Lincoln Park Nursing and Rehab LLC

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R86) of 3 sampled residents at risk for falls had interventions in place to prevent a fall with major injury. On 5/23/25 R86 sustained a fall out of bed and was sent to the hospital due to R86 being on a blood thinner and R86 being unable to vocalize if she hit her head. At the hospital R86 was found to have a left subacute infarct of left parietal and frontal lobe with petechial hemorrhage along acute infarct (brain bleed). R86 was at high risk for falls, had right sided weakness from a stroke, had contradictory assessments regarding bed mobility and interventions to be used, was on an anticoagulant and was on an air mattress which are risk factors for a fall. The facility did not assess the various risk factors and the need for possible interventions to prevent a fall with a major injury.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen and the nourishment freezer. *Dietary aide (DA)-O was observed in the main kitchen preparing and handling food without wearing a hair restraint that covered facial hair. *Food debris and sticky floors were observed over several days on the main kitchen floor. *Ground beef patties were observed unwrapped resting directly on the bottom of an opened cardboard box in the main kitchen freezer. *The freezer in the nourishment refrigerator did not have a thermometer or temperature log to ensure freezer food is kept at appropriate temperatures. This deficient practice has the potential to affect all 78 residents who receive food from the main kitchen.

Inspectors wroteBased on interview and policy review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered the facility as having excessively low weekend staffing. This has the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms were provided in writing and signed for 2 (R2 and R88) of 3 residents reviewed for notification. *R2's Guardian was not given the SNF ABN notice and the NOMNC was not signed before Medicare coverage ended. *R88 did not have a signed SNF ABN or NOMNC before Medicare coverage ended.

Inspectors wroteBased on interview and record review, the facility did not ensure proper notification was sent to the State Long-Term Care Ombudsman for 3 (R7, R19, R45) of 8 residents reviewed for transfers or discharges. R7 was transferred from the facility to the hospital on 2/27/26 and 3/8/26, R19 was transferred from the facility to the hospital on [DATE], and R45 was transferred from the facility to the hospital on 3/26/26. The facility was unable to provide evidence the State Long-Term Care Ombudsman was notified in a timely manner of R7's, R19's, or R45's transfers to the hospital.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure they provided the appropriate treatment and services to 3 out of 4 ( R26, R5, R86) residents reviewed for the development of pressure injuries. R26 was admitted to the facility with a pressure injury to the buttocks. The facility did not complete a comprehensive assessment of the pressure injury upon admission and did not obtain an order for treatment of the pressure injury until 2 days after the admission. R5 was readmitted to the facility after a hospital admission and R5's Stage 4 pressure injury was not comprehensively assessed on the day of readmission. R86 was readmitted to the facility on [DATE] following a hospitalization and the facility did not complete a comprehensive assessment of R86's skin until 6/2/26.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R45) of 3 residents observed receiving care while on enhanced barrier precautions. During the observation of catheter care for R45, registered nurse (RN)-F did not wear a gown when enhanced barrier precautions (EBP) were in place for R45.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to maintain infection prevention practices during medication administration for six of six residents (Resident (R) 4, R5, R10, R11, R13, and R15) observed. Two nurses observed placed residents' medications and medical devices on surfaces without cleaning them, failed to clean shared equipment and failed to appropriately put on (don) and doff (remove) personal protective equipment. These deficient practices had the potential to place residents at risk for the spread of infection and cross-contamination and created a risk for an increased potential for infections compromising the health and safety of residents.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R9) of 3 residents were free of significant medication errors.*R9 did not receive 2 doses of R9's ordered medications, carvedilol and tramadol. Eliquis was pulled from the Facility's Omnicell (medication dispenser) for R9 on 5/23/2025. R9 was not prescribed Eliquis, per physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 4 residents (R1 and R5) was free from physical abuse. R2 is known to have physical aggression towards residents and staff and was observed to have escalating behaviors. The facility did not ensure R1 was free from abuse by another resident (R2) residing in the facility. On 4/17/25, at 6:45 AM, facility staff observed R2 strike R1 in the arm twice while in the common area. On 4/20/25, facility staff observed R2 strike R1 in the back with a wet floor sign. R2 and R1 were separated by facility staff and escorted to separate units within the facility. Approximately 10 minutes later at 12:50 AM, R2 sought out R1, and R2 hit R1 multiple times in the head with the wet floor sign. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 4 (R1, R2, R5, and R6) of 6 residents reviewed received medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1 has a diagnosis of Alzheimer's Disease, alcohol abuse, and impaired cognitive function with behaviors demonstrated upon admission. The facility did not obtain information prior to admission that would have been pertinent to understanding R1's behaviors and how to address them. The facility failed to assess R1's behaviors. The facility did not develop and implement individualized psychosocial interventions to address R1's behavior pattern based on assessments and behavior demonstrated in the facility, thus leaving residents residing in the facility vulnerable and at risk. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure 1 allegation of resident to resident abuse, involving R5 and R6, of 3 allegations reviewed was reported to the police as a possible suspicion of a crime. R5 made an allegation that R6 hit and pinched them. The Facility reported that the police were called, however, there is no record or documentation to support this occurred.

