Landmark of Lincoln Park Rehabilitation and Nursin

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for one (R16) resident out of seven residents reviewed for physical environment in a total sample of sixteen.

Inspectors wroteBased on interview and record review, the facility failed to assure that a resident was free of unnecessary physical restraints; failed to identify the specific medical symptoms warranting the use of a physical restraint and failed to obtain physician orders with medical justification. This failure affected one resident (R4) out of five residents reviewed for abuse who was restrained by being placed in a Geri-chair with a sheet tied over the resident's body, restricting the residents ability to freely ambulate and causing bruising to the resident's body; with no physician order, no consent/permission, and no medical justification. Findings Include:R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nail care and shave one (R2) of four (R1, R6, R7) residents reviewed for ADL's (Activity of Daily Living). Findings Include:R2 was admitted to the facility on [DATE] with diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Major Depressive Disorder, Psychosis, Paralytic Gait, Lack of Coordination, Abnormalities of Gait and Mobility, History of Falling, Muscle Weakness (Generalized), Weakness, Pain in Right Lower Leg and Gastrointestinal Hemorrhage. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R2's Care Plan document in part: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain a complete and accurate medical record for one (R3) of six (R1, R2, R4, R5, R6) residents sampled for record review. Findings Include:Based on interview and record review the facility failed to maintain a complete and accurate medical record for one (R3) of six (R1, R2, R4, R5, R6) residents sampled for record review. Findings Include:R3, formally known as R1, is the subject of this complaint being investigated for the allegation of Administration/Personnel. Three (R2, R4, R6) additional residents were reviewed for Administration/Personnel with no concerns. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 3 residents reviewed for physical abuse. This failure resulted in V4 (certified nursing assistant) physically attacking R1 by pulling R1's ear and dragging R1 out of his chair by his arms, resulting in R1 sustaining bruising on his upper arms, and R1 being scared to go to the dining room. Findings Include:The surveyor confirmed by observation, interview, and record review that the deficiency practice occurred 09/04/2025 and was corrected on 09/09/2025, prior to the start of this survey and was therefore Past noncompliance. The facility suspended and fired the perpetrator, reviewed footage on additional days past 09/04/2025, to make sure no other resident was abused. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a wet kitchen sanitation cloth is kept in the sanitizing bucket and failed to discard expired milk cartons from the walk-in cooler of the kitchen. These failures have the potential to cause food borne illness in residents with a potential to affect all 150 residents that receive food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the outside garbage waste dumpsters are closed with the lids to prevent pest infestation and foul odor. This failure affects all 150 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control protocols by not providing trash receptacles in transmission-based precaution rooms and not maintaining contact/droplet isolation for COVID-19 positive residents. These failures affected two (R20 and R126) of two residents reviewed for infection control and has the potential to place all 150 residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to empty the lint compartment and filter. This failure creates an unsafe environment and a fire hazard which has the potential to affect all 150 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who depend on staff assistance for ADL (Activities of Daily Living) care and hygiene were provided oral care and timely incontinence care. These failures affected four residents (R74, R115, R132, and R140) reviewed for ADL Care assistance, in a total sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the low air loss mattress ordered for a resident at risk for pressure ulcer is functioning while the resident is in bed. This failure has the potential to affect one resident (R71) of three residents, reviewed for pressure ulcer prevention interventions, in a total sample of 64 residents.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to contain and label oxygen equipment properly; failed to display oxygen in use signage and failed to follow physician order for oxygen use. These failures affected six (R17, R20, R24, R41, R102, R124) of six residents reviewed for respiratory care in the sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refrigerate unopened insulin pens, label multi-dose medications, discard expired medications, and monitor refrigerator temperatures. These failures affected seven residents (R1, R50, R64, R67, R74, R97, R100) and has the potential to affect all 57 residents on the 3rd floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thermometers and maintain refrigerator logs for four residents' personal refrigerators. These failures affected four (R112, R120, R132, R550) of four residents reviewed for safe storage of personal food in a sample of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call lights were accessible as stated in the care plans. This failure affected two (R14 and R88) of two resident reviewed for accommodation of needs in a sample of 64.

Inspectors wroteBased on record review and staff interview, the facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication. This affected one of one resident (R102) reviewed for appropriate and necessary use of psychotropic medications in a sample of 64.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide range of motion exercises and apply restorative devices, potentially contributing to the progression of contractures. This deficient practice affected three (R57, R73, and R74) of three residents reviewed for restorative care in a sample of 64.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure controlled medications were stored in a double locked setting, failed to ensure completed controlled medications were returned to the pharmacy, and failed to ensure out going nurse signed the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. These failures affected 3 (R14, R106, and R150) residents reviewed for controlled medications in the total sample of 64 residents.

