Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 The Commons Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
The facility failed to maintain complete CNA flow sheet documentation for three residents, including individuals with Type 2 DM, HTN, UTI, dementia, anxiety, and a right lower leg infection following a fall. Policy required all services and changes in condition to be documented, yet multiple entire days and shifts in two consecutive months were left blank for each resident. A CNA reported they are expected to document care in the electronic flow sheets after providing care and noted there is no electronic alert for missing entries, while the DON stated CNAs are expected to complete flow sheets at the end of each shift and acknowledged multiple days of missing documentation.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Maintain Complete CNA Flow Sheet Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records when CNA flow sheets documenting the provision of care were left blank for multiple days and shifts for three residents. Facility policy on Charting and Documentation, revised 07/2017, required that all services provided to residents, progress toward care plan goals, and any changes in residents' conditions be documented in the medical record. For a resident admitted in November 2025 with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Urinary Tract Infection, review of CNA flow sheets for December 2025 showed multiple dates where all three shifts (day, evening, and night) were left blank, including 12/02, 12/04 through 12/08, 12/11, 12/13, and 12/14. A second resident admitted in December 2025 with diagnoses including status post fall and a right lower leg infection had CNA flow sheets for January 2026 with no documentation on several dates across all shifts, specifically 01/02 through 01/04, 01/07, 01/08, 01/12, and 01/13. A third resident admitted in December 2023 with dementia and anxiety had extensive gaps in CNA flow sheet documentation for December 2025 and January 2026, with multiple consecutive days and shifts left blank, including large portions of early, mid, and late December and early to mid-January. During interview, a CNA stated they are supposed to document care on the electronic flow sheet once completed and noted there is no electronic alert if documentation is not done. In a separate interview, the DON stated CNAs were supposed to complete their flow sheets at the end of every shift and acknowledged there were several missing days of CNA documentation for the three residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Concord | 2.7 mi | — | 3 | 0 |
| Rivercrest Long Term Care | 3 mi | — | 0 | 0 |
| Campion Health & Wellness, Inc | 4.6 mi | — | 0 | 0 |
| Carleton-willard Village Retirement & Nursing Ctr | 4.9 mi | — | 0 | 0 |
| Brookhaven At Lexington | 5 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.