Lincoln Care and Rehab

In the surveyor’s words

From the most serious findings on record at Lincoln Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Mar 11, 2025

  The facility reported a census of 39 residents with five residents sampled and one resident reviewed for served food in a form that met the resident's individual needs. Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 2 with her prescribed mechanical soft diet (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing) with ground meat texture, and instead served cut-up chicken to the resident, on her plate. R2 began to cough and choked on her food. The staff had to suction R2 when R2 could not clear her airway with coughing. The facility transferred R2 to the hospital later that evening. The hospital admitted R2 for fever, pneumonia, and dehydration. […]

• Immediate jeopardy, isolatedF678Feb 8, 2022

  The facility reported a census of 34 residents, with 12 residents included in the sample and one resident sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). The facility identified 26 residents with full code status, indicating the resident wishes for life saving measures to be utilized in emergent situations, to include CPR. Based on interview and record review, the facility staff failed to initiate CPR on a full-code Resident (R)86 on [DATE] at approximately 01:25 PM, when Licensed Nurse (LN) C and Certified Nurse Aide (CNA) D found the resident without respirations and pulseless. […]

• No harm, potential for more than minimal, widespreadF729May 15, 2025

  The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for current certified nurse aide certifications. Based on interview and record review, the facility failed to ensure one CNA had a current and valid certificate. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA LL's files revealed CNA LL was hired on 05/16/22. CNA LL's file lacked evidence of a current certified nurse aide certificate. Review of CNA LL on the Nurse Aide Registry on 05/15/25 revealed CNA LL had an inactive CNA status as of 06/07/23. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected all the CNA staff to have a current certified nurse aide certificate. […]

• No harm, potential for more than minimal, widespreadF730May 15, 2025

  The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for CNA NN and CNA LL. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA NN's files revealed CNA NN was hired on 05/16/22. CNA NN's file lacked evidence a performance evaluation was done in the last 12 months. Review of CNA LL's files revealed CNA LL was hired on 02/29/20. CNA LL's file lacked evidence a performance evaluation was done in the last 12 months. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2025

  The facility reported a census of 37 residents. The facility had one main kitchen where dietary staff prepare all the food. Based on observation, interview and record review the facility failed to store food items in a sanitary manner when staff failed to date food items in the refrigerator and freezer. This placed the residents at risk of food-borne illness. Findings included: - Observation on 05/12/25 at 09:40 AM revealed one bag of beef patties were placed in the freezer without closure of the plastic bag. Further observation revealed two bags of chicken in a store bag sat on the floor in the refrigerator . The freezer floor had food debris visible. There were numerous bags of vegetables and sandwich meat which lacked a date received. […]