Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Park Manor Inc during CMS and state inspections, most recent first.
The facility did not ensure that the director of food and nutrition services had the required certification as a CDM, as both the dietary manager and administrator were still in the process of obtaining certification. The registered dietician visited only twice a month, and the facility's policy requiring specific qualifications for this role was not met.
Staff did not consistently follow Enhanced Barrier Precautions or proper hand hygiene during wound care for two residents with pressure ulcers, including not wearing gowns, not changing gloves at appropriate times, and not performing hand hygiene between glove changes. Additionally, a resident's oxygen and nebulizer equipment was not properly stored when not in use, contrary to facility policy.
The consultant pharmacist did not provide the required monthly drug regimen review, resulting in missed communication of medication recommendations for several residents, including those prescribed antipsychotic and antidepressant medications. As a result, necessary recommendations for gradual dose reduction or physician rationale were not relayed to prescribers, and medication irregularities were not addressed in a timely manner.
Surveyors found that medication carts were left unlocked and unattended, insulin pens were not labeled or dated when opened, and expired medications were present in both medication carts and the emergency medication kit. Staff confirmed these deficiencies, which were not in accordance with facility policy requiring secure storage and proper labeling of all medications.
A resident with COPD and moderately impaired cognition was allowed to keep and self-administer an inhaler at bedside without a physician's order or documented assessment of self-administration ability. The resident's care plan required staff to administer medications, and facility policy mandated an IDT assessment and order before permitting self-administration, but these were not completed.
Staff left a resident's electronic medical record open and visible on a medication cart laptop, failing to secure protected health information. A CMA and a nurse both confirmed that screens and carts should be locked when unattended, in accordance with facility policy.
The facility did not ensure proper management and documentation of psychotropic medications for several residents, including missing stop dates for PRN antianxiety medication, lack of appropriate indications and risk/benefit documentation for antipsychotic use, and failure to obtain or document physician responses to pharmacist recommendations for gradual dose reduction of antidepressants. Required policies for psychotropic and antipsychotic medication use were not provided when requested.
Two residents with complex medical needs did not have their care plans updated after significant changes in condition, including hospital readmission and the need for Enhanced Barrier Precautions. Staff were not provided with current guidance on required care interventions or PPE use, leading to care being delivered without appropriate infection control measures and without reflecting the residents' increased need for assistance.
A resident with COPD and other conditions did not have their oxygen tubing, cannula, and nebulizer mask stored in a sanitary manner as required by facility policy. Staff left these respiratory devices unbagged and exposed in the resident's room, despite being aware of the need to keep them bagged when not in use.
Two residents receiving hospice care did not have their care plans updated to include specific details about hospice services, such as the frequency of visits, supplies, medications, and equipment provided by hospice. Although hospice documentation was present in the medical records and staff confirmed regular hospice involvement, the care plans lacked this essential information, resulting in incomplete coordination of care as required by facility policy.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications, specifically the certification as a certified dietary manager (CDM). Observations and interviews revealed that the current dietary manager and the administrator were both enrolled in classes to obtain CDM certification but had not yet completed them. The facility's policy required the director of food and nutrition services to be a CDM, a certified food service manager, be nationally certified in food service management and safety, have an associate's degree in food service management or hospitality, or have two or more years of experience in the position along with a completed course in food safety and management. At the time of the survey, these requirements were not met, and the registered dietician was only present twice a month, though available by phone.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during wound care for two residents. In one instance, two licensed nurses provided wound care to a resident with a Stage 2 pressure ulcer without following EBP guidelines, such as wearing gowns and changing gloves at appropriate times. The care plan for this resident did not include specific instructions for EBP or the required personal protective equipment (PPE), and a certified nurse aide was unaware that EBP was necessary for this resident. The resident had multiple diagnoses, including Alzheimer's disease, COPD, hemiparesis, and was dependent on staff for all activities of daily living. In another case, wound care for a resident with a Stage 4 pressure ulcer was performed without the use of protective gowns, and hand hygiene was not consistently performed between glove changes or after glove removal. One nurse applied clean gloves without performing hand hygiene, failed to don a gown, and did not sanitize hands after removing gloves or handling trash. The facility's policies required the use of gowns and gloves for high-contact care activities and specified hand hygiene before and after glove use, but these protocols were not followed during the observed care. Additionally, the facility failed to ensure that a resident's nasal cannula and nebulizer mask were properly stored when not in use, which could contribute to infection risk. The facility's own policies on EBP and hand hygiene were not adhered to during these care activities, as evidenced by staff statements and direct observation.
