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 Lincoln Village Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain required RN coverage and a full-time DON role for a census of 83 residents. The facility assessment identified the need for sufficient nursing staff, including a dedicated DON and RN positions, but nurse schedules over multiple months showed the DON repeatedly scheduled as the primary floor nurse on various halls and shifts, including performing medication passes. On some days there was no RN assignment documented at all. Staff, including an LPN and a clinical nurse consultant, reported that the DON frequently worked the floor due to ongoing staffing shortages and difficulty hiring nurses, resulting in the DON not consistently functioning in the full-time administrative role outlined in the job description.
Surveyors found that nurses repeatedly failed to document medication administration in a timely and accurate manner for multiple residents, with MARs showing extensive late entries and some undocumented doses for antibiotics, anticoagulants, insulin, pain medications, and psychotropic drugs. Facility policy requires medications to be given within 60 minutes of the scheduled time and documented immediately afterward, but staff interviews confirmed that nurses often delayed completing electronic MAR entries until after the medication pass or the end of their shift, leading to pervasive late charting across February and March.
The facility failed to ensure that IV medications were documented by the nurse who actually administered them and that only authorized personnel signed the MAR. IV antibiotics for two residents with serious infections were administered by the DON or ADON, but multiple doses were signed out in the electronic MAR by LPNs who reported they did not give IV medications. The DON acknowledged that she and the ADON typically administered all IVs while floor nurses signed the MAR entries for them, and the clinical nurse consultant confirmed that the nurse administering the medication should be the one to sign and that LPNs should not sign for IV medications restricted to RNs.
A resident who was non-ambulatory, required extensive ADL assistance, had poor trunk control, and needed a mechanical lift and two-person assistance was turned onto their side in bed by a CNA, who then left the resident unattended to retrieve supplies. The resident rolled off the bed and fell to the floor, after which staff lifted the resident without a mechanical lift. Facility documentation initially noted only minor scratches, and over subsequent days the resident received PRN analgesics for discomfort and back pain without physician evaluation or diagnostic imaging. About a week later, the resident reported rib pain and was sent to the ED, where CT imaging showed multiple new rib fractures and an L2 compression fracture and scattered bruising. The resident’s care plan lacked ADL status, safe positioning, and staffing requirements, and leadership staff acknowledged that CNAs did not reliably access care plans and that the CNA involved was unfamiliar with the resident’s needs.
A resident experienced a fall from bed during care when a CNA turned the resident on their side and briefly left the room to retrieve supplies, during which time the resident rolled off the bed. The care plan revision completed afterward only added suctioning prior to care for coughing and did not include interventions to prevent rolling from bed, instructions to remain with the resident during care, reinforcement of two-person assistance for bed mobility, or accurate ADL status and assistance needs. Staff reported relying on a binder and verbal communication for care updates, and the CNA involved did not routinely work on that unit and was unfamiliar with the resident’s needs. The CNA supervisor confirmed the absence of ADL documentation in the care plan, and the DON and ADON acknowledged they did not directly communicate care plan updates to CNAs and were unaware of the missing ADL care instructions, while the Administrator stated nursing leadership was responsible for ensuring updated care plans and necessary information for staff.
A resident with schizoaffective and other psychiatric disorders, care planned to receive Depakote as a mood stabilizer, repeatedly refused this medication over several months, with dozens of doses missed. The MARs documented frequent refusals, but the EMR lacked documentation of these multiple refusals, and the physician reported not being informed of the ongoing problem. Facility policy required reporting medication refusals and notifying the prescriber when vital medications were repeatedly refused, yet the DON confirmed there was no documentation that the physician had been notified of the resident’s regular Depakote refusals.
The facility failed to prevent resident-to-resident physical abuse in two separate dining room incidents, despite having an abuse prevention policy. In one early-morning event, a cognitively intact male resident with psychiatric diagnoses used his mobility device and hands to shove another cognitively intact male resident with alcohol-induced dementia against a wall, causing the victim to drop a metal cup, sustain facial abrasions, and later describe the event as an act of violence. In a separate incident at mealtime, a female resident with Alzheimer’s disease, severe cognitive impairment, and significant functional limitations threw a salt or sugar container at another female resident with severe cognitive impairment and multiple comorbidities, striking her in the back and causing back pain; a witness resident believed the act was intentional. These incidents show that the facility did not adequately protect residents from physical abuse by other residents as required by its policy.
A resident with multiple chronic conditions developed a severe wound complication after staff failed to follow physician-ordered wound care protocols, resulting in maggot infestation. The wound was incorrectly covered with a dry dressing instead of being left open to air as ordered, and staff did not notify the physician of changes in the wound's condition. The resident was hospitalized for infected wounds and sepsis, ultimately requiring a right above-the-knee amputation.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to inadequate pain control.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Three cognitively intact residents experienced multiple room moves without receiving the required written notice or explanation, as mandated by facility policy. Interviews confirmed that neither the residents nor their representatives were informed in writing or given reasons for the relocations, and the facility's leadership acknowledged unawareness of this requirement.
A resident with multiple complex medical conditions experienced a severe, unplanned weight loss over one month. Facility policy required prompt notification of such changes to the resident's legal representative and physician, but there was no documentation that the resident's guardian was informed. The guardian confirmed she was not notified, and the Regional Director acknowledged the lack of documentation regarding notification.
A resident, who was cognitively intact, reported that a CNA threatened to throw a trash can at them and used profane language, causing the resident to feel threatened. The incident was reported to the prior DON, but the facility was unable to confirm the identity of the CNA involved. This reflects a failure to protect a resident from staff verbal abuse as required by facility policy.
A resident with intellectual disabilities and epilepsy was administered Risperidone and Clobazam, both psychotropic medications, without documented informed consent. The resident's guardian confirmed that no verbal or written consent was provided, and facility staff could not produce any consent documentation, contrary to facility policy.
A resident reported that a CNA threatened them and used abusive language, but the incident was not immediately reported to the State Agency or the Administrator as required by facility policy. Staff interviews confirmed that the mandated reporting process was not followed.
A resident reported that a CNA cursed at them and threatened to throw a trash can, and stated they informed the prior DON, who allegedly fired the CNA. However, there was no documentation or evidence that the facility conducted an investigation into the abuse allegation, and facility leadership confirmed the incident was not reported or investigated.
Three residents transferred to the hospital did not receive required written notifications about bed hold policies or transfer/discharge, as confirmed by record review and staff interview. Facility policy mandates these notifications, but documentation was missing for each hospital transfer event reviewed.
A resident with lymphedema, diabetes, and chronic kidney disease did not receive physician-ordered consultations with a lymphedema specialist and a nephrologist. Despite staff attempts to arrange appointments, communication gaps and logistical barriers prevented the resident from receiving the required specialist care, in violation of facility policy and physician orders.
A resident with multiple comorbidities and high risk for pressure ulcers developed a stage 2 pressure ulcer on the right heel. The care plan was not updated to include the use of a pressure-relieving off-loading boot as recommended by the wound physician, and observations showed the resident's heel was not properly offloaded while in a wheelchair. The wound nurse acknowledged the lapse in both implementing and documenting necessary interventions, resulting in inadequate pressure ulcer care.