Inspectors wroteBased on interview and document review the facility failed to ensure resident the right to be free from abuse in 2 of 4 residents included in a total sample of 8 residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse. This failure affects two (R2, R4) residents out of five residents reviewed for abuse in a total sample of five. As a result of this failure, R1 pushed R2 on 04/6/25. R1 punched and yelled derogatory words to R4 on 04/29/25.

Inspectors wroteBased on observation, interview and record review the facility failed to meet the needs of residents by not responding to the nurse call activation in a timely manner in 3 of 10 residents included in the sample.

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free of abuse in 2 (R1, R2) of 4 residents resulting in minor injury to R1 and R2.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure a resident is free from abuse. This failure affected 1 (R2) out of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent staff (V3-Former Receptionist) from verbally abusing one of three residents (R2), reviewed for abuse in a total sample of three residents.

Inspectors wroteBased on interview, and record review the facility failed to provide a scheduled pain medication per doctor's order for effective pain management treatment for one (R1) resident out of four residents reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect two (R1, R2) residents' rights to be free from physical and verbal abuse out of three sampled residents. This failure resulted in R2 experiencing right foot pain and sustaining subacute fracture of distal right fourth metatarsal. Findings Include: The facility's abuse reportable dated 6/28/24 documents that on 6/24/24, R1 and R2 had a verbal disagreement regarding the washroom in R1 and R2's room. R2 stated that contact was made to R1's face. R1 stated R2 did make contact with R1's face, but stated R1 was not physically harmed, not in pain, not mental or emotionally distressed. R1's clinical records show R1 went out on pass on 7/9/24. R1's face sheet shows an admission date of 6/18/24 with diagnoses not limited to Bipolar Disorder, Anxiety Disorder, Alcohol Use, and Depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy in maintaining a safe environment free of injury, failed to follow a resident's (R2) care plan, and failed to follow up on residents' complaints of pain for two (R2, R5) out of a sample of three residents. These failures resulted in R2 experiencing new onset of right foot pain which started on 6/24/24 and R2's physician was notified four days later on 6/28/24. X-Ray was obtained for R2 on 6/30/24 with findings revealed a new healing subacute fracture of distal right fourth metatarsal. These failures also resulted in R5 experiencing left knee pain for one week and a left femoral condyle fracture diagnosed on [DATE], 7 days after injury on 7/3/2024. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, facility failed to ensure a resident (R3) with history of unsafe and self-harmful behaviors was supervised and monitored while in the day room. This failure affected one resident (R3) out of a sample of three residents resulting in R3 sustaining a nasal fracture.

Inspectors wroteBased on observation, interview and record review, facility failed to provide medication in compliance with standards of professional practice and facility policy for one resident (R5) out of a sample of two residents.

Inspectors wroteBased on interview and record review, the facility failed to perform criminal background checks for new residents within 24 hours of admission and failed to obtain fingerprint order within 72 hours of a hit on the preliminary criminal history search. These failures affected R44, R50, R114, R119, R123, R128, R134, R135, R292 and R293 in the sample of 59 residents reviewed for abuse and have the potential to affect all 137 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Health Care Worker Background Checks were thoroughly complete and done in a timely manner in an effort to prevent abuse. This failure has the potential to affect all 137 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing and failed to ensure the daily nursing staffing information was complete and accurate. These failures have the potential to affect all 137 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain adequate monitoring of food storage temperatures. This failure has the potential to affect all residents (Census 137) of the facility.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff dispose of used personnel protective equipment after sorting dirty linens and failed to ensure a sign was posted appropriately for a resident on enhanced barrier precaution in an effort to prevent spread of infectious microorganism. These failures affected R136 and has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication and/or treatment was not left inside the room of a resident whose ability to safely self-administer medications and/or treatments was not assessed. This failure affected 1 (R28) resident reviewed for self-administration of medication and/or treatment and has the potential to affect all 54 residents on the 3rd floor.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide a home like environment for 5 (R8, R13 R42, R103, and R129) residents reviewed for home like environment in a total sample of 59 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattresses were set on appropriate setting for 4 residents (R54, R72, R81, and R82) reviewed for pressure ulcer prevention in the total sample of 59 residents.

