Lincoln Knolls Health & Rehab LLC

In the surveyor’s words

From the most serious findings on record at Lincoln Knolls Health & Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF805Feb 25, 2022

  Based on medical record review, observations, staff interview, review of the facility menus and spreadsheets for mechanical soft diets, review of facility policy for therapeutic diets, consistency modified diets, and tray card policy, the facility failed to ensure 10 residents on mechanically altered diets were provided food in the correct form assessed to meet their individual needs. This resulted in Immediate Jeopardy for Residents #6, #11, #19, #30, #31, #36, #37, #201 and #345 who were served whole, intact bone-in chicken by the dietary staff and nursing assistants. Residents #6, #27, #30 and #36 also were assessed to need their liquids thickened to nectar consistency and were served the wrong consistency liquids. […]

• No harm, potential for more than minimal, widespreadF943Jul 9, 2026

  Based on interview and record review, the facility failed to ensure newly hired staff received orientation and training on abuse prohibition upon hire. This had the potential to affect all 39 residents residing in the facility. Findings include: Review of the personnel files for Certified Nursing Assistant (CNA) #509 (date of hire 06/25/26), CNA #506 (date of hire 05/13/26), Certified Medication Assistant (CMA) #507 (date of hire 06/11/26), Housekeeper #512 (date of hire 07/06/26) and [NAME] #511 (date of hire 05/21/26) revealed no evidence of orientation and training on abuse upon hire. An interview with [NAME] #511 on 07/09/26 at 11:13 A.M. revealed they had received no training on abuse since hire. An interview with Human Resources (HR) #510 on 07/09/26 at 9:58 A.M. […]

• No harm, potential for more than minimal, widespreadF570Feb 23, 2026

  Based on record review and interview, the facility failed to have a surety bond to cover the total amount of resident funds managed by the facility. This affected all 27 residents (#2, #3, #4, #8, #9, #11, #12, #16, #17, #18, #22, #23, #24, #25, #26, #27, #28, #29, #31, #33, #34, #35, #36, #37, #38, #39, and #40) who had funds managed by the facility. The facility census was 39. Findings include:Review of the facility's surety bond, signed 07/17/25, revealed they had coverage for up to $35,000. Review of the facility's resident accounts listing, dated 02/18/26, revealed the facility managed funds for Residents #2, #3, #4, #8, #9, #11, #12, #16, #17, #18, #22, #23, #24, #25, #26, #27, #28, #29, #31, #33, #34, #35, #36, #37, #38, #39, and #40. […]

• No harm, potential for more than minimal, widespreadF761Feb 23, 2026

  Based on interview, observation, and facility policy review the facility failed to ensure all medications were stored appropriately. This had the potential to affect all residents in the facility. The facility census was 38. Findings include:Observation on 02/11/26 at 10:30 A.M. of the Medication Storage room with Registered Nurse (RN) #757 present revealed a frozen dinner in the med storage freezer, a full bottle of liquid Levothyroxine 37.5 milligram/milliliter (mg/ml) with a use by date of 12/25/25, a full bottle of liquid Vancomycin 50 mg.ml with a use by date of 11/07/25, 5 bags of Micafungin 100mg/100ml ordered on 09/26/25 with use by date of 10/23/25, and 1 bag of Cefepime 2 Grams (gm)/100 ml ordered December 2025 use by date 01/13/26. […]

• No harm, potential for more than minimal, widespreadF812Feb 23, 2026

  Based on observation and interview, the facility failed to store foods in a safe an sanitary manner. This had the potential to affect all 39 residents in the facility. Findings include: On 02/10/26 at 8:00 A.M., an observation of the kitchen revealed the following: On the cereal shelf in the main kitchen area, there was one plastic container of dry cereal with no label and no open date. Interview at the time of observation with Dietary Manager #746 verified there was no label or date on the container, verbally identified the cereal as corn flakes, and was unable to state when the corn flakes were placed into that container. In the walk-in cooler, there was one unsealed plastic bag containing sliced white cheese with no label and no open date. […]