A resident with an indwelling urinary catheter did not receive required monitoring of urine output, color, and consistency, nor was catheter care performed every shift as per facility policy. Staff also failed to complete a physician-ordered voiding trial and follow-up with urology. Observation revealed dried debris at the catheter insertion site, and the resident reported that daily catheter cleaning was not performed.
Two residents with significant unplanned weight loss did not have their care plans updated to include new physician-ordered nutritional interventions, despite documented weight loss and existing orders for supplements and increased meal portions. The dietary manager confirmed that these updates were not made after the weight loss was identified.
A resident did not receive Basic Metabolic Panel (BMP) laboratory tests as ordered by the physician, with medical records showing missed intervals and incomplete compliance with the prescribed schedule. This was confirmed by facility staff during the survey.
A resident with a colostomy, pressure ulcer, and indwelling urinary catheter did not receive proper Enhanced Barrier Precautions during high-contact care when a CNA emptied the colostomy bag wearing gloves but not a gown, contrary to facility policy and posted instructions.
Two residents were involved in a physical altercation in the dining room when one resident, who is cognitively intact and uses a wheelchair, moved another resident's walker, prompting the latter, who has severe cognitive impairment, to strike him in the face. The facility did not effectively implement its abuse prevention policy, resulting in resident-to-resident physical abuse.
A facility did not thoroughly investigate an allegation of resident-to-resident abuse after an incident between two roommates. Although a skin assessment was performed and no injuries were found, there was a lack of documentation and no interviews with staff who were present. The administrator interviewed both residents but did not record these interviews or conduct a comprehensive investigation as required by facility policy.
A resident with a scabies diagnosis did not have a prescribed Permethrin treatment documented or administered, as confirmed by the DON. Additionally, two residents receiving wound care had dressings that were not labeled or dated after treatment, with an LPN stating that staff were told to document only in the TAR, not on the dressings, contrary to facility policy.
Two residents at high risk for falls were not provided with adequate supervision or timely assistance, resulting in preventable falls and injuries. One resident, dependent for bed mobility due to Parkinson's, was left unattended during care and fell from bed, sustaining an eyelid injury. Another resident, with multiple risk factors for falls, experienced repeated falls after waiting extended periods for staff to respond to call lights and not receiving frequent checks as required by her care plan. Staff did not consistently follow individualized fall prevention interventions.
The facility consistently scheduled only the minimum number of CNAs required by state regulations, resulting in frequent delays in call light responses and unmet care needs for residents, many of whom required full mechanical lifts and intensive assistance. Staff, residents, and family members reported long wait times for help, and surveyors observed call lights going unanswered for extended periods, confirming that the staffing levels were insufficient to meet the actual care needs of the resident population.
Multiple residents experienced significant delays in call light response, with some waiting over an hour for assistance after episodes of incontinence or for help with mobility. Staff interviews and grievances confirmed that inadequate CNA staffing led to these delays, and direct observation by surveyors documented call lights going unanswered for extended periods. The facility's policy requires prompt response, but both staff and residents reported that current staffing levels made this unachievable.
Surveyors observed that multiple medication carts contained unlabeled multi-dose insulin vials and delivery pens, which were not labeled with any resident's name. Nursing staff and the DON confirmed that such insulin should not be used or stored in the carts, as facility policy requires all medications to be labeled for specific residents.
A resident's allegation of physical abuse was investigated, but the facility did not follow its abuse policy by failing to interview other residents who received care from the same staff as the accused. The administrator confirmed that not all required investigation steps were completed.
A resident with severe cognitive impairment and a high risk for abuse was found with a significant bruise near the eye, and reported to his wife that a man had entered his room and caused the injury. The facility's investigation did not include interviews with other residents in the same hallway or those cared for by the same staff, despite policy requirements, and the DON confirmed the investigation was incomplete.
The facility failed to provide weekly showers for several residents, as required by their policy. Residents reported not receiving showers on scheduled days, with some having to wash themselves due to lack of assistance. The DON acknowledged issues with the shower schedule but could not provide documentation to support compliance.
The facility failed to provide sugar substitutes as per its dietary menu, affecting several residents with Diabetes Mellitus. Observations showed a lack of sugar substitutes on dining tables and trays, and residents reported having to buy their own due to shortages. The dietary manager admitted to not realizing the stock was depleted, despite the facility's policy for emergency purchases.
The facility failed to properly manage respiratory equipment for several residents, as oxygen tubing, humidification reservoirs, and other equipment were not dated, bagged, or stored correctly. An LPN confirmed these discrepancies, which were against the facility's procedures.
The facility failed to document or provide written notification to residents and/or their representatives for hospital transfers or discharges. The facility's policy requires verbal and written notifications, including details such as the reason for transfer and right to appeal. However, due to staff turnover, these notifications were not completed, potentially affecting all 73 residents.
The facility failed to employ a full-time DON, affecting 75 residents. The former DON resigned abruptly, leaving the ADON, an LPN, to fill in temporarily. The facility's assessment tool highlighted the need for a DON, but no replacement had been interviewed yet.
A resident experienced a fall resulting in a head injury, but the facility failed to notify the family until 29 hours later, contrary to its policy. The resident's PCP was informed over three hours after the incident. The facility administrator cited the resident's cognitive status as the reason for not notifying the family immediately, while the regional director confirmed the policy requires family notification.
A resident with a history of stroke and other health issues experienced an unwitnessed fall, resulting in a head injury. The facility failed to complete neurological assessments and delayed hospital transfer, leading to a late diagnosis of an occipital stroke. Initial monitoring was not continued as per protocol, and emergency services were only contacted after the resident reported vision loss and severe headache.
A resident with a high risk for falls fell from bed and sustained a femur fracture while receiving incontinence care. The CNA providing care turned away to find barrier cream, leaving the resident unsupervised, which led to the fall. The facility's investigation was inadequate as it did not include an interview with the cognitively intact resident.
An RN was caught on video misappropriating controlled substances from a medication cart, affecting eight residents. The RN was observed taking narcotic medications and placing them in her pocket. A fellow LPN suspected the RN of drug theft due to her behavior and reported it to the police, who confirmed the theft through surveillance footage. The RN was arrested and charged with related offenses.
The facility failed to obtain physician orders for catheter care, notify a physician of abnormal urine test results, and timely treat UTIs for two residents. One resident experienced severe complications, including septic shock, due to these failures. Another resident's ordered urinalysis and culture test were not completed.
The facility failed to designate a qualified Infection Preventionist to oversee the Infection Prevention and Control Program, leaving the role vacant after the previous IP nurse left. An LPN with a current IP certificate was identified as a backup but was not informed or assigned to the role, potentially affecting all 72 residents.