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to ensure resident information inside the resident's room were not in plain view of other residents and visitor. This failure affected 1 (R39) resident reviewed for dignity in the total sample of 59 residents:

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication devices identified on the resident's care plan. This failure affected 1 resident (R54) in a sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy of changing a midline catheter dressing. This applies to 1 (R54) resident reviewed for catheter care in the sample of 59.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nebulizer mask was secured when not in use for one resident (R10) and the oxygen tubing was changed weekly for one resident (R65). These failures affected 2 residents out of a sample of 59 residents.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure for resident assessment and documentation after a fall/incident for 1 resident (R1) of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate staffing to ensure that restorative services are provided for two residents (R8 and R9). This has the potential to affect all residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide timely incontinence care for R8 out of seven residents reviewed for activities of daily living care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy to conduct quarterly restorative assessments, follow therapy recommendations, follow residents' comprehensive care plan, and provide restorative services for two (R8 and R9) of nine residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and records review, the facility failed to conduct an ongoing assessment of one resident (R4) following an incident, out of 3 residents reviewed for improper nursing care. This failure resulted in a delay in care for R4, who sustained a left femur fracture, causing R4 to suffer pain level of 10 out of 10 and not receiving care for the fracture until being sent to the hospital on 9/30/23.

Inspectors wroteBased on review of records and interviews, the facility failed to follow policy related to confidentiality of medical records and social media policy by using social media platform messages including names, symptoms, placements, smoking and out on pass status of 8 out of 8 residents (R19, R20, R21, R22, R23, R24, R26, and R27) reviewed for privacy and confidentiality. These failures resulted in 8 residents' (R19, R20, R21, R22, R23, R24, R26, R27) information being made available in a social media platform and potentially have their information shared during messaging and accessed by third party.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to administer medications in accordance with written orders of the attending physician. This failure could potentially affect 4 (R9, R12, R14 and R15) residents reviewed for medication administration. On 11/14/23 at 10:36 am Medication administration conducted with V3. Observed V3 prepared the following medications for R12: 1. Allopurinol 100mg 1 tablet. 2. Duloxetine 30mg 3 capsules. 3. Gabapentin 300mg 1 capsule. 4. Isosorbide ER 30mg 1 tablet. 5. Isosorbide ER 60mg 1 tablet. 6. Metoprolol ER 200mg 1 tablet. 7. Methocarbamol 750mg 1 tablet. 8. Pantoprazole 40mg 1 tablet. 9. Nifedipine ER 60mg 1 tablet. 10. Levetiracetam 500mg 1 tablet. 11. Valsartan 40mg 1 tablet. 12. Aspirin 81mg g1 tablet. 13. Artificial tears 1 drop to both eyes. 14. Oxycodone HCL 10mg 1tablet given per R12's request. [...]

Inspectors wroteBased on interviews and records review, the facility failed to report and initiate an investigation of an injury of unknown source in the time frame required and failed to report an alleged misappropriation of property. This failure affected 2 residents (R4,R1) out of 6 residents reviewed for reporting alleged violations.

Inspectors wroteBased on interviews and records review, the facility failed to thoroughly investigate an injury of unknown source/accident and failed to investigate an alleged violation of misappropriation of resident property for one resident (R4) out of 4 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled with dates; b.) follow manufacturer guidelines for sanitizing and air-drying cooking equipment; c.) clean walk-in refrigerator and freezer door gaskets. These deficient practices have the potential to affect all 133 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpster lids were fully closed to prevent the harborage of pests. This deficient sanitation practice has the potential to affect all 133 residents who reside in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop policies and procedures to ensure each resident and staff member is educated and offered the COVID-19 vaccine. The facility also failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccine to a resident (R108) who refused vaccination. This failure has the potential to affect all residents in preventing COVID-19 infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop policies and procedures to ensure that all staff are fully vaccinated for COVID-19. This failure has the potential to affect all residents in preventing COVID-19 infection.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to follow their call light policy to always place the call light in an accessible location for 6 (R22, R45, R79, R110, R111, R123) residents in a sample of 27. Findings Include: On 04/11/23 at 10:20 AM R110 call light was observed connected to the light switch string out of reach over the head of R110. R110 was unaware where the call light was located when asked by the surveyor. R110 has diagnosis not limited to Lack of Coordination, Reduced Mobility, Dependence on Wheelchair and Weakness. R110 MDS (Minimum Data Set) Section C Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 14 indicating cognitively intact. Care Plan document in part: Focus: R110 have a self-care deficit: Impaired Bed Mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications 1 of 6 medication carts were locked while not in use or in view. These deficient practices have the potential to affect 30 residents residing on the first floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu spreadsheets and recipe for pureed bread for 12 residents receiving a pureed diet consistency in a total sample of 27 residents reviewed. Findings Include: On 04/11/23 at 9:40 AM, during initial kitchen tour observed large supply of fresh bread in dry storage area. On 04/11/23 at 1:03 PM, during lunch tray line service observed pureed diets receiving pureed fish, pureed stewed tomatoes, pureed rice, and pureed fruit. Pureed diets did not receive any pureed bread. Mechanical soft and regular diet consistency diets received baked fish, stewed tomatoes, rice, fruit cup, and a slice of bread. On 04/12/23, V1 provided surveyor with list of residents receiving pureed diets, copy of menu spreadsheets for 04/11/23 and recipe for pureed bread. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) properly store respiratory supplies for one resident (R380); b.) ensure reusable equipment was cleaned after each resident use for seven (R8, R16, R18, R72, R117, R119, R120) residents observed during medication administration. These failures affected eight (R8, R16, R18, R72, R117, R119, R120, R380) of 15 residents reviewed for infection control in the survey sample of 27 residents.

