Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eventide Lincoln Care Center during CMS and state inspections, most recent first.
Incorrect Therapeutic Diet Served to a Resident with Dysphagia: A resident with pneumonitis, dementia, and dysphagia was ordered a minced and moist diet with mildly thick liquids, but was served regular chicken at lunch instead. The resident choked in the dining room, staff performed the Heimlich maneuver, and the resident was sent to the hospital after choking on a large piece of chicken.
Failure to Revise Care Plans After Resident Falls: The facility did not revise post-fall care plan interventions for three residents with histories of dementia, repeated falls, and cognitive impairment. One resident had falls with no updated interventions after a later event, another high-risk resident had a fall without revised interventions despite other fall-related care plan updates, and a third resident with severe cognitive impairment had multiple falls with one fall lacking new interventions. The DON and an LPN confirmed the missing revisions in the EMR.
Food Storage and Dating Deficiencies: Surveyors found multiple opened food items in the prep refrigerator, freezer, and dry storage area that were not sealed or dated, along with numerous expired products stored in the kitchen. Items included tortillas, dressing, frozen vegetables, buns, noodles, crackers, cake mix, soy sauce, canned goods, and pudding mixes. The NCD confirmed that expired items needed to be removed and opened items rewrapped and dated.
QAPI plan not reevaluated after ongoing deficiencies. The facility failed to revise its corrective action plan after prior issues with care planning, med errors, and infection control continued. Survey findings included a med admin error rate of 12.82%, above the CMS acceptable rate of <5%, and additional citations for infection control and comprehensive care planning. The QA/IFC Coord and ED both confirmed the prior POC concerns had not been corrected and remained ongoing facility issues.
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
Unsecured Medications and Unlocked Medication Carts: Surveyors observed an unlocked medication cart left unattended with multiple meds, topical creams, and eye drops left on top of it, and later found another unlocked cart accessible in a resident hallway. Staff confirmed the cart should be locked when unattended and that meds should not be left out. Surveyors also found several meds in a resident room on a bedside table and floor, and an LPN confirmed the resident did not self-administer those meds and that they should have been locked in the med cart.
Failure to Notify Ombudsman of Hospital Transfers: The DON confirmed the facility did not notify the State LTC Ombudsman of multiple hospital transfers for one resident with moderate cognitive impairment and another resident with CHF, AKI, hypotension, anxiety, and SOB. Facility policy required transfer/discharge notices to include the Ombudsman’s contact information, but records showed no notification for the resident’s hospital leave after a fall or for several hospital discharges related to acute heart failure, CHF, renal failure, chest pain, and low BP.
Baseline Care Plan Missing Suprapubic Catheter Information: A resident with a long-standing suprapubic catheter was observed with the catheter in place, but the BCP did not document the indwelling urinary device or include the catheter type and indication for use. Record review showed the resident was newly admitted with diagnoses including neuromuscular dysfunction of the bladder and urogenital implants, and the DON confirmed the BCP should have reflected the catheter present on admission.
Failure to care plan respiratory needs and neck positioning. One resident with moderate cognitive impairment, a hx of COVID-19, OSA, and anxiety had oxygen therapy and nebulizer treatments in use, but the care plan did not include a respiratory focus area. Another resident with chronic pain, osteoporosis, and kyphosis was repeatedly observed with the head and neck leaning to one side, yet the care plan did not address neck positioning or interventions to assist with proper positioning.
Physician order for Quetiapine dose reduction not followed. A resident with bipolar disorder, DM2, PTSD, ADHD, essential tremors, and ASHD had a physician order to decrease Quetiapine from 200 mg to 100 mg HS, but the MAR showed the 200 mg dose continued for weeks before the lower dose was started. The DON confirmed the order had not been followed and that the nurse had not completed the required documentation on the physician visit record.
A resident was observed with a suprapubic catheter, but the active order summary, admission orders, and baseline care plan did not show an order for the catheter or its maintenance care. The resident reported having the catheter for many years, and the DON and RCM confirmed there were no physician orders for continued use or associated care.