Failure to Maintain Required RN Coverage and Full-Time DON Role
Penalty
Summary
The deficiency involves the facility’s failure to meet federal RN staffing requirements, including having a full-time Director of Nursing (DON) who is not routinely used as floor staff, despite a resident census of 83. The facility assessment dated 7/10/25 states that the facility must have sufficient nursing staff with appropriate competencies to assure resident safety and well-being, and identifies required nursing services positions including a DON, RNs, LPNs, an Infection Preventionist, a Restorative Nurse, and an MDS nurse. The DON job description assigns responsibility for monitoring major nursing programs, ensuring regulatory compliance, assuring proper staffing through hiring, and creating and maintaining work schedules to ensure nursing services meet state and federal regulations. Review of multiple nurse schedules across February, March, and early April 2026 shows that the DON was repeatedly scheduled and used as the primary assigned nurse on various halls and shifts, including frequent 6:00 am to 2:00 pm floor assignments and additional evening and partial-shift assignments on different units. On specific dates, the DON was the primary nurse on a named hallway and performed medication passes to residents during morning hours. Nurse schedules for two dates in February show no RN assignment at all. Staff interviews confirm that the DON “has to help on the floor quite a bit” and “works the floor a lot because we need coverage,” and a clinical nurse consultant reported ongoing difficulty staffing the building and an inability to hire enough nurses, resulting in the DON frequently covering floor nurse duties instead of functioning solely in the full-time DON role required for a facility with more than 60 residents.
Widespread Late and Incomplete Medication Administration Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely documentation of medication administration for six residents, contrary to its medication administration policy and nursing job descriptions. The policy requires medications to be administered within 60 minutes of the scheduled time, with the nurse recording administration on the MAR immediately after giving the medication and reviewing the MAR at the end of each pass to ensure all doses are administered and documented. The RN and LPN job descriptions require dispensing medications as ordered and completing documentation in accordance with policy and regulations. For one resident, the MAR for February and March shows repeated late administration or late charting of multiple medications, including Amoxicillin-Potassium, Hydrocodone-Acetaminophen 10-325 mg twice daily, and Doxycycline Hyclate 100 mg every 12 hours, across numerous days within the ordered treatment periods. Another resident’s MAR for the same timeframe documents late administration or late charting of IV antibiotics (Zerbaxa every 8 hours and Fetroja every 6 hours for severe sepsis) and Lantus insulin 54 units twice daily for Type II diabetes mellitus, with two doses of Fetroja not documented at all. A third resident’s MAR shows late administration or late charting of multiple antibiotics for pneumonia and bacteremia, including Amoxicillin-Potassium Clavulanate, Doxycycline Hyclate, Meropenem IV every 8 hours, and Vancomycin IV once daily, with at least one undocumented Meropenem dose. Additional residents’ MARs also show extensive late administration or late charting of critical medications. One resident had late administration or late charting of Enoxaparin, Hydrocodone-Acetaminophen, and Micafungin for sepsis over multiple days. Another resident’s records show repeated late administration or late charting of Xarelto (blood thinner) and Zosyn (antibiotic) across several date ranges. A sixth resident’s MAR documents late administration or late charting of Buspirone 15 mg, Ibuprofen 600 mg, Venlafaxine 75 mg, and Haloperidol 0.5 mg on numerous days in February and March. Staff interviews revealed that nurses dispense and administer medications but often fail to immediately complete the electronic MAR by selecting the “complete” function, instead delaying documentation until after the medication pass or the end of the shift, resulting in the pattern of late entries and undocumented doses identified by surveyors.
Improper IV Medication Documentation and Unauthorized MAR Signatures
Penalty
Summary
The deficiency involves failure to ensure that only authorized personnel documented administration of IV medications on the electronic Medication Administration Record (MAR), and that the individual who administered the medication was the one who signed for it. Facility policy dated 10/25/14 required that medications be administered only by persons legally authorized to do so, that the person who prepared the dose be the person who administered it, and that the individual who administered the medication record the administration on the MAR immediately after giving it. The Registered Nurse job description also required RNs to dispense medications as ordered and ensure appropriate documentation. Despite these requirements, review of R2’s MARs for February and March 2026 showed multiple IV antibiotic doses (Zerbaxa and Fetroja) documented as administered and signed out by LPNs, even though IV medications at the facility were reportedly administered only by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Similarly, R3’s February 2026 MAR showed an IV Meropenem dose signed out by an LPN. During interviews, an LPN stated that they did not personally administer IV medications and that the DON or ADON were the primary nurses who administered all IVs, while the floor nurses would sign out the medications on the MAR after the DON or ADON gave them. The DON confirmed that she and the ADON were usually the only nurses who administered IV medications, stating that she did not trust the other nurses and that floor nurses usually signed out the medications for her after she administered them, and that she did not usually sign them out herself. The Clinical Nurse Consultant stated that the nurse who gives the medication should be the one who signs it out on the MAR and that LPNs should not be signing out IV medications that only an RN is licensed to give. These interviews and record reviews demonstrate that IV medications were being documented on the MAR by LPNs who did not administer them and were not licensed to give IV medications, contrary to facility policy and professional practice standards.
Failure to Supervise, Safely Position, and Timely Evaluate a Resident After a Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, safe transfer and positioning practices, post-fall assessment, and timely medical evaluation for one resident. Facility policies on assisting with bed mobility require that residents not be left on the edge of the bed and that staff ensure the resident is in the middle of the bed with the bed lowered to reduce injury risk. The Falls and Fall Risk policy requires staff to identify and implement interventions to minimize serious consequences of falls. Despite these policies, the resident’s care plan did not include interventions for safe positioning during care, staff positioning, remaining with the resident during care, or documentation of the resident’s ADL abilities and required number of staff for care. The resident’s therapy records documented extensive assistance needs with ADLs, dependence on staff for transfers requiring a mechanical lift, poor trunk control, need for two-person assistance for sitting, and non-ambulatory status. On the date of the fall, a CNA reported turning the resident onto his side for care and then stepping away to retrieve supplies, leaving the resident unattended on his side. The CNA stated that upon returning, she observed the resident coughing and rolling off the bed, and although she attempted to stop the fall by grabbing the resident’s upper body, the resident fell completely to the floor. Staff then lifted the resident from the floor without using a mechanical lift because they reported being unable to get the lift into the area where the resident was lying. Following the fall, the facility’s incident note documented only minor scratches and no complaints of pain, and nursing notes over the next days recorded administration of PRN Tylenol and Tramadol for general discomfort and back pain. No physician evaluation or diagnostic imaging was obtained at that time. A week later, the resident complained of rib pain and was sent to the emergency room, where CT imaging revealed new rib fractures and an L2 compression fracture not present on prior studies, along with scattered bruising worse on the left side. Hospital staff documented that facility staff reported the fall had occurred a week earlier with no intervening physician evaluation or imaging. Interviews with the DON, ADON, and CNA supervisor revealed they did not ensure CNA access to or use of care plans, were unaware of an ADL care plan for the resident, and acknowledged that the care plan lacked ADL and safe care information, and that the CNA who provided care did not usually work on that unit and would not have been familiar with the resident’s needs.