Inspectors wroteBased on interview and record reviews the facility failed to ensure that residents' vaccination status is tracked and to follow facility's policy and procedure for influenza and pneumococcal immunization to provide education regarding immunization for five (R50, R69, R74, R95 R108) residents reviewed for immunization in a sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and confidentiality for one [R14] resident's personal medication administration record. These deficient practices have the potential to affect 30 residents residing on the first floor of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that the comprehensive care plan was updated for 1 (R123) resident reviewed for accidents and hazards in a sample of 27. Findings Include: On 04/11/23 at 11:03 AM R123 was observed sitting in a recliner chair in R123 room unsupervised with the call light on the opposite side of the bed out of reach. Upon a physical assessment, R123 was observed to have an indented area to the left side of the head due to a craniotomy. R123 helmet was observed on the window seal. On 04/11/23 at 11:05 AM surveyor asked V8 (Registered Nurse) when does R123 wear the helmet. V8 stated they put on R123 helmet when he (R123) goes to the dining room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to meet professional standards of care in pharmaceutical services for 2 [R72, R120] of 27 sampled residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure safety measures for a high fall risk resident were followed for supervision and b.) ensure recommended safety equipment was in use for 1 (R123) resident reviewed for safety in a sample of 27. Findings Include: On 04/11/23 at 11:03 AM R123 was observed sitting in a recliner chair in the room unsupervised with the call light on the opposite side of the bed out of reach. Upon a physical assessment, R123 was observed to have an indented area to the left side of the head due to a craniotomy. R123 helmet was observed on the window seal. On 04/11/23 at 11:05 AM surveyor asked V8 (Registered Nurse) when does R123 wear the helmet. V8 stated, They put on R123 helmet when he (R123) goes to the dining room. Surveyor asked V8 the position of R123 call light. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to follow policy and procedure on oxygen administration to check physician's order for accurate liter flow for one (R11) of 2 residents reviewed for Oxygen use in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Medication Administration Guidelines for 2[R72, R120] of 5 residents observed during medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below 5% as evidence by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 [R72, R120] of 5 residents observed during medication administration.

Inspectors wroteBased on interviews and record reviews the facility failed to (a) ensure that resident is free of any significant medication errors; (b) follow policy and procedure on medication administration to check physician order before administering medication. These failures apply to one (R55) resident in a sample of 27.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to maintain accurate resident record for a newly admitted resident (R281) with suspected Covid-19 to rule out Covid-19 infection for 1 out of 27 residents records reviewed out of 27 total residents. This failure has the potential to affect 1 resident (R281) in determining correct infection status of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to have the most recent survey results for the facility in a prominent and accessible area for residents and visitors to review.

Inspectors wroteBased on interview, and record review the facility failed to follow Quality Assurance / Performance Improvement Program (QAPI) policy and procedure by not establishing any QAPI programs to address care and services for the year 2022. These failures can affect all 133 residents in receiving well planned care and services in facility.

Inspectors wroteBased on interview, and record review the facility failed to follow Quality Assurance / Performance Improvement Program (QAPI) policy and procedure by not obtaining any data or feedback due to lack of QAPI program established for the year 2022. These failures can affect all 133 residents in receiving well planned care and services in facility.