A resident’s CPAP equipment was repeatedly found on the floor or under the bed, with tubing not dated, while an LPN performing wound care for another resident exited the room with gown and gloves on, handled supplies and trash inappropriately, and entered another resident’s room with soiled waste. In separate medication observations, an MA picked up spilled pills with bare hands and changed gloves without hand hygiene while preparing medications for two residents. The DON confirmed the hand hygiene and glove-use concerns.
Two residents with complex medical needs experienced repeated delays in staff response to call lights, with documented wait times far exceeding the facility's 5-minute expectation. Both residents reported long waits, and call light logs confirmed multiple instances of extended response times, indicating staff did not meet the facility's standard for timely care.
A resident with multiple diagnoses, including CHF, CKD, COPD, and a recent surgical repair of a right leg fracture, was not properly assessed for changes in condition. Facility staff failed to perform and document daily assessments and vital signs as required for a Medicare skilled stay, despite the resident experiencing significant weight gain, edema, and a weak pulse. Key aspects of the resident's condition were not consistently documented or communicated to the medical provider, as confirmed by staff interviews and record review.
A resident with multiple complex diagnoses, including CHF, CKD, and a recent surgical repair, did not have complete or accurate medical records maintained during a Medicare skilled stay. Required daily documentation of assessments and vital signs was missing, and critical information such as edema, neurovascular status, and respiratory assessments was often omitted. Staff interviews confirmed that the facility did not meet its own policy for daily skilled documentation or notify the medical provider of significant changes in the resident's condition.
The facility failed to implement effective infection control measures, including missing signage for designated zones and improper PPE usage. Observations revealed that staff did not adhere to Enhanced Barrier Precautions or perform adequate hand hygiene during resident care, increasing the risk of cross-contamination. These deficiencies were confirmed through staff interviews and observations.
The facility failed to follow the prescribed recipe for pureed hot dog meals, as Cook-N used a to-do list instead of the recipe, resulting in a watery consistency and omission of bread. The Culinary Director confirmed the deviation, potentially affecting the nutritional needs of 93 residents.
The facility inaccurately reported anticoagulant use in the MDS for a resident, despite the MAR and Comprehensive Care Plan showing no such medication was administered. The MDS Director confirmed the error.
A facility failed to complete a required PASRR Level II evaluation for a resident with serious mental illness, including Generalized Anxiety Disorder and Major Depressive Disorder. The initial evaluation approved the resident's stay for 180 days, but no follow-up evaluation was conducted after this period. Interviews with staff confirmed the oversight, which was against the facility's policy.
A facility failed to include a resident's chronic obstructive pulmonary disease (COPD) in their Comprehensive Care Plan (CCP), despite it being the primary diagnosis and the resident receiving respiratory therapy. The facility's policy required the inclusion of current medical conditions in the care plan, but this was not adhered to, as confirmed by the MDS Director.
A facility failed to obtain a physician's order for CPAP settings for a resident with chronic respiratory conditions. Despite the resident's need for respiratory care, the electronic medical record lacked specific directions for CPAP use, which was confirmed by the facility administrator.
A facility failed to maintain a medication error rate below 5%, with a 25% error rate observed. A resident received several medications late, contrary to the facility's policy, due to the resident's preference to sleep late. Medications were not administered according to specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. An LPN confirmed the errors in administration timing and medication combinations.