Failure to Update and Communicate ADL Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess, document, and communicate a resident’s Activities of Daily Living (ADL) needs and to ensure the comprehensive, person-centered care plan was timely reviewed and revised after a fall. Facility policy required that care plans be revised as changes in condition dictate and that the interdisciplinary team maintain a comprehensive care plan identifying the highest level of function attainable. A resident (R1) experienced a fall from bed during care when left unattended; an incident note documented that R1 was found on the floor between the bed and the window after being turned on his side and left while the CNA retrieved supplies. The care plan revision completed the following day added an intervention to suction the resident prior to care due to coughing but did not include interventions to prevent rolling from bed during care, instructions for staff to remain with the resident during care, reinforcement of two-person assistance for bed mobility, or accurate documentation of R1’s ADL status and required level of assistance. During interviews, the CNA who provided care at the time of the fall stated that R1 rolled off the bed while she had stepped away and that she was unable to prevent the fall due to the resident’s weight; she also reported that staff lifted the resident from the floor without a mechanical lift because they could not get the lift into the area where the resident was lying. The CNA supervisor stated that staff relied on a binder and verbal communication for care updates and confirmed that R1’s care plan did not include documentation of ADL status, noting that staff unfamiliar with the resident would not know how to safely provide care. The CNA involved did not routinely work on that unit and would not have been familiar with R1’s care needs. The DON and ADON stated they did not directly communicate care plan updates to CNAs and relied on shift report and supervisory staff, and they were unaware that R1’s care plan lacked ADL care instructions. The Administrator stated that nursing leadership was responsible for ensuring care plans were updated and that staff had the information necessary to provide care.
Failure to Notify Physician of Repeated Refusals of Mood Stabilizer
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner about a resident’s frequent refusals of a prescribed mood stabilizer, Depakote, as required by facility policy. The facility’s Medication Administration Policy states that medication refusals must be reported to the prescriber after a specified number of doses are refused and that refusals of vital medications over a certain number of consecutive doses require physician notification and documentation of the response. One resident, admitted with diagnoses including Schizoaffective Disorder, Major Depressive Disorder, Panic Disorders, and Mild Intellectual Disabilities, had a care plan indicating use of Depakote as a mood stabilizer for aggressive mood and directing nursing staff to monitor for adverse reactions and report symptoms of schizoaffective disorder to the MD. The care plan also documented a change in the resident’s usual behavior, including increased restlessness, fidgetiness, lack of initiative, and irritability, with an intervention to evaluate whether behavior was attributable to organic causes or other risk factors. Review of the resident’s MARs showed repeated refusals of Depakote over several months: 23 refusals out of 90 doses in one month, 27 refusals out of 93 doses the following month, and 7 refusals out of 37 doses in the subsequent partial month, totaling 57 missed doses in the latter two periods alone. The electronic medical record did not contain documentation of these multiple refusals over the review period. The resident’s physician stated he was not aware of the missed doses and did not recall being notified of the ongoing problem, and affirmed he would want to be notified of regular medication refusals, especially for Depakote. The Administrator confirmed the policy did not specify the exact number of doses that could be missed before physician notification, and the DON verified that the resident was regularly refusing the noon dose of Depakote and that there was no documentation of physician notification regarding these refusals during the identified period.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room Incidents
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse, contrary to its abuse prevention policy that affirms residents’ rights to be free from abuse, neglect, and mistreatment by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and includes deprivation of necessary goods or services. Despite this policy, two separate resident-to-resident altercations occurred, each involving physical contact and resulting in at least minor injury or pain to the residents involved. In the first incident, one cognitively intact male resident with diagnoses including mild intellectual disabilities, schizoaffective disorder, major depressive disorder, and panic disorder approached another cognitively intact male resident with alcohol-induced persisting dementia in the dining room early in the morning. Without provocation from the second resident, the first resident pushed him back against a wall using his hands and his mobility device, causing the second resident to drop his metal cup and spill its contents. Staff responded and separated the residents. The aggressor stated that the other resident was “in his business,” while the victim reported that the event happened quickly and that he had only gone to get ice and a straw. Documentation noted scratches on the victim’s face and an abrasion on his forehead, and the victim later described the event as an act of violence and showed a dented metal cup from the incident. In the second incident, a female resident with Alzheimer’s disease, dementia, anxiety, major depressive disorder, irritability, anger, severe cognitive impairment, and significant functional limitations, who used a wheelchair and was dependent for most ADLs, threw a salt and pepper caddy or plastic sugar container at another female resident. The target resident had severe cognitive impairment, polyarthritis, a history of transient cerebral ischemic attack, hypertension, and mild intellectual disabilities, and required supervision for ADLs. While both residents were seated in their usual dining room locations waiting for dinner, the aggressor became agitated and threw the container, which struck the other resident in the lower back. The struck resident later reported that the impact made her back hurt and that she did not like to be around the aggressor, and another resident witness stated that the throw appeared intentional. These events demonstrate that the facility did not effectively prevent abuse between residents as required by its own policy and regulatory standards.
Failure to Protect Wound from Insect Contamination and Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's wound from insect contamination and did not provide appropriate, physician-ordered wound care. The resident, who had multiple comorbidities including chronic osteomyelitis, diabetes with skin complications, heart failure, and a history of alcohol dependence, had physician orders for specific wound care treatments. These included cleansing, application of topical medications, and either covering with a dry dressing or leaving the wound open to air, depending on the most recent orders. However, documentation and staff interviews revealed that the correct wound care orders were not consistently followed, and a dry dressing was applied to the resident's right foot wound when the current order was for betadine and open to air. During a routine skin sweep, a wound nurse discovered that the resident's right foot wound was covered with a dry dressing, contrary to the physician's most recent order. Upon removing the dressing, the nurse found the wound infested with over fifty maggots (myiasis) within necrotic tissue. The nurse, unfamiliar with treating maggot infestations and unable to reach the infection preventionist, contacted the physician and arranged for the resident's immediate transfer to the hospital. The resident reported that wound dressings were changed only about once a week, and that they were not informed about the condition of their feet. Hospital records confirmed the presence of maggots in the wound and documented subsequent treatment for infected wounds, sepsis, and osteomyelitis. The resident ultimately required a right above-the-knee amputation, was placed on a feeding tube and urinary catheter, and later became unresponsive, leading to a hospice recommendation. Staff interviews indicated a lack of communication regarding changes in the wound's condition and failure to notify the physician or follow up with appropriate wound care orders.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The deficiency was identified based on the failure to provide necessary pain management interventions for a resident in need.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice of room changes to three cognitively intact residents who experienced multiple room moves. According to the facility's own policy, residents are to receive advance written notice, including the reason for the move, at least two days prior to relocation unless the move is medically necessary for safety and well-being. However, review of records and interviews revealed that no such written notices were issued to the residents or their representatives for any of the documented room changes. Interviews with the affected residents confirmed that they were not made aware of the reasons for their room moves and did not receive written notifications. One resident reported frequent room changes without explanation, while another stated he was never informed of the reason for his move. A family member of a third resident indicated she was only verbally notified of one move and was never given a reason or written notice for any of the moves. The Administrator in Training verified that the facility did not issue written notices for these room changes and was unaware of the requirement to do so.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's responsible party after a significant weight loss was identified. According to facility policy, significant unplanned weight loss must be promptly communicated to the resident, their legal representative, and the attending physician. In this case, a male resident with multiple diagnoses, including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, experienced a severe weight loss of 13.2% in one month, as documented in the facility's records. The resident's Minimum Data Set (MDS) assessment also confirmed significant weight loss not associated with a physician-prescribed regimen. Despite these findings, there was no documentation in the electronic medical record that the resident's guardian was notified of the severe weight loss. The guardian confirmed during an interview that she was not informed of the weight loss and expressed a desire to be kept updated due to her involvement in the resident's care. The Regional Director acknowledged that it was the Director of Nursing's responsibility to notify the family and could not find any evidence that such notification occurred.
