Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Haven Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Food and nutrition services staffing did not meet required qualifications because the DM was not a CFPM or RD and had only been employed for 6 weeks. The RD stated she visited bi-weekly, completed remote assessments, and was a consultant, while invoice review showed only 26.75 billed hours over 3 months. The NHA stated she handled food ordering and essentially ran the kitchen due to the DM being new.
Premises repair was not maintained when the vegetable wash sink, the 3-compartment sink, and the ice machine were observed with drain lines extending into and below the lip of floor drains, with no air gap present at the ice machine. A closet door in a room was also observed askew with a damaged top track and part of the door hanging away from the frame.
Failure to obtain informed consent for psychotropic meds: two residents received antipsychotic/antidepressant therapy without documented consent for the current order or dose/form change. One resident with bipolar disorder and anxiety had a switch from IM risperidone to oral Risperdal without a new consent, and another resident with MS and depression had venlafaxine ordered without a consent found in the EMR; the SSD also could not locate one.
Missing Bed Hold Documentation for Residents Transferred to ED: The facility failed to provide and document bed hold information for three residents who were transferred to the ED. EMR review showed blank bed hold paperwork and no record that the information was given to the resident and/or representative during hospital transfers. The SSD confirmed the bed hold information was not provided or scanned into the EMR.
Inaccurate MDS coding for resident receiving Hospice services. A resident with CHF, AFib, acute respiratory failure with hypoxia, and HTN was receiving Hospice care, but the MDS assessments and CMS 802 did not reflect Hospice status. The MDS Coordinator confirmed the resident was not coded for Hospice and stated the assessment may not have been updated after Hospice began.
Failure to document follow-up care and physician notification for elevated blood glucose: A resident with DM was on sliding-scale insulin and ordered BG monitoring. Records showed 40 BG readings over 400 mg/dL, but the MD was documented as notified only six times, and no follow-up BG rechecks were documented in the EMR to show whether levels were trending down or still elevated.
Failure to Allow A Resident to Use Own Power Wheelchair: A resident with MS and depression was not allowed to use her own PWC in the facility, despite OT documentation that she used it at home, was safe to operate it, and could transfer independently without a slide board. She reported she could only tolerate a couple of hours in the facility wheelchair, had not been up for days, and was not told at admission she could not keep her PWC. Staff interviews showed the BOM did not review the PWC policy during admission, and the NHA acknowledged the resident would benefit from using her custom PWC in her room.
Failure to follow a resident’s fluid restriction and diet order. A resident with MI and CKD had orders for 1500 cc fluid restriction, NAS diet, Lasix for edema, and daily weights, but was observed consuming fluids beyond the ordered limit, the tray card listed beverages totaling 1800 cc per day, and staff did not consistently document fluid intake or daily weights. Staff interviews showed confusion about tracking fluids, and the care plan did not reflect the ordered fluid restriction and related monitoring.
A facility failed to notify a physician of a resident's elevated blood glucose levels, which exceeded 400 mg/dL on multiple occasions. Despite the facility's protocol requiring physician notification for such levels, there was no documentation of this occurring. Interviews with staff confirmed the protocol was not followed, leading to a deficiency in care.
The facility failed to monitor and assess two residents' blood glucose levels adequately. A resident with diabetes had a high blood glucose level that was not re-checked as ordered, and another newly admitted resident lacked a baseline care plan and had missing blood glucose and vital sign records. The DON confirmed that these actions were against facility policies.
A resident with peripheral vascular disease and cellulitis was not consistently provided with physician-ordered protective boots to prevent pressure ulcers. The boots were not included in the care plan, leading to staff being unaware of the requirement. The resident was observed without the boots on multiple occasions, despite a moderate risk of pressure ulcers.
A resident admitted for rehabilitation after foot amputation did not receive timely pain management due to a delay in processing the necessary C-2 form for controlled substances. The resident, experiencing significant pain, did not receive prescribed oxycodone with acetaminophen until 20 hours post-admission. The delay was attributed to a failure in the facility's process for obtaining controlled substances, as the form was not sent to the medical director for authorization promptly.
The facility failed to properly store and dispose of medications, with discontinued controlled substances remaining in medication carts and loose pills found in another cart. The DON admitted to being too busy to destroy medications promptly, and the NHA was unclear about the frequency of medication destruction. Facility policies on medication disposal and storage maintenance were not adhered to.