Incorrect Therapeutic Diet Served to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the correct therapeutic diet for one resident who had been admitted with pneumonitis due to inhalation of food and vomit, dementia, and dysphagia. The resident’s care plan identified a nutrition focus with interventions for a general diet, minced and moist texture, and mildly thick liquids. Physician orders showed the resident had been admitted on a pureed diet and advanced with speech therapy to minced and moist on 5/20/26. On 6/7/26, the resident choked in the dining room and staff performed the Heimlich maneuver before the resident was sent to the hospital. The hospital history and physical documented that the resident had been choking on a piece of chicken approximately 8 centimeters long. The facility’s menu for that day listed baked chicken for lunch, and interviews with the Nutritional Culinary Director and the DON confirmed the resident was served regular chicken instead of the ordered minced and moist diet.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise post-fall care plan interventions for three residents after documented falls. Resident 1 was admitted with diagnoses including dementia and repeated falls, had a BIMS score of 11 indicating moderate cognitive impairment, and had fall documentation on 06/08/2026 and 06/22/2026. The care plan identified the resident as having a potential for falls and included moving the resident to a room closer to the nurses station after the first fall, but no new interventions were identified after the 06/22/2026 fall. During interview, the DON and LPN confirmed the care plan did not have revised interventions for that fall and should have. Resident 5 was admitted with diagnoses including dementia and repeated falls, had a BIMS score of 13 indicating moderate cognitive impairment, and had falls documented on [DATE], 06/08/2026, and 06/24/2026. The care plan identified the resident as high risk for falls and included new interventions after the 05/28/2026 and 06/24/2026 falls, but no new fall interventions were identified after the 06/08/2026 fall. Resident 6 was admitted with diagnoses including repeated falls and post hip replacement surgery, had a BIMS score of 03 indicating severe cognitive impairment, and had falls documented on 06/12/2026, 06/13/2026, 06/14/2026, and 06/20/2026. The care plan included new interventions after the 06/12/2026, 06/14/2026, and 06/20/2026 falls, but no new fall interventions were identified after the 06/13/2026 fall. The DON and LPN confirmed Resident 6 did not have revised interventions for that fall and should have.
Food Storage and Dating Deficiencies
Penalty
Summary
The facility failed to ensure food stored in the kitchen was not expired and that opened items were sealed and dated. During observation of the prep refrigerator, freezer, and dry storage area, surveyors found multiple food items opened with no dates, several items not sealed, and some items stored in sandwich bags or otherwise uncovered. Examples included opened flour tortillas and Caesar dressing with no date, multiple frozen vegetables and other frozen items opened without dates or not sealed, opened hot dog buns and dry goods such as noodles, crackers, cake mix, gelatin mix, and soy sauce without dates. Surveyors also found numerous expired food items in dry storage, including jars, canned tomatoes, brownie mix, cake mix, beans, Miracle Whip, mandarin oranges, espresso syrup, peppermint syrup, and multiple pudding products. The facility’s food storage policy stated that all foods must be covered, labeled, and dated, and that foods not labeled or dated need to be discarded immediately. The Nutrition and Culinary Director confirmed that expired items needed to be removed and opened items needed to be rewrapped and dated.
QAPI Plan Not Reevaluated After Ongoing Deficiencies
Penalty
Summary
The facility failed to reevaluate and revise its plan of corrective action to prevent recurrence of past performance issues related to care planning, medication errors, and infection control. A review of the facility’s undated current list of active performance improvement plans showed active PIPs for Client Satisfaction, Skin/Wound Documentation, Psychotropic Medications, and Falls, while prior survey findings from 12.17.2024 identified deficient practice in care planning, medication errors, and infection control practices. The survey ending 4.30.2026 also showed a medication administration error rate of 12.82%, above the CMS acceptable rate of less than 5%, and cited infection control, free of medication error rate, and develop/implement comprehensive care plan deficiencies. During interviews, the QA/IFC Coord confirmed the QA committee reviews the facility’s previous POC for improvement opportunities and acknowledged that care planning, medication errors, and infection control remained ongoing concerns; the ED also confirmed those previous POC concerns had not been corrected and continued to be a facility issue.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Unsecured Medications and Unlocked Medication Carts
Penalty
Summary
