Lincolnshire Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lincolnshire Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 6, 2021

  Based on record review and interview, the facility failed to provide continuous CPR (cardiopulmonary resuscitation) to a resident until EMS (Emergency Medical Services) arrived. The resident had an Advance Directive indicating the desire for CPR (full code status). The staff ceased CPR and canceled the EMS call after CPR was initiated for 7 minutes, without an order from the Resident's Physician, resulting in the death of a resident for 1 of 6 residents reviewed for Advanced Directives. The immediate jeopardy began on [DATE] when two RNs ceased CPR prior to EMS arriving at the facility and without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Nov 24, 2025

  Based on observation, record review, and interview, the facility failed to ensure food was stored and served under sanitary conditions related to touching food with bare hands, glove use, beard restraints, dirty food equipment, ice on the freezer floor, food spillage in the walk in cooler, and food brought in by visitors or resident's food that was not labeled for 1 of 1 kitchen and 1 of 2 wings. (The main kitchen and the A Wing)Findings incude:1. During the Brief Kitchen Sanitation Tour on 11/17/2025 at 9:56 a.m. with the Dietary Food Manager (DFM) the following was observed:a. Dietary [NAME] 1 was observed with a disposable glove on her left hand and her right hand was bare. […]

• No harm, potential for more than minimal, widespreadF921Nov 24, 2025

  Based on observation and interview, the facility failed to keep the kitchen and residents' environment clean and in good repair related to dirty walls, ceilings, floor tile, ceiling vents and adhered dirty against the baseboard for 1 of 1 kitchen (The main kitchen); marred and water-damaged walls, grab bar not secured to the wall, and uncontained basins (Resident Rooms A02, B01, B08) Findings include:1. During the Brief Kitchen Sanitation Tour on 11/17/2025 at 9:56 a.m. with the Dietary Food Manager (DFM) the following was observed: a. The dish room walls were observed with dried food spillage. b. The floor drains under the dish machine were dirty with a large accumulation of dirt and debris under the dish machine. c. The floor tile grout was discolored near the steam tables. d. […]

• No harm, potential for more than minimal, widespreadF727Dec 7, 2023

  Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect 64 of 64 residents who resided in the facility. Finding includes. Review of the nursing staffing schedules for November 2023 on 12/6/23 at 2 p.m., indicated there was no RN in the facility for eight consecutive hours on November 11, 2023. During an interview on 12/7/23 at 8:57 a.m., the Director of Nursing acknowledged the schedule for 11/11/23 indicated the RN who was scheduled had called off and there was no other RN in the building for eight consecutive hours. This citation related to Complaints IN00419693, IN00422944, and IN00423001. 3.1 -17(b)(3)

• No harm, potential for more than minimal, patternF684Nov 24, 2025

  Based on observation, record review, and interview, the facility failed to ensure a treatment to a surgical incision was completed as ordered, areas of bruising and scabbing were assessed and monitored, and interventions were in place for areas of dry scaly skin for 5 of 6 residents reviewed for skin conditions non-pressure related. (Residents D, H, J, F, and G)Findings include:1. The closed record for Resident D was reviewed on 11/19/25 at 3:22 p.m. Diagnoses included, but were not limited to, aortocoronary bypass graft, atherosclerotic heart disease, and type 2 diabetes mellitus. The Medicare 5-day Minimum Data Set (MDS) assessment, dated 8/9/25, indicated the resident had moderate cognitive impairment and required partial/moderate assistance with bathing and dressing. […]