The facility failed to employ a qualified Certified Dietary Manager, resulting in issues with meal quality and resident satisfaction. Residents reported minimal entree choices, decreased palatability, and some missed meals. The Registered Dietician confirmed the absence of a CDM, and the Director of Nursing temporarily assumed the role without starting CDM classes. A resident experienced significant weight loss, which was not addressed with nutritional supplementation. The Nursing Home Administrator, overseeing the department without CDM qualifications, was unaware of these concerns.
The facility failed to maintain resident equipment, including two residents' wheelchairs and bed remote controls, in safe and operational condition. One resident's wheelchair had worn wheels and lacked a cushion, while another's wheelchair had malfunctioning brakes and damaged upholstery. Additionally, bed remotes were removed from all residents' beds, causing inconvenience and potential safety concerns. Staff reported difficulties in providing care due to inaccessible bed remotes.
The facility failed to provide adequate meal choices and alternatives, affecting four residents who reported dissatisfaction with meal options, quality, and portion sizes. Residents expressed frustration with the lack of variety and the facility's failure to honor their dietary preferences and needs, including low-salt diets and fresh fruit. Staff confirmed the limited meal options and inadequate portions, leading to residents sometimes going hungry.
A resident, who was cognitively intact and the resident council president, reported that his clothing was returned from the facility laundry with bleach stains and damage. Despite raising the issue with laundry staff, no follow-up occurred, leading to frustration. The staff member acknowledged the oversight but did not report the issue due to time constraints. The facility failed to uphold the resident's rights to voice grievances and maintain personal clothing.
The facility failed to ensure fresh water was consistently offered and provided to four residents, resulting in dissatisfaction and potential dehydration. Observations and interviews revealed that residents had either warm, nearly empty water pitchers or no water at all, and fresh water was not passed out until late in the morning, contrary to the facility's policy.
Food and Nutrition Services Staffing Qualifications Not Met
Penalty
Summary
Employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian, was not met because the facility did not have a director of food and nutrition services who met the required qualifications within the allowed timeframe. During interview, the dietary manager stated she did not have a Certified Professional Food Manager Certification and was not a Registered Dietitian, and she said she had only been at the facility for a short time and had not yet obtained the certifications. She also stated the facility had a Registered Dietitian. In a phone interview, the Registered Dietitian stated she came into the facility bi-weekly, with two visits per month, and also completed remote assessments, and said she was a consultant for the corporation. The nursing home administrator stated the Registered Dietitian was full-time for the facility, but also stated the dietary manager had been employed for 6 weeks. Review of the Registered Dietitian’s invoices showed a total of 26.75 billed hours for December 2025 through February 2026 combined, with 6.25 hours in December, 10 hours in January, and 10.5 hours in February. The nursing home administrator also stated she did all of the food ordering and pretty much ran the kitchen because the dietary manager was so new.
Premises Repair and Drain Line Deficiencies
Penalty
Summary
The facility failed to maintain general repair of the premises. During observation, the vegetable wash sink was found indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain, and the Dietary Manager stated that vegetables are washed in this sink. The double doors for the closet in room [ROOM NUMBER] were observed with the left door askew, the top track damaged and no longer working, and the upper left portion of the door hanging away from the frame about 5 inches. The drain line from the third bin of the three-compartment sink was also observed extending down into and below the lip of the floor drain, and the Dietary Manager stated this sink is used to wash, rinse, and sanitize utensils that do not go through the dish machine. In addition, the ice machine used for resident food prep and drinks had drain lines extending down into and below the lip of the floor bowl drain, with no air gap present.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated on the risks and benefits of prescribed psychotropic medications and that informed consent was obtained before administration for two residents. For Resident #7, the electronic medical record showed a diagnosis of bipolar disorder and generalized anxiety, and the resident was receiving Risperdal 0.5 mg by mouth at bedtime. The record also showed a prior psychoactive medication consent for Risperdal Consta IM, signed by the responsible party, but there was no signed informed consent for the change in form and dosage from Risperdal Consta IM every two weeks to oral Risperdal daily, including the risks and benefits of the change. For Resident #21, the record showed diagnoses of multiple sclerosis and major depressive disorder, recurrent and in full remission. Progress notes documented concerns about depression, sadness, and a request for another antidepressant, and physician orders showed venlafaxine (Effexor) was prescribed. The resident stated she did not recall signing a consent for the antidepressant and was not sure she was still taking one. The social services designee could not locate a consent for venlafaxine in the electronic medical record and did not know why one was not on file. The facility policy stated residents and/or representatives would be educated on the risks and benefits of psychotropic medication use, including alternatives, before use.