Failure to Provide Timely Monthly Drug Regimen Review and Communicate Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist failed to provide a monthly Drug Regimen Review (MRR) for February 2025, as required by facility policy and federal guidelines. This omission resulted in the facility and physicians not receiving timely recommendations regarding residents' medication regimens. Specifically, the pharmacist did not communicate recommendations for gradual dose reduction (GDR) or request a physician's rationale and risk versus benefit analysis for certain psychotropic medications prescribed to residents. The absence of the February 2025 MRR meant that medication irregularities were not identified or addressed in a timely manner. For one resident with diagnoses including Alzheimer's disease, hypertension, anxiety, and depression, the medical record showed ongoing use of antipsychotic, antidepressant, and antianxiety medications. The pharmacist's review noted the lack of an allowable diagnosis for the antipsychotic medication and requested a risk versus benefit statement or discontinuation, but this recommendation was not sent to the facility or physician, resulting in no physician response. The resident's care plan required quarterly consultation with pharmacy and physician to consider dosage reduction, but this process was not followed due to the missing review. Another resident with diabetes and major depressive disorder was prescribed sertraline, an antidepressant. The pharmacist had previously recommended a GDR or rationale for continued use, but no physician response was documented. The February 2025 MRR, which reiterated this recommendation, was not sent to the facility until months later, and the physician did not receive it. Facility policy required the consultant pharmacist to review each resident's medication regimen monthly and communicate any irregularities to prescribers and facility leadership, but this was not done for the month in question.
Failure to Secure, Label, and Remove Expired Medications
Penalty
Summary
Surveyors observed multiple instances where the facility failed to ensure the proper labeling, dating, and secure storage of medications and biologicals. On several occasions, medication carts were found unlocked and unattended, and medications such as insulin pens were not labeled with resident names or dates of opening. Additionally, expired medications, including aspirin, Systane eye drops, Dulcolax pills, melatonin, artificial tears, lidocaine jelly, and epinephrine auto-injectors, were found in both medication carts and the emergency medication kit. These findings were verified by various staff members, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, who acknowledged the presence of expired and unlabeled medications and the failure to secure medication carts as required by facility policy. The facility's policies, dated February 2023, required that all medication storage areas be locked when not in use, that medication labels include the resident's name and expiration date, and that insulin pens be labeled and dated when opened. Despite these policies, staff did not consistently follow procedures for medication security and labeling, resulting in the presence of expired and improperly labeled medications accessible in the facility. No specific residents were identified as directly affected in the report, but the deficiencies were confirmed through direct observation and staff interviews.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, edema, chronic pain, anxiety, hypertension, and atrial fibrillation, was allowed to keep and self-administer a Breztri inhaler at her bedside without a physician's order or a documented assessment of her ability to safely self-administer medications. The resident's medical record indicated moderately impaired cognition and a care plan that directed staff to administer medications as ordered. The self-administration assessment documented that the resident required assistance for all medications, including inhalants, and there was no order permitting self-administration or bedside storage of the inhaler. During medication administration, a licensed nurse discovered the inhaler was not in its box and found it on the resident's bedside table. The resident self-administered the inhaler in the nurse's presence. Facility policy required an interdisciplinary team assessment and a physician's order before allowing self-administration or bedside storage of medications, but these steps were not completed for this resident.
Failure to Secure Resident Medical Record on Medication Cart Laptop
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left a resident's point of care information open and visible on the electronic medical record system at the medication cart laptop, making the information accessible to unauthorized individuals. A certified medication aide acknowledged that the screen should not be left unlocked with resident information displayed. A licensed nurse confirmed that both the medication cart and the laptop screen should always be locked when unattended, and an administrative nurse stated that nursing staff are expected to lock any screen on the laptop and secure the medication cart when not in direct sight. The facility's policy requires that protected health information not be used or disclosed except as permitted by law.
Failure to Ensure Proper Management and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate management and documentation of psychotropic medications for multiple residents. For one resident with diagnoses including vascular dementia, anxiety, bipolar disorder, and major depressive disorder, the physician’s order for PRN Ativan lacked a required stop date, and the medication was administered without issue. The facility did not provide a policy for psychotropic medication use when requested, and the administrative nurse confirmed that the Ativan order should have included a stop date and reassessment by the physician. Another resident with Alzheimer’s disease, anxiety, and depression was prescribed Seroquel for anxiety and agitation, with the dose later increased. The care plan directed staff to consider dosage reduction quarterly, but the physician’s order did not include an appropriate indication or documentation of risk versus benefit for the antipsychotic use. The administrative nurse acknowledged that agitation was not an appropriate diagnosis for Seroquel and that the physician needed to provide ongoing justification for its use. The facility was unable to provide a policy for antipsychotic medication use upon request. A third resident with diabetes and major depressive disorder was prescribed sertraline, with the consultant pharmacist recommending a gradual dose reduction or rationale for continued use. There was no documented physician response to these recommendations, and the administrative nurse confirmed that the physician had not received or responded to the pharmacist’s recommendations. The facility’s pharmacy services policy required monthly medication regimen reviews and communication of recommendations, but the facility did not provide a specific policy for psychotropic drugs.
