Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Lincoln, Llc, The during CMS and state inspections, most recent first.
A resident with a history of falls and recent knee surgery, identified as high fall risk, was left unattended in the bathroom and shower by staff, despite care plans requiring supervision. The resident fell twice, sustaining a major injury after the second fall when a CNA left to retrieve supplies, resulting in a femur fracture and subsequent transfer to hospice care.
The facility failed to serve food that was consistently palatable and at the correct temperature, as reported by multiple residents and confirmed by test tray observations. Residents frequently complained about cold, bland, and overcooked meals, with specific issues noted in breakfast items and meat dishes. The executive chef acknowledged the temperature issues and the lack of adherence to specific recipes by the dietary staff, contributing to the deficiency.
The facility failed to maintain sanitary conditions in food preparation and storage. Staff were observed handling ready-to-eat foods with bare hands or improperly using gloves, leading to potential cross-contamination. Additionally, food items in the kitchen and nourishment refrigerators were found unlabeled, undated, or expired, indicating a lack of adherence to proper food storage protocols.
The facility failed to provide baseline care plans within 48 hours of admission for four residents, as required by their policy. Despite attending initial care conferences, residents did not receive copies of their care plans, and there was no documentation of signed acknowledgments in their EMRs. Interviews revealed that the MDS nurse was responsible for this task, but the facility did not adhere to its process, resulting in a deficiency.
The facility failed to effectively involve residents and their representatives in discharge planning, did not update discharge plans with specific goals, and inadequately documented the process in EMRs. Residents expressed concerns about lack of communication and involvement, while staff interviews revealed that case managers did not document active discharge planning in EMRs, leading to residents feeling uncertain about their care transitions.
The facility failed to maintain an effective infection control program, with staff not consistently wearing appropriate PPE in COVID-19 positive rooms and during wound care. Observations revealed improper use of gauze and gloves, and a lack of awareness regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices. This led to systemic issues in infection control practices.
A facility failed to obtain informed consent for a psychotropic medication for a resident before administration. The resident, with cognitive impairment and depression, was given Venlafaxine without a signed consent form until four days post-admission. Staff interviews revealed lapses in the consent process, with some agency staff missing forms and delays occurring if residents wanted family input. Despite a statement claiming all forms were signed on admission, records showed a later date, indicating non-compliance with facility policy.
A resident's preference for receiving bed baths during the day shift was not honored by the facility, despite her repeated requests. The resident, who was cognitively intact and dependent on staff for bathing, found the night-time schedule inconvenient and had communicated her preference to both CNAs and the DON. The facility's failure to adjust the schedule led to the resident refusing the night-time baths, resulting in a deficiency related to resident choice and self-determination.
The facility failed to prevent the misappropriation of personal property for three residents, including missing money and a smartwatch. A resident reported $200 missing after it was left in her closet, another resident's smartwatch was tracked to a residential address but not recovered, and a third resident suspected a CNA of taking $40 from her wallet. The facility did not offer adequate security measures for residents' belongings, and staff training on handling such incidents was inconsistent.
The facility failed to meet the socialization needs of two residents, leading to deficiencies in their care. One resident, cognitively intact but requiring assistance, was not invited to group activities and lacked one-to-one interactions. Another resident, severely cognitively impaired, was not provided with suitable activities or invited to group activities. Staff interviews revealed a lack of proactive engagement in meeting residents' activity needs, with reliance on family visits for interaction.
A resident developed moisture-associated skin disorder (MASD) wounds due to the facility's failure to provide appropriate care and honor her preferences for bed baths. The staff did not clean under her abdominal folds properly, leading to wound development. Infection control practices were not followed during wound care, and the worsening condition was not communicated to the primary care physician or referred to a wound physician in a timely manner.
A resident at high risk for skin breakdown due to limited mobility and sensory response was not consistently provided with heel protection boots as ordered by a physician. Despite the presence of the boots in the room, they were often not applied, leaving the resident's heels in direct contact with surfaces. Staff interviews confirmed the importance of the boots, but they were not consistently used, contrary to the facility's policy and physician's orders.
A resident with a history of a left femur fracture and other conditions experienced inadequate pain management at the facility. Despite reporting pain levels above her acceptable threshold, she did not receive timely pain relief. The facility failed to administer pain medication or implement non-pharmacological interventions promptly, and staff interviews revealed documentation errors, contributing to the deficiency.