Missing Bed Hold Documentation for Residents Transferred to ED
Penalty
Summary
The facility failed to provide required bed hold information for three residents who were transferred to the ED. Resident #3 was transferred on 12/16/25, Resident #6 was transferred on 1/8/26, 3/19/26, and 3/27/26, and Resident #17 was transferred on 12/10/25 and 3/7/25. For each of these residents, the EMR did not contain documentation showing that bed hold information was provided to the resident and/or the resident representative at the time of transfer. During record review, each resident’s bed hold paperwork was found blank and not completed. On 3/30/26, the Social Services Designee was interviewed and provided a binder with the facility’s transfer and bed hold information, and confirmed that Residents #3, #6, and #17 did not have bed hold information provided during the transfers and that none was scanned into the EMR. The facility policy stated that bed hold information is to be provided at admission and again prior to transfer due to hospitalization or therapeutic leave, and that a copy of the resident’s bed-hold or release record is to be filed in the medical record.
Inaccurate MDS coding for resident receiving Hospice services
Penalty
Summary
The facility failed to ensure accurate resident assessments for a resident receiving Hospice services. The resident was admitted to the facility with diagnoses including congestive heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and hypertension. The resident’s legal guardian reported that the resident was currently receiving Hospice services, and the EMR showed a Hospice admission notification signed by the Hospice provider, with the resident listed as having Hospice as the primary payer. Hospice records also showed the resident was admitted to Hospice with an active benefit period through 4/26/2026. Despite this, the resident’s MDS assessments dated 10/29/2025, 11/12/2025, and 1/27/2026 did not code Section O, K1 for Hospice Care and instead marked Z1, None of the Above, indicating the resident was not receiving Hospice care in the facility. The facility’s CMS 802 matrix also did not identify the resident as receiving Hospice care. The MDS Coordinator confirmed the resident was not coded for Hospice services and stated she was unsure why the MDS did not reflect the resident’s Hospice status, noting she may have forgotten to update the assessment after Hospice was initiated.
Failure to document follow-up care and physician notification for elevated blood glucose
Penalty
Summary
The facility failed to ensure follow-up care was documented for elevated blood glucose levels and failed to communicate with the physician as ordered for one resident receiving insulin therapy. The resident had diagnoses of diabetes mellitus, weakness, depression, and anxiety, and had physician orders for sliding-scale insulin lispro with blood glucose monitoring. One order required blood glucose checks three times daily before lunch, dinner, and bedtime, with the physician to be called if blood glucose was greater than 400; an earlier order required checks twice daily at 11:00 AM and 8:00 PM, with the physician to be called if blood glucose was greater than 400. Review of the resident’s blood glucose records from 10/1/25 through 4/1/26 showed 40 blood glucose results over 400 mg/dL, but the physician was documented as notified only six times. No follow-up blood glucose rechecks were documented in the EMR to show whether the blood glucose was trending down or remained elevated. The NHA stated that when a resident’s blood glucose was greater than 400, the nurse should contact the physician, perform a follow-up blood glucose, and document it in the EMR. The facility policy also stated to call the physician immediately if blood glucose was greater than 300 or as ordered, recheck blood glucose per physician order, and document blood sugar results, treatment, and resident response in the medical record.
Failure to Allow Resident to Use Own Power Wheelchair
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve a resident’s range of motion and mobility when it did not allow Resident #21 to use her own power wheelchair in the facility. R21 was admitted with multiple sclerosis and major depressive disorder, and during interviews she stated she had been using a power wheelchair at home, could tolerate only a couple of hours in the high-back wheelchair provided by the facility, and had not been up in her wheelchair for several days. She also stated she was not aware at admission that she would not be able to use and keep her power wheelchair during her stay. The record showed that occupational therapy had previously documented that R21 used a power wheelchair in her home environment, spent all day in it, and could transfer without a slide board. A wheelchair assessment found she was safe to use the power wheelchair and could navigate the joystick for positioning and driving, with recommendations to resume power wheelchair use upon return home. During later interviews, OT staff stated it would be life changing for her to have the power wheelchair, and one OT noted her left leg contracture had worsened, her muscle tone had decreased, and she had not been getting out of bed related to pain. The facility’s admission agreement lacked discussion of the policy regarding electrical appliances, including power wheelchairs. The BOM stated she did not cover the power wheelchair policy during admission, and the NHA stated R21 was not allowed to have her power wheelchair because she was not safe to use it in the facility, while also acknowledging she should be re-evaluated and would benefit from using her own custom power wheelchair in her room. The facility policy stated motorized equipment such as wheelchairs are not permitted in house for safety, with the administrator having final decision if limited use is required, and the ADL policy stated the facility would provide necessary care and services to ensure a resident’s abilities do not diminish unless unavoidable.
