Inspection·July 2, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R5) reviewed for abuse in a sample of four. Findings include: Facility's Abuse Policy, reviewed 5/19/25, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflected upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Facility's Initial and Final Reports to (State Department of Public Health) for R4 and R5, dated 5/19/25, document: There was an altercation between R4 and R5. R4 ambulates with his walker and attends activity sessions in the dining room. While R4 was seated with the walker by his side, R5, who propels himself with a wheelchair, entered the dining room and moved R4's walker to provide more space. As soon as R5 moved R4's walker, R4 hit R5's face in attempt to stop him from moving it. 1. R5's diagnoses include: Mantle cell lymphoma, malignant neoplasm of prostate, generalized anxiety disorder, personal history of other venous thrombosis and embolism. R5's Minimum Data Set/MDS dated [DATE] documents R4 has a BIMS (Brief Interview of Mental Status) of 6 on a scale of 00 - 15 indicating severe impairment. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R5's progress note, dated 5/18/25 documents: (R5) involved in altercation in dining room with another resident (R4) and was struck in the Left cheek. On 6/27/25 at 1:35pm, R5 stated he did not remember any altercation that he had with R4. 2. R4's diagnoses include: Mild intellectual disabilities, malignant neoplasm of right testis, schizoaffective disorder, major depressive disorder, chronic kidney disease. R4's Minimum Data Set/MDS dated [DATE] documents R4 has a BIMS score of 15 on a scale of 00 - 15. (continued on next page) 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 5 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 07/02/2025 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)