Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure the resident needs were
accommodated for one of three sampled residents (Resident 17), when the call light was not answered.
Residents Affected - Few
This failure had the potential to result in the resident not attaining his highest practicable physical,
psychosocial and emotional well-being.
Findings:
Resident 1 was admitted to the facility in early 2024 with diagnoses which included paraplegia (paralysis of
the legs and lower body), pressure sores of both heels, and muscle weakness.
During a review of Resident 1's Admission/readmission Evaluation/Assessment (A/RE/A), dated 1/3/24, the
A/RE/A indicated Resident 1 had no memory impairment, had paralysis, and needed assistance with
activities of daily living (ADLs).
During a review of Resident 1's Nursing Care Plan (NCP), dated 1/10/24, the NCP indicated, ADL/Mobility
.Interdisciplinary team .has established a goal for Functional Abilities and Goals based on Prior Level of
Functioning .chair/bed-to-chair transfer, eating, lower body dressing, lying to sitting on side of bed .
During a concurrent observation and interview on 1/11/24 at 10:36 a.m., Resident 1's room call light was
turned-on. A medication cart was in front of the room with Licensed Nurse 1 standing in front of the
medication cart and not answering the call light. When asked if LN 1 was going to answer the call light, LN
1 ignored the question, walked away and left, and did not answer the call light.
During a concurrent observation and interview on 1/11/24 at 10:37 a.m. in Resident 1's room, a dirty diaper
was found on the floor in between the two beds. Resident 1 was in bed, awake, alert and verbally
responsive. Resident 1, stated, I had to throw my dirty diaper on the floor. I have turned on my call light but
nobody was coming to help. I have to change my diaper and I have to do it myself.
During a concurrent observation and interview on 1/11/24 at 10:38 a.m. in Resident 1's room, Resident 1
stated, I have been here, maybe about a week. I have sores. I'm also having pain sometimes. I'm in a
wheelchair. So with the wounds and my physical health issues, it's difficult for me to live by myself . When
asked about his call light, Resident 1 stated, I have been trying to call for help because I wanted to change
my diaper .I threw my dirty diaper out because I have been trying to change myself and I cannot get help. I
feel awful because when you need help you don't get it .When you can't get help, it is very frustrating .My
only concern is I need help when I have to change my
(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 3
Event ID:
555333
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
555333
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Meadows Care Center
1550 Third Street
Lincoln, CA 95648
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
diapers because I'm paralyzed down to my legs, and I don't want to stay wet. That's why I took my diapers
off and threw it on the floor because no one is coming to help me out.
During a concurrent observation and interview on 1/11/24 at 10:40 a.m. in Resident 1's room, LN 1 entered
and verified the dirty diaper on the floor, and stated, Like that, I mean, as a nurse I would say that's not
right. That would be an infection control issue if somebody goes in there and steps on the dirty diaper.
During an interview on 1/11/24 at 10:41 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 entered
Resident 1's room, and stated, [Resident 1] needs help with changing his diaper. I will come back and get
him ready in a few minutes. I have to attend to the other patient quickly.
During an interview on 1/11/24 at 10:45 a.m. with CNA 1 at the facility hallway, CNA 1 stated, I am assigned
for this hallway today .I have the left section and not on the right section [Resident 1's side]. When asked
why she answered the call light on the right section, CNA 1 stated, We should answer the call lights right
away .I just came on the other side .If the lights are on, there is a nurse available to answer the call lights
.Everybody is responsible to answer the call light.
During an interview on 1/11/24 at 11:02 a.m. with LN 1 in the hallway, when asked what staff do when a call
light was turned on, LN 1 stated, I have to check what the resident needs and turn off the call light.
Everybody answers the call lights. I know I did not answer the call light.
During an interview on 1/11/24 at 11:16 a.m. with LN 2 in the hallway, LN 2 stated, Everybody should
answer the call light .If the CNAs are busy, we are also responsible to answer the call lights. If the resident
needs care, we answer the call light and let them know help will be coming in a few minutes. You just have
to talk to them and explain what the situation was.
During an interview on 1/11/24 at 11:28 a.m. with CNA 2 in the hallway, CNA 2 stated, If I see a call light, I
go and see and ask what they want .Everybody should answer the call light. You don't know what they want.
During an interview on 1/11/24 at 11:45 a.m. with the Director of Nursing (DON), the DON stated, When a
call light is turned on, everybody has to answer the call light .[Resident 1] is alert and oriented. The staff
should have answered the call light and provided what the resident needed.
During an interview on 1/11/24 at 12:05 p.m. with the Administrator (ADM), the ADM stated, My expectation
is to answer the call light as soon as possible.
During a review of the facility's policy and procedure (P&P) titled, Answering Call Lights, revised 10/22, the
P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs .When the
resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .If you are
uncertain as to whether the request can be fulfilled or if you cannot fulfill the president ' s (sic) request, ask
assistance from the nurse .
During a review of the facility's P&P titled, Accommodation of Needs, revised 3/21, the P&P indicated, Our
facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or
achieving safe independent functioning, dignity and well-being The resident's individual needs and
preferences shall be accommodated to the extent possible and in accordance to the resident's wishes, for
example . interacting with the residents in ways that accommodate the physical
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555333
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
555333
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Meadows Care Center
1550 Third Street
Lincoln, CA 95648
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 0558
or sensory limitations of the residents, promote communication, and maintain dignity.
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's P&P titled, Resident ' s Rights, the P&P indicated, Residents are entitled to
exercise their rights and privileges to the fullest extent possible .Our facility will make every effort to assist
each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness
and dignity.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555333
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
FAQ · About this visit
Common questions about this visit
What happened during the January 11, 2024 survey of LINCOLN MEADOWS CARE CENTER?
This was a inspection survey of LINCOLN MEADOWS CARE CENTER on January 11, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LINCOLN MEADOWS CARE CENTER on January 11, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.