Failure to Follow Fluid Restriction and Document Intake
Penalty
Summary
The facility failed to monitor fluids and provide the diet as ordered for a resident with a history of myocardial infarction and chronic kidney disease. The resident had a physician order for a 1500 cc fluid restriction, a regular no added salt diet, and daily weights related to bilateral lower extremity swelling and weight gain. The resident was observed with swollen legs, sitting with his feet elevated, and later was seen drinking chicken noodle soup, water, and grape juice at lunch. The tray card did not include the no added salt order and listed beverages that totaled 1800 cc per day on the meal tray card alone, not including fluids given with medications. Record review showed inconsistent and incomplete fluid documentation. Daily weights were missing on multiple dates, and the MAR had a section for the fluid restriction order but no indication of the amount of fluids consumed, even though nurses signed it twice daily. CNA and LPN interviews showed confusion about who was responsible for totaling fluids and documenting fluids given with medications, and one LPN stated he did not record fluids given with medications. The EMR also showed several dates with no fluid documentation, and the nursing home administrator could not present documentation showing how the 1500 cc restriction was totaled each day. The resident’s care plan addressed risk of dehydration related to diuretic use, but did not include the fluid restriction, salt limitation, Lasix use for edema, or weight monitoring focus reflected in the physician orders.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of a change in condition related to blood glucose monitoring for a resident with type two diabetes mellitus. The resident's electronic medical record indicated several instances of elevated blood glucose levels exceeding 400 mg/dL, which required physician notification according to the facility's protocol. Despite these elevated readings, there was no documentation that the physician had been informed, as required by the physician's order and the facility's policies. Interviews with the facility's staff, including a Registered Nurse and the Director of Nursing, confirmed that the protocol for notifying a physician when blood glucose levels are out of range was not followed. The facility's policies, including the Notification of Change and Diabetic Management Program, clearly outlined the necessity of notifying a physician for blood glucose levels greater than 400 mg/dL. However, the failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Monitor and Assess Residents' Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor and assess two residents, leading to deficiencies in their care. Resident #5, who has Parkinson's disease and type two diabetes mellitus, had a blood glucose level of 518 mg/dL, which was not followed up with a re-check as per the physician's order. The Licensed Practical Nurse (LPN) involved was unsure why the follow-up was not documented, and the Director of Nursing (DON) confirmed that the blood glucose levels should have been re-checked and documented according to the physician's orders. This oversight was contrary to the facility's policy on notification of change, which requires monitoring and reassessment of the resident's status and response to interventions. Resident #177, admitted with osteomyelitis, peripheral vascular disease, hypertension, and diabetes mellitus, did not have a baseline care plan accessible to Certified Nursing Assistants, and there was a lack of documented blood glucose monitoring and vital signs for several days following admission. The DON acknowledged that new admissions should have a full set of vital signs taken twice a day and that blood glucose monitoring should be completed for diabetic residents, especially those on a sliding scale. The facility's diabetic management program policy was not adhered to, resulting in a failure to provide standardized guidance for diabetic management.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement physician-ordered interventions for a resident with a moderate risk of pressure ulcers. The resident, who had diagnoses including peripheral vascular disease and cellulitis, was observed without the prescribed protective boots on multiple occasions. The boots were intended to be worn while the resident was in bed to reduce pressure on the heels, which were noted to be soft and slightly red. Despite the physician's order for the boots to be applied every shift, the resident reported that staff did not consistently apply them, and there was no record of refusal from the resident. The deficiency was further compounded by the lack of communication and documentation within the facility. The Certified Nursing Assistant (CNA) was unaware of the requirement for the resident to wear the protective boots, as it was not included in the care plan. The Licensed Practical Nurse (LPN) confirmed the existence of the physician's order but acknowledged that it was not reflected in the care plan, which CNAs rely on for resident care instructions. The Director of Nursing (DON) admitted that the omission of the boots from the care plan was an oversight, as CNAs do not have access to physician orders, highlighting a gap in the facility's documentation and communication processes.