Failure to Protect Resident from Staff Verbal Abuse
Penalty
Summary
A facility failed to protect a resident from staff-to-resident verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who allegedly threatened to throw a trash can at a resident and used profane language. The resident, who was assessed as cognitively intact, reported feeling threatened by the CNA's actions and stated that the incident was reported to the prior Director of Nursing. The facility's Abuse Prevention Policy prohibits all forms of abuse, including verbal abuse, and defines it as the use of language that is disparaging, derogatory, or threatening toward residents. Despite the resident's report and the facility's policy, the identity of the CNA involved could not be confirmed by the current Administrator-In-Training, as the resident indicated the CNA no longer worked at the facility. The incident was not witnessed by others, and the facility was unable to determine the specific staff member responsible. The deficiency centers on the facility's failure to ensure the resident was protected from verbal abuse by staff.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident diagnosed with unspecified intellectual disabilities and epilepsy. According to the facility's own policy, psychotropic medications should not be prescribed without the informed consent of the resident, guardian, or authorized representative. Despite this, the resident was receiving Risperidone 0.5 mg twice daily and Clobazam 5 mg twice daily without documented consent. The resident's guardian confirmed that she had never verbally given nor signed an informed consent for these medications. Facility staff, including the Administrator in Training and the Regional Nurse Consultant, were unable to produce any documentation of informed consent for the use of psychotropic medications for this resident.
Failure to Immediately Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not immediately reporting an allegation of resident abuse to the State Agency and the Administrator. A cognitively intact resident reported that about a month prior, a CNA threatened to throw a trash can at them and used abusive language. The resident stated they reported the incident to the prior DON, who allegedly terminated the CNA for abuse. However, there was no documentation in the resident's electronic health record or the facility's abuse investigations indicating that the administrator or the State Agency was notified of the allegation, as required by facility policy. Interviews with facility staff confirmed that the required reporting did not occur. The Administrator-in-Training stated they were on leave at the time, and the Regional Director confirmed that the prior DON did not report the allegation as mandated. The facility's policy requires immediate internal and external reporting of abuse allegations, but this process was not followed in this instance.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate an allegation of resident abuse as required by its Abuse Prevention Policy. A cognitively intact resident reported that approximately one month prior, a CNA cursed at them and threatened to throw a trash can at them. The resident stated they reported the incident to the prior DON, who allegedly responded by firing the CNA. However, review of the resident's electronic health record and the facility's abuse investigation documentation revealed no evidence that an investigation was conducted regarding the allegation. Interviews with facility leadership confirmed that the allegation was not reported or investigated, resulting in a lack of documented follow-up on the reported abuse.
Failure to Provide Bed Hold and Transfer Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide required written notifications regarding bed hold policies and transfer notices to residents or their representatives when residents were transferred to the hospital. Specifically, three residents who were transferred to the hospital did not have documentation in their medical records indicating that they or their representatives received written notice of the facility's bed hold policy or a written notice of transfer/discharge at the time of their hospital transfer. The facility's own policies require that such notifications be provided both verbally and in writing, including information about the reason for transfer, effective date, location, appeal rights, and contact information for the state long-term care ombudsman and other advocacy agencies. Record review confirmed that for each of the three residents transferred to the hospital, there was no evidence that the required notifications were given on the dates of transfer. This was further verified by the Administrator in Training, who acknowledged that the notifications were not provided as required by facility policy. The deficiency was identified through interviews and review of census sheets and medical records, which consistently lacked the necessary documentation for each hospital transfer event reviewed.
Failure to Provide Physician-Ordered Specialist Consultations
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered consultations with a lymphedema specialist and a nephrologist. The resident, who had diagnoses including lymphedema, type 2 diabetes mellitus, stage 2 chronic kidney disease, and hyponatremia, had documented physician orders for follow-up with a nephrologist and an outpatient lymphedema clinic. Despite these orders, there was no evidence in the medical record that the resident received either consultation. Staff interviews revealed that attempts were made to schedule the lymphedema appointment, but the process was not completed due to referral requirements and the inability to locate a specialist within the facility's transportation radius. The nephrology appointment was not scheduled because the responsible staff were not informed of the need for the follow-up. The resident was observed with significant swelling and skin issues related to lymphedema and expressed that she had not received the specialist appointments she expected upon admission. Staff involved in scheduling and transportation confirmed communication gaps and incomplete follow-through on the physician's orders. The facility's policies required nursing staff to follow physician orders and assist with transportation for outside services, but these procedures were not effectively implemented for this resident, resulting in missed consultations.
Failure to Update Care Plan and Implement Pressure-Relieving Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan and implement pressure-relieving interventions for a resident with a newly developed stage 2 pressure ulcer on the right heel. Despite the resident being identified as very high risk for pressure ulcer development due to conditions such as cerebral palsy, epilepsy, intellectual disabilities, and hypothyroidism, and being dependent on all activities of daily living, the care plan did not include the use of a pressure-relieving off-loading boot as recommended by the wound physician. Observations showed the resident's right heel was repeatedly resting on the wheelchair foot pedal, both with a sock and a tennis shoe, rather than being offloaded or protected as required. The wound nurse acknowledged that the resident should have been using a pressure-relieving boot to prevent further deterioration of the pressure ulcer, but this intervention was not implemented or communicated to the wound physician. The nurse also admitted responsibility for not updating the resident's care plan with new interventions to offload the heel, both in bed and while out of bed. The facility's own policies outlined the need for such preventative measures and equipment, but these were not followed, resulting in a failure to provide appropriate pressure ulcer care and prevention.
Failure to Monitor and Provide Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident with an indwelling urinary catheter. Specifically, staff did not monitor or document the resident's intake and output, assess urinary catheter drainage each shift, or perform catheter care every shift as required by facility policy and the resident's care plan. The resident's medical record lacked evidence of these essential assessments and interventions from the date of admission through the review period. Additionally, the facility did not complete a physician-ordered voiding trial or arrange for a follow-up with urology as directed in the hospital discharge orders. During observation, the resident was found in bed with an indwelling urinary catheter that had brown dried debris at the insertion site, and the resident reported that staff did not clean the catheter tubing daily. The Regional Nurse Consultant confirmed that the voiding trial and urology follow-up were not completed, and that monitoring of intake and output, urinary drainage, and catheter care every shift did not occur. These findings indicate a failure to follow physician orders, facility policy, and the resident's care plan regarding catheter management and infection prevention.