The facility failed to store medications securely and failed to keep medication carts locked when unattended. Survey observations showed a medication aide walking away from a medication cart that was unlocked, with multiple medication cards, topical creams, and eye drops left on top of the cart and no other staff nearby. The medications left unsecured included drugs for residents with conditions such as depression, dementia, high blood pressure, diabetes, pain, bladder symptoms, sleep, and eye pressure, along with topical skin products and eye drops. Additional observations showed an unattended medication cart on the first-floor resident hallway that was unlocked and accessible to residents for several minutes. Another medication aide later left the cart unattended and unlocked while entering a resident room, and confirmed that the cart should not have been left that way. Staff interviews confirmed the expectation that the cart should be locked when unattended, that medications should not be left sitting out, and that controlled medications were kept in a locked box within the cart. Surveyors also observed medications left unsecured in a resident room. In one room, mupirocin ointment, brimonidine eye drops, latanoprost eye drops, and dorzolamide eye drops were found on a bedside table and on the floor, with no lockbox present. An LPN confirmed the resident did not self-administer medications and stated the medications should have been locked in the medication cart. The LPN then removed the medications from the room and locked them in the cart.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of multiple resident hospital transfers. For Resident 5, the clinical census showed an admission date of 12/15/2025, and the MDS with a target date of 3/10/2026 documented a BIMS score of 11, indicating moderate cognitive impairment. The clinical census showed a hospital leave on 2/27/2026, and a progress note dated 2/27/2026 at 9:49 PM stated the resident was transferred to the hospital for further evaluation due to a fall. The facility policy on Notice of Transfer or Discharge, dated 2/16/2026, stated the notice would include the name, address, and telephone number of the State Long-Term Care Ombudsman. During interview on 4/29/2026 at 2:02 PM, the DON confirmed the Ombudsman was not notified of Resident 5's transfer to the hospital and should have been. For Resident 123, the admission record showed diagnoses including acute chronic systolic congestive heart failure, acute kidney failure, hypotension, anxiety disorder, and shortness of breath. The MDS dated 2/19/2026 showed a BIMS score of 15. Progress notes documented hospital admissions for acute heart failure, congestive heart failure, renal failure, chest pain, and low blood pressure. Review of the February and March notifications to the Ombudsman showed no notification for the resident's hospital discharges on 2/8/2026, 3/9/2026, 4/4/2026, and 4/17/2026. The facility policy dated 2/16/2026 required the notice of transfer or discharge to include the State Long-Term Care Ombudsman's name, address, and telephone number, and on 4/29/2026 at 7:06 AM the DON confirmed the facility could not locate a notification and that the Ombudsman should have been notified.
Baseline Care Plan Missing Suprapubic Catheter Information
Penalty
Summary
The facility failed to ensure the baseline care plan included interventions to address the healthcare needs of Resident 125, who had an indwelling suprapubic urinary catheter. An observation and interview on 04/27/2026 found the resident in their room with a catheter present and hung at the side of their chair. The resident reported having a suprapubic catheter for many years due to medical reasons. Record review showed the resident was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder and presence of urogenital implants. The admission orders dated 04/21/2026 indicated the resident did not have an indwelling urinary device on admission and no orders were placed at that time. The MDS had not been completed because the resident was newly admitted, and the baseline care plan contained no information indicating that the resident had an indwelling urinary device. The facility policy for suprapubic catheters stated that the care plan must include the type of catheter and the indication for use. The DON confirmed on 04/29/2026 that the baseline care plan did not indicate the catheter was present on admission and should have documented it.
Failure to Care Plan Respiratory Needs and Neck Positioning
Penalty
Summary
The facility failed to care plan the services provided to attain or maintain the highest practicable well-being for two residents. Resident 16 had an MDS BIMS score of 12 indicating moderate cognitive impairment, a history of COVID-19, obstructive sleep apnea, and anxiety, and was observed with an oxygen nasal cannula and a nebulizer machine at the bedside. Medical record review confirmed physician orders for inhalation therapy, and the DON confirmed that Resident 16 received nebulizer treatments and oxygen therapy, but the care plan did not include a respiratory focus area for the nebulizer machine or oxygen therapy. Resident 110 was admitted with diagnoses including chronic pain, age-related osteoporosis without current pathological fracture, and unspecified kyphosis. The resident’s MDS showed a BIMS score of 13, and multiple observations showed the resident sitting or sleeping in a recliner with the head and neck leaning on the left shoulder, including while awake, asleep, and propelling a wheelchair. The resident stated that holding the head upright could be tiring. The care plan last revised on 02/02/2026 did not address neck positioning or interventions to assist with neck positioning, and the DON confirmed that the resident had therapy and that the facility should have care planned the resident’s neck positioning and interventions to assist with proper neck positioning.