Failure in Timely Pain Management for Post-Operative Resident
Penalty
Summary
The facility failed to provide timely pain management for a resident who was admitted with a history of osteomyelitis, peripheral vascular disease, hypertension, and diabetes mellitus, and had recently undergone an amputation of his right toes and partial foot. Upon admission, the resident had a prescription for oxycodone with acetaminophen to manage post-operative pain. However, due to a breakdown in the facility's process for obtaining controlled substances, the resident did not receive his prescribed pain medication until approximately 20 hours after admission. This delay occurred because the necessary C-2 form was not sent to the medical director for authorization in a timely manner, resulting in the resident experiencing significant pain, rated at 8-9 on a scale of 0-10. The medical director expressed frustration over not receiving the C-2 form promptly, which was supposed to be faxed by the admitting night nurse. The Director of Nursing confirmed that the process for obtaining controlled substances involves faxing the C-2 form to the doctor for a signature, then to the pharmacy for an authorization code, which was not completed as required. The resident underwent a dressing change without pain medication, further exacerbating his discomfort. Interviews with the resident and staff highlighted the failure in communication and procedural adherence that led to the delay in pain management, impacting the resident's comfort and quality of care.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage and timely destruction of medications, as observed in two medication carts. In one instance, three controlled substances that had been discontinued were still present in the medication cart. These included tramadol and lorazepam tablets belonging to residents who had either been discharged or had their medication orders discontinued. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were unclear about the frequency of medication destruction, and the DON admitted to being too busy to destroy the medications promptly. Additionally, the East medication cart was found to contain loose tablets of alendronate and a blister pack with remaining tablets, which were supposed to be administered to an unidentified resident. The presence of loose pills indicated that the resident might not have received the full prescribed dose. The DON acknowledged that loose pills should not be present in the cart and that the carts had been recently cleaned. The facility's policies on the disposal of discontinued medications and maintenance of medication storage areas were not followed, contributing to the deficiencies observed.
Lack of Qualified Dietary Manager Leads to Meal Quality Issues
Penalty
Summary
The facility failed to employ a qualified Certified Dietary Manager (CDM) to manage the food service department, leading to several issues with meal quality and resident satisfaction. During a lunch meal, five residents expressed concerns about minimal entree choices, limited or no alternates, decreased palatability, and some missed meals due to the limited choices and poor quality of the food. The Registered Dietician (RD) confirmed that there was no current CDM or Dietary Manager (DM) working in the food services department, and the Director of Nursing (DON) had assumed the role temporarily but had not yet started CDM classes. The RD also noted a significant weight loss of 5% in one resident over the past month, which they were not informed about, and no nutritional supplementation had been added. Interviews with staff and the Nursing Home Administrator (NHA) revealed that the DON had been pulled from the DM role to cover nursing shifts, and the NHA was overseeing the kitchen staff and food services department in the interim, despite not being a CDM or DM. The NHA denied awareness of resident-reported concerns and the weight loss issue. The Regional Director of Operations acknowledged the absence of a CDM or DM and was not aware of the food concerns or weight loss. The lack of a qualified CDM or DM led to inadequate food service management, impacting meal quality and resident nutrition.
Deficient Maintenance of Resident Equipment
Penalty
Summary
The facility failed to maintain essential resident equipment in safe and operational condition, specifically concerning the wheelchairs of two residents and the bed remote controls. One resident, identified as R2, reported issues with their manual wheelchair, which had worn wheels causing it to veer to the side instead of moving straight. Additionally, R2 expressed discomfort due to the absence of a wheelchair cushion. Another resident, R10, was concerned about the malfunctioning brakes on their wheelchair, which did not lock properly, posing a risk of falling. R10's wheelchair also lacked brake covers and a seat cushion, and the upholstery was damaged. The facility's maintenance director confirmed the issues with both wheelchairs, acknowledging the need for repairs. The nursing home administrator was made aware of these concerns during an observation. Furthermore, the facility faced issues with bed remote controls, as several were not functioning, and the administrator had restricted the ordering of replacements to one per month. This led to the removal of all bed remotes from residents' beds, which were later reattached, but not without causing inconvenience and potential safety concerns for residents who could independently operate them. Staff interviews revealed that the removal of bed remotes was a directive from the nursing home administrator following a citation related to a hospital bed remote. The remotes were removed from all residents' beds, not just those with cognitive impairments, and were later zip-tied under the beds, making them difficult to access. Staff reported difficulties in providing care due to the lack of accessible bed remotes, which affected their ability to adjust bed heights and positions for dependent residents, leading to awkward body mechanics and delays in care.