A resident with multiple health conditions did not receive prescribed inhaler medications due to a miscommunication between the facility and the pharmacy. The pharmacy misinterpreted and deleted the correct medication list, leading to the unavailability of the inhalers. The DON was not informed, and the issue was not documented by the nursing staff, resulting in a failure to meet the resident's pharmaceutical needs.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, admitted for postoperative left knee replacement rehabilitation and identified as a high fall risk due to her medical history and recent surgery, was left unattended in the bathroom and later in the shower. The facility's fall prevention policy required high-risk residents to have interventions such as supervision, routine toileting schedules, and line-of-sight monitoring. Despite these requirements, the resident experienced two unwitnessed falls: the first in the bathroom and the second in the shower after being left alone by a CNA who left to retrieve supplies. The resident's care plans and physical therapy notes indicated she required supervision or touching assistance with transfers, toileting, and bathing. Staff interviews confirmed that the resident was known to be a fall risk, wore a fall risk wristband, and had signage in her room. The CNA involved in the second fall admitted to leaving the resident alone in the shower, contrary to the care plan and facility policy, because she believed it was acceptable since the resident was scheduled for discharge that day. The CNA also acknowledged that she should have called for assistance rather than leaving the resident unsupervised. As a result of being left unattended, the resident attempted to get up on her own, fell, and sustained a left femur fracture that was deemed inoperable due to her comorbidities. The incident led to the resident being transferred to the hospital and subsequently discharged home with hospice care. The failure to consistently implement fall prevention interventions and provide adequate supervision directly resulted in a major injury for the resident.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to consistently serve food that was palatable and attractive, as evidenced by multiple resident interviews and test tray observations. Residents reported that the food was often served cold, lacked seasoning, and was sometimes overcooked or undercooked. Specific complaints included cold breakfast meals, rubbery eggs, overcooked meat, and bland vegetables. The resident council minutes also documented ongoing concerns about food temperature and palatability, which were not addressed by the facility staff. The facility's policy on food palatability, revised in August 2022, emphasized the importance of serving food that is palatable, attractive, and at a safe and appetizing temperature. However, the policy was not effectively implemented, as evidenced by the residents' consistent complaints and the test tray evaluation. The test tray, which included beef fajitas, rice, and vegetables, was found to be overcooked, bland, and lacking in flavor. The executive chef acknowledged issues with food temperature and palatability, noting that the dietary staff did not follow specific recipes and that the plate warmers were inadequate. Staff interviews revealed that the executive chef was aware of the temperature issues and was considering different plate warmers to address the problem. However, the chef also noted that the dietary staff often did not follow specific recipes, which may have contributed to the lack of seasoning and flavor in the meals. Despite the facility's efforts to address some complaints by delivering meals individually to residents, the overall quality and palatability of the food remained a significant concern, as evidenced by the numerous resident complaints and the test tray findings.
Sanitation and Food Handling Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the main kitchen and nourishment refrigerators. Observations revealed that ready-to-eat foods were handled in an unsanitary manner, with staff using bare hands or improperly using gloves. For instance, a cook was observed handling lettuce with bare hands and using the same hands to stabilize tortillas while serving food. Another dietary aide used the same pair of gloves to handle various food items and equipment, leading to potential cross-contamination. Additionally, the facility did not adhere to proper food storage protocols in the kitchen and nourishment room refrigerators. Several food items were found unlabeled, undated, or past their expiration dates. For example, a pitcher of tea and a container with meat were found without labels or dates, and several cartons of milk and yogurt were past their expiration dates. The nourishment refrigerators on different units contained various food items that were either unlabeled, undated, or expired, contributing to unsanitary conditions. Interviews with the executive chef revealed a lack of consistent adherence to food safety protocols. The executive chef admitted that dietary staff were not allowed to use gloves during food service, contradicting the facility's policy. Furthermore, the executive chef acknowledged that the nourishment refrigerators were supposed to be cleaned twice a week, but observations indicated that this was not effectively carried out, as evidenced by the presence of expired and improperly stored food items.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to develop and provide a baseline care plan within 48 hours of admission for four residents, as required by their policy. The policy, revised in March 2020, mandates that a baseline care plan be developed to address the resident's immediate needs and be provided to the resident or their responsible party. However, the facility did not ensure that Residents #380, #376, #382, and #225 received a copy of their baseline care plan within the stipulated timeframe. Resident #380, who was cognitively intact, expressed frustration at not being aware of her care plan, despite having attended an initial care conference. Similarly, Resident #376, with moderate cognitive impairment, reported not receiving her care plan in writing or any communication from the case manager. Resident #382, also with moderate cognitive impairment, stated she had not been given a copy of her care plan or received communication regarding her discharge plan. Resident #225, who was cognitively intact, had attended a care conference where her care plan was discussed, but there was no documentation of her receiving a copy. Interviews with the case manager and the DON revealed that the MDS nurse was responsible for developing the baseline care plan and providing it to residents. The DON confirmed that the facility's process required residents to sign an Acknowledgement of Care Plan form upon receiving their care plan, which would then be uploaded to their EMR. However, the facility did not have signed forms for the four residents, indicating a failure to adhere to their policy and procedure for baseline care plans.