Physician Order for Quetiapine Dose Reduction Not Followed
Penalty
Summary
The facility failed to ensure physician orders were followed for one resident. Resident 9 was admitted with diagnoses including bipolar disorder, type 2 diabetes, essential tremors, PTSD, ADHD, and atherosclerotic heart disease, and had a BIMs score of 15 on the MDS, indicating cognitive intactness. A physician visit record dated 2/25/26 showed an order to reduce Quetiapine from 200 mg at bedtime to 100 mg at bedtime, and the nurse marked the order as completed on the form. A pharmacist recommendation dated 3/18/26 also referenced reducing Quetiapine 200 mg at bedtime, and the physician noted on that form that the 2/25/26 order had not been initiated. The MAR showed the resident continued receiving Quetiapine 200 mg at bedtime from 2/25/26 through 3/25/26, and did not start Quetiapine 100 mg until 3/26/26. The DON confirmed during interview that the physician orders had not been followed for Resident 9 and that the nurse had not marked the pharmacy, care plan, and computer sections as completed on the Physicians Visit Record.
Missing Order for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure an active physician’s order was in place for the continued use of Resident 125’s indwelling suprapubic urinary catheter and for the associated maintenance care. Resident 125 was observed in their room with a catheter hanging at the side of their chair and reported having a suprapubic catheter for many years due to medical reasons. Record review showed diagnoses of neuromuscular dysfunction of the bladder and presence of urogenital implants, but the active order summary did not include an order for the suprapubic catheter or its maintenance care. The admission orders dated 04/21/2026 showed the resident did not have an indwelling urinary device on admission and no orders were placed at that time. The baseline care plan also did not indicate that Resident 125 had an indwelling urinary device. Facility staff confirmed that the resident had a catheter in place upon admission, but there were no physician orders for continued use of the suprapubic urinary catheter or associated maintenance care.
Infection Control Breaks During CPAP Storage, Wound Care, and Medication Prep
Penalty
Summary
The facility failed to maintain infection prevention and control practices during CPAP storage, wound care, and medication preparation. Resident 96 was admitted with encephalopathy, epilepsy, acute kidney failure, hypertensive heart disease with heart failure, and sleep apnea, and had a CPAP order in place. Survey observations found the CPAP tubing and mask on the floor and under the bed, later still on the floor at the bedside, and at another point on the bedside table with the tubing not dated. The resident stated the equipment was not stored on the floor at home and also reported that staff never help with the device when it came apart overnight. The DON stated CPAP equipment should not be stored on the floor and should be stored in a bag at the bedside, and also stated that the baseline care plan did not include CPAP. During wound care for Resident 6, who had a BIMS score of 14 and diagnoses including a displaced comminuted fracture of the right tibial shaft with malunion, an LPN performed multiple steps in a manner that did not follow the facility’s glove and hand hygiene policies. The LPN exited the room with gown and gloves on to obtain a bedside table, removed the gown in a common area trash can, performed hand hygiene, then put on a new gown and retrieved gloves from a scrub pocket behind the gown. The LPN obtained wound care supplies from the resident’s room drawer during the procedure, used scissors and dressing materials, repeatedly changed gloves, and placed unused supplies back in the resident’s drawer. The LPN then left the room and entered another resident’s room with soiled trash from the wound care. The LPN later confirmed that supplies should have been opened before treatment, gloves should have been readily available, and wound care trash should not have been taken into another resident’s room. Medication preparation observations also showed breaks in hand hygiene and glove use. A medication aide picked up spilled pills from the medication cart with bare hands and returned them to the medication cup. During preparation of another resident’s medications, the medication aide touched multiple bottles and cart drawers with gloved hands, removed gloves and went to another medication cart without hand hygiene, then put on new gloves to prepare another medication item. The medication aide later removed gloves to sign out a controlled medication and put on new gloves without performing hand hygiene. The DON confirmed that staff should perform hand hygiene when changing gloves.
Failure to Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.
