Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on record review and interview the facility failed to document in the resident's medical records or
provide written notification to residents and/or resident representatives for hospital transfer/discharges. This
failure has the potential to affect all 73 residents residing in the facility.
Findings include:
The facility Long Term Care Facility Application for Medicare and Medicaid, dated 1/28/25, documents 73
residents reside in the facility.
The facility Transfer and Discharge Policy, dated 1/2024, documents: To assure transfers and discharges
will be conducted in accordance with the resident's rights, physician orders, and in such a manner as to
maintain continuity of care for the resident; discharges from a skilled nursing facility to a hospital; when the
facility transfers or discharges a resident under any circumstance, the resident/authorized legal
representative must be notified verbally and in writing in an emergent situation; the facility must include in
the written notice to the resident/authorized legal representative the following (reason for transfer, effective
date of transfer/discharge, location of discharge/transfer, statement that resident has right to appeal,
name/address/telephone number of state Ombudsman; and document the provision of such notice in the
resident's clinical record.
On 1/29/25 at 1:26 PM, V7 (Regional Director of Operations) stated, I cannot find any written notifications
because we are not doing them for any resident when they discharge to the hospital. We got tagged for that
a couple of years ago and were doing good with doing them, but we have had turnover in that position and
now it seems they have not been getting done again.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145719
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145719
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Village Healthcare
2202 North Kickapoo Street
Lincoln, IL 62656
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was
dated, bagged, and kept off the floor per facility policy and professional standards for four (R20, R28, R39,
and R125) of six residents reviewed for respiratory therapy in a sample of 26.
Residents Affected - Some
Findings include:
A facility procedure titled Respiratory Therapy, dated 11/2017, documents The purpose of this procedure is
to guide prevention of infection associated with respiratory therapy tasks and equipment, including
ventilators, among residents and staff. Steps in the procedure include, 2. Use distilled water for
humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after
twenty four (24) hours. It also documents, e. Change the reservoir every forty-eight (48) hours and disinfect
with 2%/percent alkaline glutaraldehyde or sterilize. Additionally, this procedure documents, 7. Change the
oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing
used prn (as needed) in a plastic bag when not in use.
1. R125's Physician Order Report has an order dated 12/28/24 documenting, Oxygen: change tubing and
mask weekly and PRN (as needed). Label. Once a day on (Sunday).
On 01/28/25 at 1:13 PM, R125 was sitting in a recliner in her room with oxygen being administered per
nasal cannula from a concentrator with bubble humidity. R125's nasal cannula tubing had no date. R125's
reservoir for humidity was dated 12/29/24.
On 01/28/25 at 2:28 PM, V4/Licensed Practical Nurse (LPN)/Infection Preventionist (IP) confirmed R125's
oxygen tubing was not dated and R125's humidification reservoir was dated 12/29/24.
On 01/29/25 at 9:23 AM, R125's humidification reservoir was dated 01/28/25 which was written in black
marker with the previous 12/29/24 date visible underneath.
On 01/29/25 at 9:53 AM, V4 confirmed the 01/28/25 date was written over the previously marked date of
12/29/24 and stated, I'm so sorry. I will make sure this is changed.
2. On 01/28/25 at 1:19 PM, R39 was sitting in his room with humidified oxygen from a concentrator being
delivered per nasal cannula. R39's oxygen tubing or humidification reservoir were not dated. R39's
nebulizer mask was tucked into a wheelchair seat in R39's room.
On 01/28/25 at 2:28 PM, V4 LPN/IP confirmed R39's oxygen tubing and humidification reservoir were not
dated, and R39 had an order for oxygen.
On 01/29/25 at 9:29 AM, R39's oxygen tubing and humidification reservoir had no dates. R39's nebulizer
mask was hanging over a handle of a wheelchair and dangling approximately six inches from the ground,
uncovered.
On 01/29/25 at 9:53 AM, V4 confirmed R39's oxygen tubing or humidification had no dates and discarded
R39's nebulizer mask. V4 stated any oxygen equipment not being used should be stored in a plastic bag.
3. On 01/28/25 at 1:26 PM, R28 was sitting in a wheelchair in his room with humidified oxygen from
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145719
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145719
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Village Healthcare
2202 North Kickapoo Street
Lincoln, IL 62656
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
a concentrator being delivered per nasal cannula. R28's nasal cannula or humidification reservoir were not
dated.
On 01/28/25 at 2:32 PM, V4 LPN/IP confirmed R28's nasal cannula and humidification reservoir had no
dates, and R28 had an order for oxygen.
Residents Affected - Some
4. On 01/28/2025 at 1:32 PM, R20 was in bed with a CPAP (Continuous Positive Airway Pressure) mask
on. R20's concentrator tubing, CPAP tubing, and nebulizer tubing were not dated. There was a gallon of
distilled water sitting on the floor in R20's room which was approximately 1/4 full with no date.
On 01/28/25 at 2:28 PM, V4 LPN/IP confirmed R20's tubing's did not have dates, and R20 had an order for
the CPAP and nebulizer.
On 01/29/25 at 9:33 AM, R20's distilled water was slightly lower in volume than observations on 01/28/25
and was again sitting on the floor. This gallon of distilled water is now dated 01/27/25 at 1800 (6PM).
On 01/29/25 at 9:53 AM, V4 confirmed R20's distilled water jug should not be sitting on the floor. V4 also
stated a nurse added the date yesterday (1/28/25) but she wasn't sure why she dated it 1/27/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145719
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
FAQ · About this visit
Common questions about this visit
What happened during the January 30, 2025 survey of LINCOLN VILLAGE HEALTHCARE?
This was a inspection survey of LINCOLN VILLAGE HEALTHCARE on January 30, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LINCOLN VILLAGE HEALTHCARE on January 30, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.