Brentwood Care Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Envive Of Evansville | 1.5 mi | ★★★★★ | 7 | 0 |
| Columbia Healthcare Center | 2 mi | ★★★★★ | 9 | 0 |
| Evansville Protestant Home | 2 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 2.1 mi | ★★★★★ | 0 | 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.