Deficient Discharge Planning and Documentation
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for nine residents, as observed through interviews, record reviews, and staff interactions. The deficiencies included a lack of involvement of residents and their representatives in the discharge planning process, failure to update discharge plans with residents' specific goals, and inadequate documentation of the discharge planning process in the residents' electronic medical records (EMR). The facility's policy required that discharge planning be resident-focused, but this was not adhered to, as evidenced by the generic and non-person-centered care plans. Several residents expressed concerns about their discharge planning. For instance, one resident, who had undergone lumbar surgery, reported not receiving any communication regarding her discharge and felt forced to stay until deemed ready by the case manager. Another resident, who had difficulty walking and muscle weakness, was worried about transportation for outpatient therapy and had not been informed of any options. Additionally, a resident with Parkinson's disease felt that the case manager did not understand her limitations and was not involved in her discharge planning. Staff interviews revealed that case managers did not document active discharge planning in the residents' EMRs, instead keeping notes in a binder. This lack of documentation and communication led to residents and their families being uninformed about discharge plans and progress. The facility's failure to ensure proper discharge planning and documentation resulted in residents feeling uncertain and uninvolved in their care transitions.
Infection Control Deficiencies in PPE Usage and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple observations and interviews. Staff did not consistently wear appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms. For instance, a housekeeper entered a COVID-19 positive resident's room wearing only a surgical mask, without donning an N95 mask, gown, gloves, or protective eyewear. Similarly, a certified nurse aide (CNA) entered the same room without performing hand hygiene or wearing protective eyewear. Additionally, a visitor entered the room without any PPE, and a registered nurse (RN) failed to educate the visitor on the necessary precautions. The facility also did not adhere to proper infection control practices during wound care. The certified wound nurse (CWN) was observed using the same piece of gauze multiple times to clean wounds and did not change gloves or perform hand hygiene between treating different wounds. This practice was contrary to infection control protocols, which require changing gauze after each wipe and changing gloves between wound sites to prevent cross-contamination. Furthermore, the facility lacked an effective process to ensure staff were aware of which residents required Enhanced Barrier Precautions (EBP). Several residents with wounds or indwelling medical devices did not have EBP signs or PPE bins outside their rooms, as required by facility policy. Staff interviews revealed confusion about the implementation of EBP, with some staff members incorrectly believing that masks were required, while others did not recognize the need for EBP for residents with wounds. This inconsistency in EBP implementation was observed across multiple residents, indicating a systemic issue in the facility's infection control practices.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of psychotropic medications for a resident prior to administration. The resident, aged 74, was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, and depression. The facility's policy required psychotropic consent to be obtained from the resident or family within 72 hours of admission. However, the consent form for the antidepressant medication Venlafaxine was not signed by the resident until four days after admission, despite the medication being administered daily from the day of admission. Interviews with facility staff revealed inconsistencies in the process of obtaining consent. An LPN mentioned that agency staff sometimes missed consent forms, and there could be delays if residents wanted family members to review the forms. Another LPN stated that the admitting nurse was responsible for ensuring consents were signed, and the unit manager would follow up to ensure compliance. A registered nurse indicated that the consent form might have been missed by the agency nurse who admitted the resident. The DON confirmed that consent forms were necessary for high-risk medications and should be signed immediately upon admission. Despite a signed statement from the resident provided after the survey exit, indicating that all consent forms were signed upon admission, the electronic medical record showed the consent form was signed four days later. This discrepancy highlights the facility's failure to adhere to its policy and ensure informed consent was obtained before administering psychotropic medication.
