Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Community Care Center during CMS and state inspections, most recent first.
Care plans were not revised for three residents when their conditions changed. One resident was using a mechanical lift for transfers, but the care plan still directed a sit-to-stand lift. Another resident with cerebral palsy and severe cognitive impairment had a contracted hand, but contractures were not addressed in the care plan. A third resident no longer had a Foley catheter, yet the care plan still listed one and included catheter monitoring instructions; the DON acknowledged the omissions.
Failure to Track and Trend Antibiotic Use: Facility staff did not implement an Antibiotic Stewardship Program with protocols to monitor and track antibiotic use. The ADON said he/she tried to review residents on antibiotics using EMR order reports and McGeers assessments, but had no printed reports, no documentation of physician contact, and no tracking or trending data for the past year. The DON said the ADON was responsible for the program, while the Administrator said the ADON should be maintaining the documentation and knowing the top infection trends.
Facility staff failed to refund resident funds within 30 days of discharge for 17 residents, with balances ranging from $605.21 to $15,619.10. The facility's policy lacked guidance on refunds, and the Business Office Manager was not trained on managing resident credits. The administrator was unaware of the outstanding balances.
Facility staff failed to update care plans with fall interventions for several residents who experienced falls, and did not document the use of side rails for a resident despite observations of their use. Residents with cognitive impairments and physical dependencies experienced falls that were not reflected in their care plans, and staff interviews revealed a lack of communication and follow-through in updating care plans.
Facility staff failed to conduct neurological assessments after unwitnessed falls for two residents and did not obtain physician orders for two residents to self-administer eye drops. Despite facility policies requiring neurological checks for unwitnessed falls, these were not documented for residents with cognitive impairments. Additionally, eye drops were found at the bedsides of two cognitively intact residents without orders for self-administration, indicating a lack of adherence to medication administration policies.
The facility failed to provide a consistent program of activities for residents on weekends, as required by their policy. The activity calendar showed limited weekend activities, primarily religious services and repetitive activities. Residents expressed dissatisfaction with the lack of engaging activities, and staff confirmed the absence of designated personnel to lead activities on weekends, resulting in inconsistent availability of activities.
The facility failed to conduct proper entrapment assessments for residents using side rails, as required by their policy. The assessments lacked appropriate measurements for the residents' size and weight. Interviews revealed that the Maintenance Director, responsible for these assessments, measured without the resident in the bed, contrary to requirements. The DON and administrator were unaware of the correct procedure, indicating a systemic issue in safety protocol adherence.
Care Plans Not Updated for Changed Transfers, Contractures, and Foley Catheter Status
Penalty
Summary
The facility failed to review and revise comprehensive care plans for three sampled residents when their conditions and care needs changed. The facility policy stated that comprehensive, person-centered care plans are to be developed, implemented, and revised as resident assessments and conditions change, and the DON said care plans should be updated when changes occur in transfers, catheters, contractures, and weight loss. For one resident with moderate cognitive impairment and non-Alzheimer's dementia, staff observed the resident with a mechanical lift sling under the resident and later transferred the resident from a wheelchair to bed using a mechanical lift. However, the care plan remained undated and still directed staff to use a sit-to-stand lift for all transfers due to leg weakness. The DON stated the resident had returned from the hospital and was now using a mechanical lift for transfers, and acknowledged the care plan should have been updated to reflect that change. For a second resident with severe cognitive impairment, cerebral palsy, and spastic hemiplegia affecting the left nondominant side, staff observed the resident in a recliner with a contracted left hand on multiple occasions, but the undated care plan did not address contractures. For a third resident, the quarterly MDS showed severe cognitive impairment and no Foley catheter, the POS did not contain an order for a Foley catheter, and records showed the catheter had been removed and catheter-change orders discontinued months earlier; however, the undated care plan still stated the resident had a Foley catheter and instructed staff to monitor intake and output. The DON stated the catheter issue had been overlooked and that all risks should be addressed on the care plan.
Failure to Track and Trend Antibiotic Use
Penalty
Summary
Facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 44. Review of the facility’s policy showed that antibiotic usage and outcome data were to be collected on a facility-approved tracking form, and that all resident antibiotic regimens were to be documented with information including the resident name, medical record number, unit and room number, date symptoms appeared, antibiotic name, start date, pathogen identified, site of infection, culture date, stop date, total days of therapy, outcome, and adverse events. The facility’s infection surveillance policy also required detailed infection reporting, monthly line listings, and monthly or quarterly trending of infections by site, pathogen, and comparison to prior data. During interview, the ADON said he/she was responsible for the antibiotic stewardship program and tried to pull an Order Listing Report from the electronic medical record showing residents on antibiotics, the antibiotic ordered, and the start date, then completed a McGeers assessment for each resident on an antibiotic. He/she said that if the medication was not warranted, he/she contacted the ordering physician, but he/she did not have the printed Order Listing reports, documentation of physician contact, or documentation of tracking or trending antibiotics for the last year. He/she also said he/she did not know the top infection for October or any other month. The DON said the ADON was responsible for the program and that the administrator, who held the IP certificate, oversaw the ADON, while the DON only used the program for MDS purposes. The Administrator said he/she printed reports for the ADON and that the ADON filled in the required information and talked to physicians as needed, but also stated the ADON should be keeping track of the information, maintaining documentation, and knowing the top infection trends.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility staff failed to refund resident funds within 30 days of discharge for 17 residents out of 41 sampled, despite the facility's census being 55. The facility's policy on refunds was undated and lacked specific guidance for staff on handling resident refunds post-discharge. A review of the facility's aging report revealed that several residents had significant balances remaining in the facility's operating account after their discharge. These balances ranged from $605.21 to $15,619.10, indicating a systemic issue in processing refunds in a timely manner. Interviews with the Business Office Manager (BOM) and the administrator highlighted a lack of training and awareness regarding the management of resident credits and third-party liability credits. The BOM admitted to not having balanced the aging report for some time and expressed a lack of knowledge about the process, including when to contact Medicaid regarding credit balances. The administrator acknowledged that resident balances should be refunded within 30 days and that Medicaid should be notified within three days of discharge or death, but was unaware of the existing balances for discharged or deceased residents.