Failure to Update Care Plans with Weight Loss Interventions
Penalty
Summary
The facility failed to update the care plans with new weight loss interventions for two residents who experienced significant unplanned weight loss. For one resident with diagnoses including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, a significant weight loss of 13.2% in one month was documented. Although physician orders were in place for nutritional supplements, these interventions were not reflected in the resident's care plan after the weight loss was identified. Similarly, another resident with quadriplegia, cerebral infarction, Alzheimer's, type 2 diabetes, and major depressive disorder experienced a 16.6% weight loss over six months and 5.2% in one month. This resident also had physician orders for nutritional supplements and double meal portions, but the care plan was not updated to include these interventions after the significant weight loss was identified. The facility's policy requires individualized care plans to address causes of weight loss, set goals, and include interventions and monitoring parameters. However, the dietary manager confirmed that the care plans for both residents were not updated with the new physician-ordered interventions following the identification of significant weight loss. This omission was acknowledged during interviews, with the dietary manager stating that the updates had not yet been made.
Failure to Obtain Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain a physician-ordered Basic Metabolic Panel (BMP) for one resident as required. According to the facility's policy, nursing staff are expected to follow physician orders. The resident had an active order for a BMP to be performed every two weeks starting from a specified date. However, medical record review showed that the BMP was not obtained at the prescribed intervals, with only a few tests documented and significant gaps between them. This deficiency was confirmed by the Regional Nurse Consultant, who verified that the laboratory tests were not performed as ordered.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for a resident with multiple risk factors for infection. According to the facility's policy, EBP, including the use of gown and gloves, is required during high-contact care activities for residents with wounds, indwelling devices, or known colonization or infection with multi-drug-resistant organisms (MDROs). One resident had a colostomy, a pressure ulcer on the right buttock, and an indwelling urinary catheter, all of which necessitated EBP as documented in the care plan and physician orders. During observation, a CNA was seen emptying stool from the resident's colostomy bag while wearing gloves but not a gown, despite a posted EBP sign on the resident's door. The CNA later acknowledged forgetting to wear a gown, and the facility's Infection Preventionist confirmed that a gown should have been worn during this care activity. This lapse in following established infection control protocols constituted a failure to implement the facility's EBP policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a physical altercation between two residents. One resident, who uses a walker and has a BIMS score indicating severe cognitive impairment, was seated in the dining room when another resident, who propels himself in a wheelchair and is cognitively intact, moved the first resident's walker to create more space. In response, the resident with the walker struck the other resident in the face. Staff observed the incident, but the altercation occurred before they could intervene. Both residents were assessed after the incident, and no injuries were found. The resident who initiated the physical contact has a history of behavioral symptoms, including physical aggression and verbal outbursts when agitated, as documented in his care plan. His diagnoses include mild intellectual disabilities, schizoaffective disorder, and major depressive disorder. The other resident involved has significant medical conditions, including mantle cell lymphoma and generalized anxiety disorder, and was unable to recall the incident. The facility's policy affirms residents' rights to be free from abuse, but the policy was not effectively implemented to prevent this resident-to-resident physical abuse.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two roommates. According to progress notes, an incident occurred between the two residents, resulting in one being moved to another room. Documentation indicated that a skin assessment was performed and no injuries were noted, but there was no further documentation in the electronic health records regarding the incident for either resident. The facility's abuse policy requires prompt and aggressive investigation and documentation of all reports and allegations of abuse, neglect, or mistreatment, but this was not followed in this case. Interviews revealed that the administrator interviewed both residents about the incident but did not document these interviews in the health records. Additionally, the administrator did not interview staff who were aware of the incident, including the LPN on duty at the time. The administrator stated that she believed she had enough information and did not pursue a further investigation, and there was no other documentation or investigation record regarding the incident.
Failure to Document and Implement Treatment Orders and Label Wound Dressings
Penalty
Summary
The facility failed to document and implement a prescribed treatment order for one resident diagnosed with scabies. Although a specialty physician ordered Permethrin (Elimite) 5% cream to be applied to the resident's whole body for 12 hours and repeated in seven days, there was no evidence in the electronic health record or treatment administration record that the order was documented or carried out. The Director of Nursing confirmed that the treatment order was not entered into the resident's records and that the resident was apparently not treated as prescribed. Additionally, the facility did not follow its own policy regarding the labeling and dating of wound dressings after treatment for two other residents. Observations showed that dressings on these residents were clean and intact but lacked required labeling and dating. The wound nurse acknowledged that staff were instructed to document wound care only in the treatment administration record and not to label or date the dressings, contrary to facility policy. These actions resulted in a failure to ensure proper documentation and implementation of wound care treatments as ordered.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents identified as high risk for falls. One resident, with a history of polyneuropathy, generalized muscle weakness, cognitive deficits related to Parkinson's, and requiring extensive assistance with bed mobility, was left unattended in bed by a CNA who walked away to obtain supplies during care. This resulted in the resident rolling out of bed and sustaining a right eyelid injury. The resident's care plan specified that they should never be left in an unsafe or uncomfortable position, and assessments documented the need for extensive assistance for all bed-related activities. Another resident, also identified as high risk for falls due to spinal stenosis, generalized edema, muscle weakness, poor safety awareness, and a history of falls, experienced multiple falls. The care plan required frequent checks and assistance with bathroom needs. On one occasion, the resident attempted to get up alone after waiting an extended period for staff to respond to a call light, resulting in a fall to her knees. The resident reported frequent long waits for assistance, especially at night, sometimes resulting in accidents. On another occasion, the resident fell while trying to use the bathroom, and investigation revealed that staff did not follow the care plan intervention for frequent checks. Interviews with the Director of Nursing confirmed that in both cases, staff failed to provide the required supervision and did not adhere to individualized care plan interventions. The facility's Fall Reduction Program policy required individualized interventions and supervision based on assessed risks, but these were not consistently implemented, leading to preventable falls and injuries.
Inadequate Staffing Leads to Delayed Resident Care and Unanswered Call Lights
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by consistent understaffing on both day and night shifts. Staffing assignment sheets showed that although extra CNAs were scheduled, they were routinely sent home if the state minimum staffing was met, leaving only six CNAs on day shift and four on night shift for a census of 72 to 76 residents. Staff, residents, and family members reported frequent delays in call light responses, with some residents waiting up to an hour or more for assistance with incontinence care, transfers, or other needs. Multiple grievances were filed regarding slow response times, and direct observations by surveyors confirmed call lights going unanswered for extended periods, including one instance where a resident's call light was not answered for 21 minutes until the surveyor intervened. Several residents required high levels of care, including 31 out of 72 residents needing full mechanical lifts for transfers, which require two CNAs to operate safely. Staff interviews revealed that the reduction in CNA staffing made it difficult to provide timely care, complete showers, and respond to call lights, especially on halls with residents requiring more intensive assistance. The facility's own assessment acknowledged the need for sufficient nursing staff with appropriate competencies to ensure resident safety and well-being, but staffing decisions were based solely on meeting state minimum requirements rather than the actual acuity and needs of the resident population. Specific incidents included a resident who waited over an hour to be changed after incontinence, another who attempted to transfer herself after waiting too long for help and subsequently fell, and multiple reports from residents and family members about long waits and unmet care needs. The Director of Nursing and other staff confirmed that staffing was determined by census and state minimums, despite the heavy care needs of many residents. The facility's grievance log, staff, and resident interviews, as well as direct observations, all supported the finding that inadequate staffing led to delays in care and unmet resident needs.