Failure to Honor Resident's Bathing Schedule Preference
Penalty
Summary
The facility failed to honor a resident's preference for receiving bed baths during the day shift, as opposed to the night shift. The resident, who was cognitively intact and dependent on staff for various activities of daily living, including bathing, had repeatedly requested to have her bed baths scheduled during the day. Despite these requests, the facility continued to schedule her bed baths at night, which the resident found inconvenient as it interfered with her evening routine. The resident's care plan and preference sheet did not accurately reflect her desire for daytime bed baths, leading to her refusal of the scheduled night-time baths. Interviews with the resident and staff revealed that the resident had communicated her preference to both the CNAs and the DON, but her requests were not acted upon. The DON acknowledged that the resident's preference should have been honored and was unaware of the resident's refusals due to the timing of the baths. The facility's failure to adjust the resident's bathing schedule according to her preferences resulted in a deficiency related to resident choice and self-determination.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent the misappropriation of personal property for three residents during their stay. Resident #228, who was cognitively intact, reported missing $200 that was intended for a hair appointment. The money was placed in her bag inside her closet before she went outside with her sister, and upon returning, the money was gone. The facility did not offer her a lockbox or a safe to secure her belongings, which contributed to the loss. Resident #46, also cognitively intact, reported a missing smartwatch that was last seen on a charger in her room. The watch was electronically tracked to a residential address, but no connection to the facility staff was found. The resident's daughter initially reported the watch as potentially missing and later confirmed it was gone. The facility's investigation did not resolve the issue, and the watch was not recovered. Resident #229, who was cognitively intact, reported $40 missing from her wallet, which she had hidden in a towel in her bathroom drawer. She suspected CNA #4, who had asked about the wallet, but was not entirely certain. The facility's investigation involved interviewing staff and residents, but the money was not recovered. CNA #4 was suspended during the investigation but later quit. The facility's failure to provide adequate security measures for residents' belongings and the lack of consistent staff training on handling such incidents contributed to the ongoing issue of misappropriation.
Failure to Meet Residents' Socialization Needs
Penalty
Summary
The facility failed to meet the socialization needs of two residents, leading to deficiencies in their care. Resident #373, a 75-year-old with spinal stenosis and muscle weakness, was cognitively intact but required maximum assistance with activities of daily living. Despite expressing a desire for companionship and participation in group activities, she was not invited to scheduled activities such as painting, Monopoly, and pet visits. Her care plan indicated a need for one-to-one activities, but these were not provided by the facility staff, and she was only offered activities on two occasions in November 2024. Resident #36, who was severely cognitively impaired and dependent on staff for various needs, was observed calling out for attention without receiving appropriate responses from staff. Her care plan noted her interest in television, reading, and family time, but she was not provided with suitable activities or invited to group activities. The facility's activities staff relied on family visits for one-to-one interactions, and the resident was not given books or other leisure supplies, despite her interests. Interviews with staff revealed a lack of proactive engagement in meeting residents' activity needs. The Activities Director (AD) did not conduct one-to-one activities and relied on family and friends for resident interaction. The AD also did not re-evaluate residents' activity preferences during their stay. The Nursing Home Administrator (NHA) acknowledged the need for a change in approach to ensure residents' needs were met, but the current system failed to provide adequate socialization and activity opportunities for the residents involved.
Failure to Provide Appropriate Wound Care and Honor Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to the development of moisture-associated skin disorder (MASD) wounds. The resident, admitted for rehabilitation services with a history of a left femur fracture, end-stage renal disease, type two diabetes, and morbid obesity, was noted to have a surgical incision and bruises upon admission, but no abdominal wounds. However, by 10/24/24, the resident had developed two MASD wounds under her abdominal folds, which were not documented in the initial assessments. The resident expressed that her preference for receiving bed baths during the day was not honored, and the staff failed to clean under her abdominal folds properly. This lack of adherence to her care preferences and inadequate hygiene practices contributed to the development and worsening of the wounds. Observations revealed that the facility did not follow proper infection control practices during wound care, as the certified wound nurse used the same gauze multiple times and did not change gloves between wound sites, increasing the risk of infection. Furthermore, the facility failed to communicate the worsening condition of the wounds to the primary care physician and did not ensure a timely referral to a wound physician. The primary care physician and nurse practitioner were not adequately informed about the deterioration of the wounds, including the presence of eschar and slough, which are indicators of wound deterioration. This lack of communication and timely intervention contributed to the resident's ongoing wound issues.