Failure to Provide Adequate Meal Choices and Alternatives
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice regarding their meals, as evidenced by the experiences of four residents. Resident 2, who was cognitively intact, expressed dissatisfaction with the limited meal options, stating that only fish and ravioli were available, neither of which she liked. She reported not receiving fresh fruit and described an incident where she was given a fried bologna sandwich, which she did not eat, leading to hunger. Resident 4, also cognitively intact, reported the poor quality of meals, such as Salisbury steak resembling a TV dinner, and the lack of alternative options when she disliked the meal. She expressed frustration with the food quality and portion sizes, stating that she was sometimes left hungry. Resident 1, with a cardiac diagnosis requiring a low-salt diet, was not receiving appropriate meals. A complaint noted that she was served a fried bologna sandwich and cream of mushroom soup without alternatives, and there was a lack of fresh fruit. On Mother's Day, she reportedly did not receive dinner until much later, after other residents had eaten. The facility's dietary manager confirmed that the menu was considered adequate for a no-added-salt diet, despite the resident's complaints about the food's saltiness and lack of variety. Staff reported that residents often had only one meal choice, and dietary staff were unavailable to provide alternatives after dinner service. Resident 7, who was cognitively intact, reported dissatisfaction with the meals, stating that she sometimes skipped meals due to the lack of variety and quality. The facility's menu cycle was outdated, with no listed alternatives, and leftovers were served for up to three days. Staff expressed concerns about inadequate meal portions and the lack of an always-available menu for entrees. The facility's policy stated that residents have the right to nutritious meals and reasonable food substitutes, which were not consistently provided, leading to the deficiency in honoring residents' rights to meal choices and preferences.
Failure to Address Resident Grievance Regarding Damaged Clothing
Penalty
Summary
The facility failed to address a grievance raised by a resident, identified as R8, who was cognitively intact with a BIMS score of 15/15. R8, who also served as the resident council president, reported that his pajama pants and other clothing items were returned from the facility laundry with bleach stains. Despite reporting this issue to the laundry staff two weeks prior, R8 did not receive any explanation or follow-up regarding the damage, leading to feelings of frustration. An observation confirmed the pajama pants were damaged beyond wear, with bleach stains, holes, and frayed edges. Laundry Staff B acknowledged being informed of the issue by R8 over a week before but failed to report it to the Business Office Manager, Staff F, as per the facility's protocol. Staff B admitted to not filing a grievance form due to time constraints and being off work for a week. The Nursing Home Administrator confirmed the expectation that a grievance form should have been completed and the issue reported. The facility's failure to act on the grievance violated the resident's rights to voice grievances without reprisal and to have personal clothing maintained in a clean, home-like environment.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure fresh water was consistently offered and provided to four residents, resulting in dissatisfaction and potential dehydration. Observations on 2/6/24 revealed that residents had either warm, nearly empty water pitchers or no water at all. Interviews with the residents confirmed that they had not received fresh water since the previous night, despite requests made earlier in the morning. The residents' BIMS scores indicated varying levels of cognitive impairment, with some residents being moderately impaired and others having no cognitive impairment. Further observations and interviews with staff revealed that fresh water was not passed out until late in the morning, contrary to the facility's policy of providing fresh water at the start of each shift. The Director of Nursing confirmed that the night shift was responsible for collecting used water cups for cleaning, and fresh water should be distributed each morning. However, staff reported difficulties in receiving clean water cups from the kitchen, contributing to the delay in providing fresh water to the residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — 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 Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jamieson Nursing Home | 2.8 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Alpena | 27.4 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Green View | 28 mi | ★★★★★ | 0 | 0 |
| Lakeview Manor Healthcare Center | 28.8 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Tawas City | 29 mi | ★★★★★ | 15 | 0 |
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