Failure to Respond Timely to Resident Call Lights Due to Insufficient Staffing
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for seven residents, as evidenced by direct observations, interviews, and review of facility records. The facility's own policy requires call lights to be answered as soon as possible, and the facility assessment states that sufficient nursing staff must be available to meet resident needs. Multiple grievances were filed by residents regarding slow call light response times, and staff interviews confirmed that inadequate staffing contributed to delays. Certified Nursing Assistants (CNAs) reported being overwhelmed and unable to answer all call lights promptly due to insufficient staffing levels. Residents described waiting extended periods for assistance, with one resident reporting a wait of an hour and a half after an episode of incontinence, and another stating that call lights could go unanswered for over an hour. Direct observation by the surveyor confirmed call lights going unanswered for 10 to 21 minutes. Family members also reported long waits for call light responses. The administrator acknowledged that call lights should be answered within five to ten minutes and that it was unacceptable for them to go unanswered for 20 minutes or more.
Unlabeled Insulin Vials and Pens Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove and discard unlabeled multi-dose insulin vials and insulin delivery pens from four active medication carts. This deficiency affected 17 residents who were reviewed for insulin usage. During observations, multiple instances were noted where unlabeled insulin vials and pens were stored in the insulin compartments of medication carts across several halls, including Harmony I, Harmony II, and the respiratory unit. Interviews with nursing staff confirmed that these insulin vials and pens were not labeled with resident names and should not be used or stored in the carts. The facility's policies require that all medications be stored in containers with pharmacy labels and be prepared and administered only to the residents for whom they were ordered. The Director of Nursing and nursing staff acknowledged that insulin vials and pens not labeled with a resident's name should be immediately discarded and never used for any resident. Despite these policies, the presence of unlabeled insulin in active medication carts was observed for all residents in the facility who regularly utilize insulin.
Failure to Follow Abuse Investigation Procedures
Penalty
Summary
The facility failed to fully implement its Abuse Prevention Policy during an investigation into an allegation of physical abuse made by a resident. According to the policy, the appointed investigator is required to interview the person who reported the incident, anyone likely to have direct knowledge, the resident if possible, and other residents who receive care from the same staff member accused, as well as employees who regularly work with the accused. In this case, the investigation did not include interviews with other residents who received care from the same caretakers as the resident who made the allegation. The administrator confirmed that these required interviews were not conducted during the investigation, as the investigation was handled by another appointed individual in her absence.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with significant cognitive deficits, as evidenced by a BIMS score of 00 and a care plan noting risk factors for abuse. The incident began when the resident's wife, a retired nurse and mandated reporter, observed a severe bruise near the resident's eye and reported that the resident claimed a man had entered his room and caused the injury. The facility's abuse prevention policy requires interviews with the person reporting the incident, anyone with direct knowledge, the resident if possible, and other residents and staff who may have relevant information. During the investigation, staff who worked the night of the alleged incident were interviewed and reported not seeing any male enter the resident's room. However, the investigation did not include interviews with other residents residing near the affected resident's room or those who received care from the same staff. The Director of Nursing confirmed that some interviewable residents in the hallway should have been included in the investigation, acknowledging that the process was not thorough and did not meet the facility's own policy requirements.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide weekly showers for seven out of eight residents reviewed in a sample of nine. The facility's policy requires that showers be documented weekly, but records show that residents did not receive showers as scheduled. The facility's shower schedule indicates bi-weekly showers for the residents, but documentation was missing for several weeks, indicating a failure to adhere to the schedule. Residents expressed dissatisfaction with the shower schedule, with some stating they were not receiving showers on their scheduled days. One resident, who is the Resident Council President, reported that staff often claimed they did not have time to provide showers or promised to return but did not. Another resident on hospice care expressed discomfort with the way showers were administered and noted that they often had to wash themselves due to lack of assistance. The Director of Nursing acknowledged the issues with the shower schedule, stating that improvements were being made but could not provide additional documentation to support compliance with the shower policy. This lack of documentation and adherence to the shower schedule led to the deficiency identified in the report.
Failure to Provide Sugar Substitutes for Diabetic Residents
Penalty
Summary
The facility failed to adhere to its dietary menu by not providing necessary condiments, specifically sugar substitutes, for residents with dietary preferences and needs. The facility's Week at a Glance Dietary Menu indicated that condiments should be served with all meals, but observations on multiple occasions revealed the absence of sugar substitutes on dining room tables, individual serving trays, and the main dining room condiment cart. This deficiency affected six out of nine residents reviewed, all of whom had a diagnosis of Diabetes Mellitus, necessitating the use of sugar substitutes. Interviews with residents and the dietary manager highlighted the ongoing issue of insufficient sugar substitute supplies. Residents reported having to purchase their own sweeteners due to frequent shortages, and the dietary manager acknowledged the high demand and occasional hoarding of sweetener packets by residents. Despite the facility's policy allowing for emergency purchases from local stores, the dietary manager admitted to not realizing the stock had been depleted, resulting in a lack of sugar substitutes available for residents from March 10 to March 27.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to adhere to its own respiratory therapy procedures and professional standards, resulting in deficiencies in the management of respiratory equipment for several residents. Specifically, the facility did not ensure that oxygen tubing, humidification reservoirs, and other respiratory equipment were properly dated, bagged, and stored off the floor. For instance, one resident's nasal cannula tubing was not dated, and the humidification reservoir was improperly dated, with a new date written over an old one. Another resident's oxygen tubing and humidification reservoir were also undated, and a nebulizer mask was found hanging uncovered and close to the ground. Additionally, other residents were observed with undated nasal cannulas and humidification reservoirs, and one resident had a CPAP mask with undated tubing. A gallon of distilled water, used for humidification, was found sitting on the floor without a date, and later dated incorrectly. These observations were confirmed by the facility's LPN/Infection Preventionist, who acknowledged the discrepancies and the failure to follow the facility's respiratory therapy procedures.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to document in the residents' medical records or provide written notification to residents and/or their representatives regarding hospital transfers or discharges. This deficiency was identified through record review and interviews, revealing that the facility did not issue written notifications for any resident when they were discharged to the hospital. The facility's Transfer and Discharge Policy requires that residents or their authorized legal representatives be notified both verbally and in writing in emergent situations, including details such as the reason for transfer, effective date, location, right to appeal, and contact information for the state Ombudsman. However, the Regional Director of Operations admitted that these notifications were not being completed due to staff turnover, despite previous compliance following a similar issue identified a couple of years ago. This oversight has the potential to affect all 73 residents residing in the facility.
