Lincoln County Nursing & Rehab
1145 East Cherry Street, Troy, MO 63379 · Lincoln County · 90 certified beds · avg 78 residents/day · certified since Jun 26, 1990
Abuse citation flag (CMS)SFF
Part of chain: JAMES & JUDY LINCOLN (56 facilities, chain avg rating 2.4★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: —/5 · CMS overall rating: —/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 17, 2023 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 12, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 16, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 30, 2026 (Past Non-Compliance)
▲ Actual harm, repeated · May 23, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Jul 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 23, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 23, 2024 · F-0742
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 29, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 29, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 29, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 27, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 10, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (111)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 16, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 16, 2026 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Apr 16, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 8, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Oct 8, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| May 23, 2024 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 23, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| May 23, 2024 | ▲ G · Actual harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 23, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 23, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 23, 2024 | C · Minimal risk, facility-wide | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 23, 2024 | C · Minimal risk, facility-wide | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| May 23, 2024 | C · Minimal risk, facility-wide | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| May 23, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| May 23, 2024 | C · Minimal risk, facility-wide | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Mar 29, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 29, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 29, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 29, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 29, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 29, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 3, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jan 3, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 17, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 17, 2023 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Oct 27, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 27, 2022 | C · Minimal risk, facility-wide | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Oct 27, 2022 | C · Minimal risk, facility-wide | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (54 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 26 | 1 | G ▲ |
| 2023 | 3 | 1 | J ▲ |
| 2024 | 64 | 6 | H ▲ |
| 2025 | 3 | 0 | E |
| 2026 | 15 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $259,609, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Apr 16, 2026 | Fine | $24,195 |
| Apr 16, 2026 | Payment Denial | 3 days from May 26, 2026 |
| May 23, 2024 | Fine | $151,801 |
| May 23, 2024 | Payment Denial | 21 days from Jul 24, 2024 |
| Mar 29, 2024 | Fine | $30,641 |
| Oct 17, 2023 | Fine | $52,972 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.10 | 3.66 | 3.95 | bottom 27% in Missouri; bottom 17% in the U.S. |
| Registered Nurse hours | 0.34 | 0.49 | 0.69 | bottom 35% in Missouri; bottom 14% in the U.S. |
| Weekend total nurse staffing | 2.80 | 3.22 | 3.50 | bottom 33% in Missouri; bottom 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.33 | 0.48 | bottom 17% in Missouri; bottom 7% in the U.S. |
| Total nursing staff turnover (%) | 74.2 | 56.0 | 45.8 | bottom 10% in Missouri; bottom 4% in the U.S. |
| RN turnover (%) | 66.7 | 47.8 | 42.9 | bottom 26% in Missouri; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.45, RN 0.27, weekend 2.22. Staffing rating: —/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lincoln, James | Individual | 5% or Greater Direct Ownership Interest | 50% | 08/01/1998 |
| Lincoln, Judy | Individual | 5% or Greater Direct Ownership Interest | 50% | 08/01/1998 |
| Brick, Julie | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/29/2017 |
| N & R of Lincoln County, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/16/1990 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Troy Manor | 0.4 mi | Troy, MO | ★☆☆☆☆ | 1/5 | |
| Elsberry Missouri Health Care Center | 12.9 mi | Elsberry, MO | ★★★★☆ | 3/5 | |
| Warrenton Manor | 14.3 mi | Wright City, MO | ★☆☆☆☆ | 2/5 | |
| Cottages of Lake St Louis | 17.5 mi | Lake Saint Louis, MO | ★★★★☆ | 4/5 | |
| Abbey Senior Health | 18.3 mi | O Fallon, MO | ★★★☆☆ | 2/5 | abuse |
| Sunterra Springs Dardenne Prairie | 18.7 mi | Dardenne Prairie, MO | ★★☆☆☆ | 2/5 | |
| Garden View Care Center | 19.4 mi | O Fallon, MO | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 265433.