Lincoln Village Healthcare

In the surveyor’s words

From the most serious findings on record at Lincoln Village Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 25, 2026

  Based on interview, and record review, the facility failed to ensure adequate supervision, safe transfer practices, post-fall assessment, and timely medical evaluation for one (R1) of four residents reviewed for accidents in the sample list of four. This failure resulted in R1 sustaining multiple rib fractures and a spinal compression fracture following a fall from R1's bed on 3/10/26, with no physician evaluation or diagnostic testing completed until seven days later. Findings include:The facility's undated Assisting a Client with Bed Mobility policy documents do not leave the resident lying on the edge of the bed. Stand next to the side of the bed the person is closest to, assist them to roll to their side and face you. […]

• Actual harm, isolatedF684Sep 11, 2025

  Based on interview and record review the Facility failed to protect a wound from insect contamination and failed to provide appropriate physician ordered wound care leading to a decline in the Resident's physical well-being for one of three Residents (R1) reviewed in sample of five. This failure resulted in R1 requiring emergent transport to the local hospital and hospitalization. Findings include:The Facility Pressure/Skin Breakdown-Clinical Protocol Policy, reviewed 1/2025, documents: document the individual's significant risk factors; nurse must document/report a full assessment of skin condition; identify factors contributing or predisposing Residents for skin breakdown such as co-morbidities; document signs/symptoms of infection, skin condition assessment and the impact of co-morbid… […]

• Actual harm, isolatedF697Jul 20, 2025

  Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the residents were not receiving their prescribed pain relieving opioid medications, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for three of three residents (R2, R14, and R22) reviewed for pain in the sample of 30. […]

• Actual harm, isolatedF755Jul 20, 2025

  Based on observation, interview, and record review the facility failed to implement a process for the timely ordering and reordering of medications, failed to notify the physician of the need for opioid analgesic medications and anti-anxiety medication prescription refill orders, failed to notify the physician of the need for an alternative to ordered Ozempic, and failed to obtain physician ordered opioid analgesic medications, anti-antianxiety medication, and weight-loss medication from the pharmacy for four of four residents (R2, R14, R18, and R22) reviewed for pharmacy services in the sample of 30. […]

• Actual harm, isolatedF689May 15, 2025

  Based on interview, observation and record review, the facility failed to provide supervision and implement fall prevention interventions to prevent resident falls for two of three residents (R1 and R4) reviewed for falls in the sample of 24. These failures resulted in R1 falling and sustaining an injury to right eyelid and R4 falling and experiencing left hip pain. Findings include: The facility's Fall Reduction Program (revised April 2019) documents the following: It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. […]