A list of the most recent deficiencies for Lincoln Village Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-11 | 2024-01-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-11 | 2024-01-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-11 | 2024-01-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-14 | 2024-01-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-14 | 2024-01-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-14 | 2024-01-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-28 | 2023-12-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-25 | 2023-11-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-25 | 2023-11-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-03 | 2023-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-10-22 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-03 | 2023-10-22 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-03 | 2023-10-22 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-10-03 | 2023-10-22 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-10-03 | 2023-10-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-03 | 2023-10-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-03 | 2023-10-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-03 | 2023-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-03 | 2023-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-03 | 2023-09-22 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-03 | 2023-09-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-03 | 2023-09-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-04-19 | 2023-05-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-19 | 2023-05-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-19 | 2023-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-19 | 2023-05-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-18 | 2023-05-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-29 | 2022-10-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-25 | 2022-10-10 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-14 | 2022-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-04-14 | 2022-05-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-14 | 2022-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-14 | 2022-05-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-19 | 2022-04-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-19 | 2022-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-19 | 2022-04-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-06 | 2022-04-25 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-06 | 2022-04-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-10 | 2022-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-03-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-10 | 2022-03-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-23 | 2021-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-02 | 2021-07-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-02 | 2021-07-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-02 | 2021-07-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-02 | 2021-07-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-02 | 2021-07-23 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-07-02 | 2021-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-07-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-07-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-02 | 2021-07-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-02 | 2021-07-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-02 | 2021-07-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-02 | 2021-07-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-07-02 | 2021-07-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Establish methods for sharing information. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-07-01 | 2021-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-07-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-24 | 2021-07-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-27 | 2021-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-27 | 2021-05-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-04 | 2021-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-20 | 2021-05-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-20 | 2021-05-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-20 | 2021-05-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-20 | 2021-05-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-31 | 2021-04-16 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-03-31 | 2021-04-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-23 | 2021-04-09 | Y |