Failure to Implement Heel Protection for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and services according to professional standards of practice, specifically in the prevention of pressure ulcers. The resident, who was over 65 years old and had a history of cerebral hemorrhage, dysphagia, aphasia, hypertension, and pre-diabetes, was at high risk for skin breakdown due to limited mobility and sensory response. Despite a physician's order for heel protection boots to be worn at all times, except during ambulation, the resident was repeatedly observed without the boots, with her heels resting directly on the mattress or wheelchair foot pedals. Observations revealed multiple instances where the resident's heel protection boots were not applied, even though they were present in the room. On several occasions, the boots were found lying on a desk or bed, while the resident's heels were in direct contact with surfaces, increasing the risk of pressure ulcers. Interviews with staff, including a CNA and an RN, confirmed that the resident required assistance with mobility and that the heel protection boots were crucial for preventing skin breakdown. However, the boots were not consistently used as per the physician's order. The facility's policy required a full skin evaluation upon admission and the implementation of interventions based on risk assessments. Despite this, the resident's care plan and physician's orders were not adequately followed, as evidenced by the lack of consistent application of the heel protection boots. The DON acknowledged the importance of the boots in preventing skin breakdown and indicated that it was the responsibility of the nursing staff to ensure compliance with the physician's orders.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #382, who experienced continuous and acute episodes of pain. The facility's policy required that pain management interventions be initiated at admission and evaluated every shift, with both pharmacological and non-pharmacological approaches considered. However, the facility did not adhere to these standards, as evidenced by the resident's reports of pain levels exceeding her acceptable threshold on multiple occasions without receiving appropriate interventions. Resident #382, who was cognitively intact and required assistance with activities of daily living, reported significant pain related to a left femur fracture and other conditions. Despite having orders for scheduled and as-needed pain medications, the resident did not receive adequate pain relief. On several occasions, the resident reported pain levels higher than her acceptable level, yet the facility failed to administer pain medication or implement non-pharmacological interventions in a timely manner. Specifically, on one occasion, the resident waited over two hours for pain relief after expressing severe pain, and the facility did not administer any analgesic until the next scheduled dose. Interviews with the resident and staff revealed discrepancies in the documentation and administration of pain management. The resident expressed that her pain was not being managed effectively, impacting her ability to participate in therapy. Staff interviews confirmed that there were errors in documentation, such as the incorrect recording of Gabapentin administration, which was not ordered for the resident. The facility's failure to address the resident's acute pain promptly and accurately document interventions contributed to the deficiency in pain management.
Failure to Provide Necessary Inhaler Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring that two inhaler medications were ordered and delivered as prescribed by the physician. The resident, an 85-year-old individual with multiple diagnoses including COVID-19, sepsis, and acute respiratory failure, was admitted to the facility after a hospital stay. The comprehensive care plan required the administration of medications per physician orders to minimize respiratory risks. However, the facility did not administer the prescribed Fluticasone-Salmeterol and Spiriva inhalers on several occasions due to their unavailability. The deficiency arose from a miscommunication and error in the medication ordering process. The facility's policy required medications to be faxed to the pharmacy upon verification with the provider. However, the pharmacy misinterpreted the medication list as containing duplicate orders and subsequently deleted the correct list sent by the facility. This error resulted in the inhalers not being delivered or administered during the resident's stay. The Director of Nursing (DON) was not informed of the medication issue by the nursing staff, and the situation was not documented or reported to the DON by the registered nurse who contacted the pharmacy. Interviews with the DON and nursing staff revealed a lack of communication and documentation regarding the medication error. The DON stated that the pharmacy discarded the correct medication list, and the facility did not have the inhalers in their emergency medication kit. The registered nurse assumed the pharmacy would comply with the request to send the missing medications but did not document the conversation or report the issue to the DON. This lack of follow-through and communication contributed to the failure to provide the necessary pharmaceutical services to the resident.
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 279 citations issued within 25 miles in the last 12 months — including the 3 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 Parker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Stonegate | 3.8 mi | — | 0 | 0 |
| Parker Post Acute | 5.3 mi | — | 19 | 0 |
| Silver Heights Skilled Nursing And Rehabilitation | 6.4 mi | — | 0 | 0 |
| Brookside Inn | 8.8 mi | — | 14 | 1 |
| Brookdale Greenwood Village | 10.6 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Center At Lincoln, Llc, The.
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 August 2026) and official state health department websites.