Failure to Assess and Document Change in Condition for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to properly assess a resident for a change in condition, specifically neglecting to perform and document daily assessments and vital signs as required for a Medicare skilled stay. The resident, who had multiple complex diagnoses including a surgically repaired right leg trimalleolar fracture, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure, was admitted from an acute care hospital and later discharged back to a hospital. Documentation revealed that the resident experienced significant weight gain (11.4 pounds in ten days), edema in both legs, and a weak pulse in the right foot, but there was no evidence that these changes were communicated to the medical provider or that appropriate assessments were performed and recorded daily. Review of the resident's progress notes and vital signs showed inconsistent and incomplete documentation. Several nursing and Medicare notes failed to address key aspects of the resident's condition, such as edema, neurovascular status of the right foot, and the presence or condition of the cast or splint. The facility's own policy required daily documentation for skilled Medicare residents, including full assessments and vital signs, but this was not consistently done. The resident's weight record indicated a notable increase, yet there was no documentation of provider notification regarding this change. Interviews with facility staff, including a registered nurse, resident care manager, provisional administrator, and director of nursing, confirmed that the required daily assessments and documentation were not present in the electronic health record. Staff acknowledged that, given the resident's diagnoses, assessments should have included respiratory status, oxygen saturation, edema, and neurovascular checks of the right foot at least daily, but these were not documented. The deficiency was identified through record review and staff interviews, which verified the lack of appropriate assessment and documentation for the resident's change in condition.
Failure to Maintain Complete and Accurate Medical Records for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who was admitted following a right leg trimalleolar fracture repair and had multiple complex diagnoses, including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure. Documentation reviews revealed that required daily assessments and vital signs were not consistently recorded during the resident's Medicare skilled stay. Specifically, there were gaps in documentation regarding the resident's edema, neurovascular status of the right foot, and the presence or condition of the cast or splint, despite orders for regular monitoring and the resident's high-risk medical profile. Progress notes and assessments frequently omitted critical information such as edema, neurovascular checks, and respiratory status, even though the resident experienced significant weight gain and changes in condition. The medical provider was not notified of the resident's weight gain, and there was no evidence of daily skilled documentation as required by facility policy and professional standards. The facility's own policy required daily documentation for Medicare skilled residents, including full assessments and vital signs, which was confirmed by staff interviews as not being met in this case. Interviews with nursing staff, the Resident Care Manager, the Provisional Administrator, and the Director of Nursing confirmed the lack of required documentation and assessments. The absence of daily monitoring and communication with the medical provider regarding significant changes in the resident's condition, such as weight gain and edema, contributed to the incomplete and inaccurate medical record. The deficiency was substantiated by both record review and staff interviews.
Infection Control Deficiencies in Signage and PPE Usage
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of appropriate signage and personal protective equipment (PPE) usage in designated zones. Observations revealed that Yellow Zone signs were not posted at the entrances to the 100 hallway, and [NAME] Zone signs were missing at the entrances of [NAME] and Good Houses. Additionally, passive screening education was not visible at the entrances to [NAME], [NAME], and Good Houses, and staff were observed not wearing masks in these areas. Interviews confirmed that these zones were designated due to positive COVID-19 cases, yet the necessary precautions were not communicated or enforced. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations showed that EBP signs were not present in the rooms of residents with visible urinary catheter bags, and staff did not use appropriate PPE during high-contact care activities. Furthermore, during wound care for Resident 39, staff did not perform hand hygiene or change gloves between wound sites, increasing the risk of cross-contamination. Similar lapses were noted during catheter care for Resident 114, where contaminated gloves were used to obtain cleansing wipes, and hand hygiene was not performed for the recommended duration. Additional deficiencies were observed in the facility's adherence to contact precautions and hand hygiene protocols. Staff entered contact isolation rooms without wearing the required gowns and gloves, and hand hygiene was not performed for the required 20 seconds. These failures were confirmed through interviews with staff and the facility's Infection Preventionist, highlighting a systemic issue in the facility's infection control practices.
Failure to Follow Recipe for Resident Meals
Penalty
Summary
The facility failed to adhere to the prescribed recipe for preparing resident meals, specifically the pureed hot dog meal. During an observation of meal preparation, Cook-N was seen using a to-do list instead of the recipe provided for the meal. Cook-N used water from the pot where hot dogs were boiling and added it to a blender with hot dogs and a liquid thickener, without measuring the water or using the recipe instructions. This resulted in a watery liquid consistency for the pureed hot dogs, and no bread or bun was used as required by the recipe. The Culinary Director confirmed that Cook-N did not prepare any buns, did not measure the water used, and did not have the recipe out during meal preparation. This deviation from the recipe had the potential to affect the nutritional needs of the 93 residents who received food from the kitchen, as the facility census was 139. The failure to follow the recipe could impact the quality and consistency of the meals provided to the residents.