Failure to Update Care Plans After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that care plans for two residents were updated to reflect their current care needs following significant changes in their conditions. One resident, who had diagnoses including Alzheimer's disease, COPD, hemiparesis, and anxiety, was dependent on staff for all activities of daily living and had a Stage 2 pressure ulcer. Despite being on hospice and requiring Enhanced Barrier Precautions (EBP) due to an open area, the care plan did not include interventions or directions for staff regarding the use of personal protective equipment (PPE) necessary for infection control. Staff interviews revealed a lack of awareness about the resident's EBP status, and care was provided without appropriate PPE, as confirmed by both nursing and administrative staff. Another resident, with diagnoses of paraplegia, hypertension, pressure ulcer, and osteomyelitis, experienced a significant change in condition after a hospital stay and was placed on hospice services. The resident's Minimum Data Set (MDS) indicated increased dependence on staff for activities of daily living, but the care plan was not revised to reflect these changes. The care plan continued to document previous levels of independence and did not address the resident's current needs for assistance, despite the resident now requiring more substantial support and the use of a mechanical lift with two staff members for transfers. Facility policy required that comprehensive, person-centered care plans be developed and updated within specific timeframes following significant changes in a resident's condition, including after hospital readmission and at least quarterly. In both cases, the care plans were not updated as required, resulting in a lack of clear guidance for staff and the potential for delayed or missed care.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
Staff failed to provide adequate respiratory care and services for a resident diagnosed with COPD, vascular dementia, anxiety, bipolar disorder, and major depressive disorder. The resident had physician orders for supplemental oxygen via nasal cannula and nebulizer treatments, with care plans and facility policy directing that oxygen tubing, cannula, and nebulizer mask be stored in a plastic bag when not in use to prevent infection. However, observations revealed that the resident's oxygen tubing and cannula were left unbagged and draped over a lamp, and the nebulizer mask was left unbagged on a table beside the resident's recliner on multiple occasions. Interviews with staff confirmed awareness of the policy requiring these respiratory devices to be bagged when not in use, and staff acknowledged that bags had been provided for this purpose. Despite this, the resident's preference to drape the tubing over the lamp was noted, and staff did not consistently ensure proper storage as required by facility policy. The facility's infection prevention policy specifically directed staff to keep these items in a plastic bag when not in use, but this was not followed, resulting in a failure to maintain sanitary storage of respiratory equipment.
Failure to Coordinate and Document Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure proper collaboration and communication between hospice providers and facility staff for two residents receiving hospice care. For one resident with Alzheimer's disease, COPD, hemiparesis, and anxiety, the care plan documented receipt of hospice services and provided general instructions for comfort and medication administration. However, it lacked specific details about the hospice services being provided, such as the frequency of support visits, supplies and medical equipment covered by hospice, medications provided, and the hospice provider's contact information. The resident's records confirmed hospice admission, and staff interviews indicated that hospice staff visited regularly, but the care plan was not updated to reflect these arrangements. For another resident with paraplegia, hypertension, a stage 4 pressure ulcer, and osteomyelitis, the care plan noted a terminal prognosis and receipt of hospice services. The plan included directions for comfort measures and collaboration with the hospice team but did not specify which durable medical equipment, supplies, or medications were provided by hospice, nor did it detail the hospice staff involved or the frequency of their visits. Although the resident's electronic medical record contained the hospice plan of care and related documentation, this information was not incorporated into the care plan used by facility staff. Facility policy required coordinated care plans for residents receiving hospice services, including the most recent hospice plan of care and details of care and services provided by both the hospice and the facility. Staff interviews confirmed that care plans should include all relevant hospice information, but this was not consistently done for the residents in question. As a result, the facility did not ensure comprehensive and coordinated care planning for residents on hospice, as required by its own policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Ellsworth Village | 23.3 mi | ★★★★★ | 1 | 0 |
| Wilson Care And Rehab | 23.6 mi | ★★★★★ | 19 | 0 |
| Minneapolis Healthcare And Rehabilitation Center | 24.7 mi | ★★★★★ | 0 | 0 |
| The Nicol Home | 27.3 mi | ★★★★★ | 0 | 0 |
| Mitchell County Hospital Health Systems Ltcu | 28.9 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.