Facility Lacks Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which is a requirement for providing adequate support and care for residents. This deficiency was identified through observation, interviews, and record reviews. The facility's daily census report documented 75 residents, and the facility assessment tool highlighted the necessity of a DON for the facility's operations, including infection control and compliance with state and federal regulations. However, the assessment did not document a current DON, and the job summary for the DON position outlined critical responsibilities that were not being fulfilled due to the vacancy. The deficiency arose when the former DON resigned abruptly, leaving the facility without a DON for several weeks. During this period, the Assistant Director of Nursing (ADON), who is a Licensed Practical Nurse (LPN), was temporarily filling in for the DON role. The Administrator in Training acknowledged the absence of a DON and mentioned efforts to interview a potential candidate, although no interviews had been conducted at the time of the report. This lack of a full-time DON has the potential to affect all 75 residents in the facility.
Failure to Notify Family of Resident Fall
Penalty
Summary
The facility failed to notify a family member of a resident's fall, which was a deficiency identified during the survey. The facility's policy requires prompt notification of the resident, their attending physician, and their representative in the event of a change in the resident's condition or status, including falls. In this case, a resident self-reported a fall in their room, resulting in a head injury. The fall was documented, but there was no record of the family being notified until 29 hours later, despite the facility's policy. The resident's primary care physician was informed of the fall over three hours after it was reported, but the family was not notified until the following day. The delay in communication led to the family requesting the resident be sent to the hospital for further evaluation. The facility administrator confirmed that the family was not notified initially because the resident was cognitively intact and their own power of attorney. However, the regional director confirmed that the facility's policy is to notify family members or emergency contacts of such incidents.
Failure to Complete Neurological Assessments and Timely Hospital Transfer
Penalty
Summary
The facility failed to implement complete neurological assessments, provide continuous monitoring, and ensure timely hospital transfer for a resident who experienced an unwitnessed fall. The resident, who had a history of cerebral infarction, chronic respiratory failure, and other significant health conditions, fell in their room and hit their head, resulting in a knot on the occipital region. Initial assessments were conducted, and neurological checks were initiated but not completed as per the facility's protocol. The resident self-reported the fall and was noted to have a knot on the head with no loss of consciousness. Despite the initial assessment and the initiation of neurological checks, the monitoring was not continued beyond a certain point, and the resident later complained of complete vision loss in one eye and severe headache. It was only after these symptoms were reported that the facility contacted emergency services for hospital transfer. The hospital evaluation revealed that the resident had suffered an occipital stroke, which was not immediately identified due to the incomplete neurological assessments and delayed response. The facility's failure to adhere to its own policy for monitoring and timely intervention contributed to the delay in the resident receiving appropriate medical care.
Resident Fall Due to Inadequate Supervision During Care
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R6, during incontinence care, which resulted in a fall and subsequent injury. R6, who has a history of falls and is at high risk for falls due to conditions such as contractures, dementia, and a traumatic brain injury, was being assisted by a CNA when the incident occurred. The CNA was providing care and turned away from R6 to find barrier cream, during which time R6 fell from the bed and hit her head, leading to a fracture of the left femur. The facility's policies require that CNAs ensure resident safety during care, including keeping necessary supplies within reach and maintaining a hazard-free environment. However, during the incident, the CNA did not maintain physical contact with R6 and turned away, which contributed to the fall. The CNA was unaware if R6 was reaching for something or trying to grab onto something due to falling, indicating a lack of adequate supervision and safety measures during the care process. The investigation into the fall was insufficient, as the facility administrator only interviewed the CNA involved and did not speak with R6, who was cognitively intact and could have provided valuable information about the incident. The Regional Director later educated the administrator on the importance of interviewing the resident involved in such incidents. The facility's failure to conduct a thorough investigation and ensure proper supervision during care led to the deficiency noted in the report.
Misappropriation of Controlled Substances by RN
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substance medications for eight residents. The incident involved a Registered Nurse (RN), identified as V8, who was observed on video surveillance taking controlled substances from the medication cart and placing them into her pocket. This occurred on the Respiratory Care Unit, where V8 had access to the medications of residents R2, R7, R9, R10, R11, R12, R13, and R14. The facility's video footage showed V8 unlocking the medication box, flipping through the narcotic count book, and discreetly removing narcotic medications over a span of two minutes. The report also includes statements from a Licensed Practical Nurse (LPN), identified as V10, who suspected V8 of stealing medications due to her behavior and appearance, which reminded V10 of someone with a pill addiction. V10 reported these suspicions to the police, who confirmed the theft after reviewing the surveillance footage. V8 was subsequently arrested and charged with forgery, possession of a controlled substance, and theft. The facility's administrator verified the theft after reviewing the surveillance footage, which clearly showed V8's actions.
Failure to Obtain Physician Orders and Timely Treat UTIs
Penalty
Summary
The facility failed to obtain physician orders for the use and care of an indwelling urinary catheter for a resident, failed to notify a physician of abnormal urine laboratory test results, and failed to timely treat a urinary tract infection (UTI). These failures resulted in the resident experiencing lower abdominal pain, urine with increased sediment in the catheter tubing and bag, and abnormal urine laboratory test results with a delay in physician notification and treatment. The resident was subsequently transferred to two different hospitals and admitted to the intensive care unit with a diagnosis of UTI with septic shock. The resident's medical records did not contain documentation that the indwelling catheter care was completed daily. The resident's urine laboratory results indicated a UTI, but the results were not promptly communicated to the physician, and no treatment orders were obtained. The resident's spouse reported that the resident had been complaining about lower abdominal pain and not feeling well for almost a week, and the staff did not take appropriate action despite the spouse's concerns. Another resident also had a physician-ordered urinalysis and culture and sensitivity test that was not completed. The Director of Nursing verified that the test should have been collected but was not done. This indicates a pattern of failure to follow through with physician orders and proper documentation, leading to significant health risks for the residents.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee the Infection Prevention and Control Program (IPCP). The job summary for the IP role, dated 2/13/20, outlines responsibilities such as tracking infections, updating electronic medical records, and conducting staff in-service training on infection control. However, the Key Personnel List provided on 4/23/24 was blank in the section for the Infection Preventionist, indicating no staff member was designated for this role. Interviews revealed that the previous IP nurse left the facility on 4/2/24, and although a Licensed Practical Nurse (LPN) with a current IP certificate was identified as a backup, this LPN had not been informed or assigned to the IP role. The LPN confirmed not having worked in the IP capacity since the previous IP nurse's departure. This lack of a designated IP has the potential to affect all 72 residents currently residing in the facility.
What surveyors are citing around you — mapped
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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 68 citations issued within 25 miles in the last 12 months — including the 1 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
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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) |
|---|---|---|---|---|
| St Clara's Rehab & Senior Care | 2.7 mi | — | 1 | 0 |
| H & J Vonderlieth Lvg Ctr, The | 10.4 mi | — | 8 | 0 |
| Mason City Area Nursing Home | 18 mi | — | 1 | 0 |
| Goldwater Care Clinton | 19.6 mi | — | 52 | 0 |
| Villa Health Care East | 23.1 mi | — | 6 | 1 |
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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.