Lincoln Haven Nursing & Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Lincoln Haven Nursing & Rehabilitation Community, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Nov 18, 2021

  MI 459 Based on observation, interview, and record review, the facility failed to provide an environment free from physical, psychosocial and sexual abuse involving eight Residents (#4, #12, #22, #24, #31, #33, #85, & #86) of nine residents reviewed for abuse. This deficient practice resulted in a determination of immediate jeopardy with the likelihood of sustained physical, psychosocial and sexual abuse to affect the entire facility population. The immediate jeopardy (IJ) began on 10/3/21 when Resident #22 had made an allegation to the Director of Nursing (DON) involving Resident #31 attempting to crawl into bed with her. The DON subsequently did not investigate and dismissed the allegation made by Resident #22 based on her own observations alone. […]

• Actual harm, isolatedF627Aug 17, 2026

  This citation pertains to intake #3109721. Based on interview and record review the facility failed to ensure a safe discharge for one Resident (#12) of three residents reviewed for discharge planning. This deficient practice resulted in hospitalization with sepsis, dehydration, plugged feeding tube, aspiration pneumonia, and hospitalization for Resident #12. Findings include:Resident #12 (R12)According to intake #3109721 filed with the State Agency (SA) on 7/23/26, read in part Individual was discharged from LTC [Long Term Care] to his home.There was no power or running water upon arrival home. The individual was discharged with a Jujunostomy [sic] tube without homecare. The Jujunostomy [sic] was supposed to be set to run 50cc/hr [cubic centimeters/hour] for patency. […]

• Actual harm, isolatedF684Nov 18, 2021

  This citation pertains to Intake MI 064. Based on interview and record review, the facility failed to ensure an appropriate response for a change in condition for one Resident (#32) of 12 residents reviewed for quality of care. This deficient practice resulted in the deterioration of Resident #32's condition and subsequent death. Findings include: Resident #32 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32's most recent Minimum Data Set (MDS) Assessment, dated [DATE], revealed Resident #32 was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF801Apr 1, 2026

  Based on interview and record review the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed. Findings include:On 03/30/2026 at 11:15 AM the dietary manager (DM) F stated she does not have her Certified Professional Food Manager Certification and she is not a Registered Dietitian. DM F stated she has only been at this facility for a short time and has not had a chance to obtain the certifications. […]

• No harm, potential for more than minimal, widespreadF921Apr 1, 2026

  Based on observation, interview, and record review the facility failed to maintain general repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 03/30/2026 at 11:05 AM observed the vegetable wash sink was indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain. During this observation, when asked what this sink is used for, Dietary Manager (DM) F stated that vegetables are washed in this sink.On 03/30/2026 at 12:21 PM observed the double doors for the closet in room [ROOM NUMBER] with the left closet door askew. […]