Lincoln Meadows Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 13, 2022

  Based on interview and record review, the facility failed to ensure care and services were provided to prevent the development of pressure ulcers (PUs, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) for one of three sampled residents (Resident 1) when documentation of resident repositioning was not maintained per facility policy. This failure resulted in the resident developing several avoidable pressure ulcers. Findings: According to the Resident Face Sheet, Resident 1 was admitted in the Spring of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Jun 14, 2022

  Based on interview and record review, the facility failed to implement measures for the prevention of pressure ulcers for one resident (Resident 1) of seven sampled residents when, Resident 1 developed an unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is covered by extensive dead tissue black, tan or brown in color) at her coccyx. This failure resulted in Resident 1 aquiring a preventable pressure ulcer and suffering pain. Findings: According to the Resident Face Sheet, Resident 1 was admitted in early 2022 with diagnoses including wedge compression fracture of T11-T12 vertebra (collapse of the front of the vertebral body or bone structure at the bottom of the thoracic spine), urinary tract infection and difficulty in walking. […]

• Actual harm, isolatedF689May 30, 2022

  Based on interview and record review, the facility failed to ensure one of 8 sampled residents (Resident 1) received adequate assistance with transfers when, the resident was transferred to her wheelchair by 1 CNA (Certified Nursing Assistant). This failure resulted in the resident sustaining a rib injury with pain. Findings: According to the Resident Face Sheet, Resident 1 was admitted in the summer of 2021 with diagnoses including generalized muscle weakness. A review of Resident 1's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 12/12/21, indicated the resident had no memory impairment. […]

• No harm, potential for more than minimal, widespreadF803Mar 14, 2025

  Based on observation, interviews, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets (modified diets from regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during lunch on 3/12/25 when: 1. 19 Residents (Resident (3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291, and 341) with regular portion with regular texture diets got 6 ounces (oz.) (3/4 cup) of pasta instead of 4 oz. (1/2 cup) 2. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2025

  Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve in a safety manner when: 1. Various sizes of metal pans were found having issues stored in the clean and ready-to-use storage areas: - Stacked wet - Were not clean with food particles 2. The storage areas for storing the clean and ready-to-use metal pans were not clean 3. The blade of the can opener was not well maintained 4. Dietary Aide (DA) 1 was not able to verbalize the process of manual dishwashing by 2-compartment sink 5. DA 2 was not able to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas 6. […]