Lincoln Haven Nursing & Rehabilitation Community

Inspectors wroteBased on interview and record review the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain general repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 03/30/2026 at 11:05 AM observed the vegetable wash sink was indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain. During this observation, when asked what this sink is used for, Dietary Manager (DM) F stated that vegetables are washed in this sink. On 03/30/2026 at 12:21 PM observed the double doors for the closet in room [ROOM NUMBER] with the left closet door askew. The track that the door was to follow on top was damaged and no longer working, and the upper left portion of the left door was hanging away from the door frame about 5 inches. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's and/or their representatives were educated on the risks and benefits of prescribed psychotropic medications by obtaining informed consent prior to administration for two Residents (#7 and #21) of five residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide requisite bed hold information for three Residents (R3, R6, and R17) of four residents reviewed for hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of assessments for one Resident (#29) of two residents reviewed for Hospice services.

Inspectors wroteBased on interview and record review, the facility failed toEnsure follow-up care was documented for elevated blood glucose levels, and;Communicate with physician as ordered,for one Resident (R3) of one resident reviewed for insulin therapy.

Inspectors wroteResident #21 (R21)Review of R21's electronic medical record (EMR), revealed an admission date to the facility on 7/3/26 with medical diagnoses of multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerve fibers, causing inflammation and scar tissue), and major depressive disorder, recurrent and in full remission. On 3/30/26 at 12:35 PM, an interview was conducted with R21 in her room. R21 was noted to have a high back wheelchair sitting next to a table and R21 was resting in her bed. R21 was asked the last time she was up in her wheelchair and replied, It has been a few days. R21 was asked why she has not been up today and replied, I can only tolerate a couple hours in that wheelchair, it is not my normal wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R4) of two residents reviewed for fluid concerns.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition related to blood glucose monitoring for one Resident (#5) of thirteen residents reviewed for a change in condition.

Inspectors wroteBased on interview and record review, the facility failed to monitor and assess 2 Residents (#5 & #177) of 13 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented per physician's orders for one Resident (#16) of three residents reviewed for positioning and pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat pain timely for one Resident (#177) of one resident reviewed for pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications in two of two medication carts reviewed for pharmacy services.

Inspectors wroteThis citation relates to Intake #Mi00144666 and #MI00144651. Based on interview and record review, the facility failed to employ a qualified Certified Dietary Manager (CDM) to manage the food service department.

Inspectors wroteThis citation relates to Intake #MI00144651. Based on observation and interview, the facility failed to properly maintain resident equipment in safe, operating condition including two Residents (R2, R10) wheelchairs and residents' bed remote controls. This deficient practice resulted in two resident's wheelchairs being in disrepair, and the risk of injury to residents from lack of access to bed remote controls.

Inspectors wroteThis citation relates to Intake #Mi00144666 and #MI00144651. Based on observation, interview, and record review, the facility failed to provide four Residents (R1, R2, R4, and R7) of 12 residents reviewed for food preferences and alternate meal options, who were reviewed for food concerns.

Inspectors wroteThis citation relates to Intake #MI00144651. Based on observation, interview, and record review, the facility failed to act on a concern for one Resident (R8) of one resident reviewed for grievances. This deficient practice resulted in feelings of frustration for R8, and lack of timely follow-up for damaged clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 25 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart, expired medications were removed from the active medication supply room and maintain clean and sanitary medication cart for one of two medication carts and one of one medication rooms reviewed for medication storage. This deficient practice had the potential for complications related to delivery of expired medications and or medications to be lost, stolen, accidental consumed by cognitively impaired residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of new pressure ulcers and failed to provide adequate care to heal facility acquired pressure ulcers for one Resident (R27) out of two residents reviewed for pressure ulcers. This deficient practice resulted in development of additional pressure ulcers and the potential for delayed healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed safety by permitting physical access to the electronic bed remote (pendant) to one cognitively impaired Resident (#14) of seven residents reviewed for bed safety. This deficient practice resulted in the potential for accidents including falls and/or other injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the fluid needs for one Resident (R23) of one Resident reviewed for hydration. This deficient practice resulted in feelings of thirst and fluid seeking for a resident solely dependent on fluids via a tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fresh water was consistently offered and provided for four residents (R3, R4, R5, and R6) of four residents reviewed. This deficient practice resulted in resident dissatisfaction and the potential for feelings of thirst and dehydration.