Failure to Update Care Plans with Fall Interventions and Equipment Use
Penalty
Summary
The facility staff failed to ensure that care plans were reviewed and revised to include appropriate fall interventions for six residents out of eight sampled. These residents experienced falls, but their care plans did not reflect these incidents or the necessary interventions to prevent future falls. For instance, Resident #10, who had moderate cognitive impairment and used a wheelchair, fell after getting tangled in bed sheets, yet their care plan lacked documentation of this fall or any interventions. Similarly, Resident #12, with severe cognitive impairment, suffered a fall resulting in a hematoma and other injuries, but their care plan was not updated to include this incident or any preventive measures. Additionally, Resident #13, who was dependent on assistance for transfers and positioning, was found on the floor, but their care plan did not document the fall or any interventions. Resident #19, with moderate cognitive impairment and physical impairments, also experienced a fall that was not reflected in their care plan. Resident #35, with severe cognitive impairment, had multiple falls, including sliding out of a wheelchair and being found on the bathroom floor, yet their care plan did not include these incidents or interventions. Furthermore, the facility failed to ensure that care plans reflected the use of side rails for Resident #42. Despite observations of the resident in bed with raised bedrails, the care plan did not document this, and the resident's bed rail assessment indicated that bed rails were not needed. Interviews with staff, including the RN, DON/MDS coordinator, and the administrator, revealed a lack of communication and follow-through in updating care plans with necessary interventions and equipment use, contributing to the deficiencies identified.
Failure to Conduct Neurological Assessments and Obtain Medication Orders
Penalty
Summary
The facility staff failed to maintain professional standards of practice by not completing neurological assessments after unwitnessed falls for two residents. The facility's policy requires neurological checks to be initiated for unwitnessed falls, but this was not done for Resident #35 and Resident #42. Resident #35, who had moderate cognitive impairment and a diagnosis of dementia, experienced multiple falls, some of which were unwitnessed, yet there was no documentation of neurological exams being conducted. Similarly, Resident #42, with modified cognitive impairment, also had unwitnessed falls without the required neurological assessments being documented. Additionally, the facility staff did not obtain physician orders for two residents to self-administer eye drops. Resident #33, assessed as cognitively intact, had eye drops on their bedside table without a physician's order for self-administration, and this was observed over several days. Similarly, Resident #39, also cognitively intact, had lubricating eye drops at their bedside without an order for self-administration. Interviews with staff revealed a lack of awareness regarding the presence of these medications at the residents' bedsides and the absence of necessary orders. Interviews with the facility's RN, DON, and Administrator highlighted a lack of awareness and adherence to the facility's policies regarding fall assessments and medication administration. The RN and DON acknowledged the importance of neurological checks after unwitnessed falls but were unaware that these were not being conducted. The Administrator also emphasized the need for orders and care planning for self-administration of medications, which was not being followed in these cases.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests of residents on weekends, as required by their policy. The activity calendar for several months showed limited activities scheduled on weekends, primarily consisting of religious services and repetitive activities like social coloring, funny videos, and movies. Interviews with residents revealed dissatisfaction with the lack of diverse and engaging activities on weekends, with some residents expressing a desire for more activities during these times. Resident #4, who is cognitively intact and independent with activities of daily living, expressed that there are no activities on weekends except for occasional church services. Resident #16, with moderate cognitive impairment and communication difficulties, indicated through non-verbal communication a desire for weekend activities. Resident #24, also cognitively intact, emphasized the importance of group activities and noted the absence of such activities on weekends, aside from church services. Interviews with facility staff, including CNAs, RNs, the Activity Director, the DON, and the administrator, confirmed the lack of staff-led activities on weekends. Staff indicated that activities on weekends were limited to movies and church services, with no designated personnel to lead activities. The responsibility for initiating activities fell on CNAs or other staff if they had time, but there was no structured program or assigned staff to ensure activities were conducted, leading to inconsistent availability of activities for residents.
Failure to Conduct Proper Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility staff failed to complete entrapment assessments for four residents who use side rails, which is a requirement to ensure the environment remains safe and free of accident hazards. The facility's policy mandates that an assessment should be made to determine the resident's risk of entrapment and the appropriateness of the bed's dimensions for the resident's size and weight. However, the entrapment assessments for the residents did not contain the appropriate measurements for their size and weight, which is a critical component of the assessment process. Interviews with the Maintenance Director, Director of Nursing/MDS coordinator, and the administrator revealed a lack of awareness and understanding of the proper procedure for conducting entrapment assessments. The Maintenance Director, who is responsible for these assessments, admitted to measuring the distance of the railing with the mattress without the resident in the bed, contrary to the requirement. The Director of Nursing and the administrator also confirmed that they were unaware that measurements should be done with the resident in the bed, indicating a systemic issue in the facility's adherence to safety protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 74 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 Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Care Center | 7.9 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Warsaw | 10.1 mi | ★★★★★ | 9 | 0 |
| Windsor Healthcare & Rehab Center | 14.7 mi | ★★★★★ | 0 | 0 |
| Golden Age Living Center | 18.8 mi | ★★★★★ | 1 | 0 |
| Fair View Health Care Center | 21.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lincoln Community Care Center.
100% money-back within 48 hours.
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.