Inaccurate MDS Reporting for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. A review of the Resident Assessment Instrument (RAI) User's Manual indicated that the MDS should accurately reflect the number of days an anticoagulant was received by the resident during a 7-day look-back period. However, for one resident, the MDS inaccurately indicated the use of an anticoagulant, despite the Medication Administration Record (MAR) for September and October showing no use of such medication. Additionally, the resident's Comprehensive Care Plan did not document the use of an anticoagulant for cardiovascular status. An interview with the MDS Director confirmed that the anticoagulant should not have been marked for this resident.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident, as required. The resident, who was admitted to the facility, had a history of serious mental illness, including Generalized Anxiety Disorder, Major Depressive Disorder, and Bipolar Disorder. The initial PASRR Level II evaluation, conducted in March 2024, confirmed the need for nursing facility services and approved the resident's stay for 180 days. However, after the 180-day period elapsed, no additional PASRR Level II evaluation was conducted. Interviews with facility staff, including a social worker and the administrator, confirmed that the PASRR Level II evaluation was due in September 2024 but was not completed. This oversight indicates a failure to adhere to the facility's policy, which mandates that all admissions with a Level II screen follow the recommendations on the PASRR screen. The facility's census at the time was 139, and this deficiency was identified for one of the four sampled residents.
Failure to Include COPD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered Comprehensive Care Plan (CCP) that accurately reflected the care needs of a resident with chronic obstructive pulmonary disease (COPD). The facility's policy required the Interdisciplinary team (IDT) to develop a comprehensive care plan that includes the reason for admission, current medical conditions, and treatments. However, the baseline care plan and the CCP for the resident did not include the diagnosis or interventions for COPD, despite it being the primary diagnosis. The resident had been receiving respiratory therapy four times in the prior seven days, indicating the need for such interventions. This deficiency was confirmed during an interview with the MDS Director, who acknowledged that the COPD diagnosis should have been included in both the baseline care plan and the CCP.
Failure to Obtain Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP) for one of the sampled residents, identified as Resident 14. This deficiency was identified through interviews and record reviews. The facility's policy, dated 1/17/14, requires complete provider orders for therapeutic and skilled services that legally require such orders. However, a review of Resident 14's electronic medical record revealed no physician's order for CPAP settings, despite the resident's need for respiratory care. Resident 14 had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, obstructive sleep apnea, and mild persistent asthma. The resident's physician orders dated 12/12/24 included the use of CPAP/BiPAP at home or hospital settings, but no specific directions for the CPAP settings were provided. An interview with the facility administrator confirmed the absence of a physician's order for the CPAP settings, acknowledging that such an order should have been in place.
Medication Administration Errors Result in 25% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 25% error rate observed during the administration of 28 medications, with 7 errors affecting one resident. The facility's policy on medication administration, dated August 2016, requires medications to be administered according to a set schedule, within one hour before or after the scheduled time, and precisely as ordered. However, during an observation, it was noted that the Medication Administration Record (MAR) for a resident was entirely red, indicating that all morning medications were late. The resident's MAR showed several medications scheduled for 6:00 AM, including Metoprolol Succinate, Levothyroxine, Furosemide, Cephalexin, Potassium chloride, Citalopram, and Amlodipine Besylate. These medications were administered late at 12:25 PM, and not according to the specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. The Medication Aide (MA) admitted to administering the medications late because the resident preferred to sleep late. An LPN confirmed that Levothyroxine and Potassium should not have been given together and that all morning medications were administered late.
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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) |
|---|---|---|---|---|
| Gateway Vista | 0.8 mi | ★★★★★ | 1 | 0 |
| St. Jane De Chantal | 1.1 mi | ★★★★★ | 27 | 0 |
| Ambassador Health Of Lincoln | 1.2 mi | ★★★★★ | 15 | 0 |
| Eastmont | 1.4 mi | ★★★★★ | 2 | 0 |
| Holmes Lake Rehabilitation & Care Center | 1.6 mi | ★★★★★ | 10 | 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 August 2026) and official state health department websites.