Inspectors wroteBased on observation, interview, and record review the Facility did not update the comprehensive person-centered care plan for 2 (R5, R6) of 5 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R5 and R6's care plans were not thoroughly updated after a resident to resident altercation to prevent potential further abusive situations. Additionally, R5 and R6's care plan and smoking assessment are not consistent for interventions.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure 1 (R1) of 5 Residents were provided with reasonable accommodations of Resident needs and preferences. *The Facility was aware of R1 having concerns regarding the shower room being too cold for R1 to take a shower, causing R1 to refuse showers. R1 was noted to have 1 documented bed bath in the last 30 days. R1 was not offered or given interventions to allow R1 to stay warm while taking a shower.

Inspectors wroteBased on interview and record review the facility did not report 1 (R4) of 2 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. R4 voiced concerns of staff being rough with him. This allegation of mistreatment was not reported to the Nursing Home Administrator or State agency.

Inspectors wroteBased on interview and record review the facility did not ensure 2 of 2 allegation of abuse, neglect, exploitation or mistreatment involving R4, R9, & R10 were investigated or thoroughly investigated timely. * R4 allegation of staff being rough with him was not investigated. * R9 & R10 resident to resident altercation was not thoroughly investigated.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R7) of 8 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * On 3/3/25 R7 was not wearing tubigrips according to R7's physician orders and plan of care.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R2) of 1 Residents reviewed with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. *R2 was observed not wearing R2's right hand splints to prevent further decrease in range of motion. Findings Include: Surveyor reviewed the facility policy and procedure Range of Motion Exercises revised 10/2010 which documents: .Documentation The following information should be recorded in the Resident's medical record: 4. Whether the exercise was active or passive. 7. Any problems or complaints made by the Resident related to the procedure. 8. If the Resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. [...]

Inspectors wroteBased on observation, interviews and record review the facility did not ensure 1 (R1) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice. *R1 was not provided ostomy supplies and R1 ordered ostomy supplies from (community pharmacy name) & R1 was provided the incorrect ostomy supplies, per R1's order.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 of 4 residents observed during medication pass had appropriate dispensing of medication that did not break infection control practices. On 3/4/25 at 8:03 a.m. Surveyor observed Registered Nurse (RN)-H dispense R11's medications. RN-H touched each of the pills dispensed for R11 with bare hands.

Inspectors wroteBased on interviews, personnel file review, and review of the job description, the facility failed to ensure a qualified person was designated to serve as the Director of Food and Nutrition Services for 83 of 83 census residents. This failure had the potential to affect kitchen sanitation and resident quality of care related to food and nutrition.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure four of four residents (Residents (R) 331, 11, 57, 18) and/or their power of attorney (POA) reviewed for hospitalization, received written notice of transfer.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure four of four residents (Residents (R) 331, R11, R57, R18) and or their power of attorney (POA) reviewed for hospitalization received written notice of the bed hold policy upon transfer to the hospital. This failure had the potential to cause confusion or distress regarding return to the same room after hospitalization for 83 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food prepared by the facility was served at a palatable temperature for five of six residents (Resident (R) 34, R285, R9, R64 and R54) reviewed for palatability of 33 sample residents. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure one of one resident (Resident (R)30) with medications at the bedside had been assessed and evaluated to self-administer medications.

Inspectors wroteBased on interviews, record review and policy review the facility failed to ensure that residents are free from abuse from another resident for one of five residents (Resident (R) 25) reviewed for abuse out of a sample of 23. After R25 bumped into R66 with the wheelchair, R66 aggressively grabbed R25 arm causing an injury of bruising on the left arm of R25. Failure to protect residents from abuse has the potential to result in injury to residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of resident-to-resident abuse to the state agency for two residents (Residents (R)52, R77) reviewed for abuse out of a sample size of 33.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure the care plan included interventions for aggressive behavior, alcohol abuse with disruptive behaviors, and change of a urinary catheter from a Foley to a suprapubic urinary catheter for two of five residents (Resident (R)66 and R77) reviewed for abuse, one of three residents (R69) reviewed for urinary catheter care. As a result of this deficient practice the residents had the potential for lack of needed care and supervision.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to reconcile, transcribe, and administer medications to ensure medications were provided to residents as indicated or ordered for three residents reviewed (Resident (R) 12, R18, and R282) out of a sample of 33 residents. This failure had the potential to result in adverse health outcomes.

Inspectors wroteBased on interviews, record review, and interviews, the facility failed to provide care in accordance with physician orders and the plan of care for one (Resident (R) 76) out of six residents reviewed for care planning, out of 33 sampled residents. Specifically, the facility failed to perform wound care treatments as ordered.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure physician orders for oxygen administration were followed and ensure residents with continuous positive air pressure (CPAP) had physician orders to administer the CPAP treatment for two of three residents (Resident (R) 30 and R36) reviewed for respiratory therapy. As a result of this deficient practice the residents had the potential for harm due to inaccurate oxygen administration and providing treatment without physician orders.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure there was ongoing pre- and post-dialysis communication for a resident receiving dialysis three times a week for one out of one resident (Resident (R)59) reviewed for dialysis out of a sample of 33 residents. This had the potential to affect all residents receiving dialysis.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents received medications as ordered by the physician for four of eight residents (Resident (R) 4, R33, R135, and R12) reviewed for medications of 33 sample residents. This failure could result in unwarranted medication side effects and mismanaged medical conditions.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had four errors in thirty-one opportunities, which resulted in a 12.9 percent error rate. This affected two (Resident (R) 135, and R12) out of three residents observed. Medication errors have the potential to result in adverse health outcomes. Refer to F658 and F755.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure that one of medication carts on Unit 3 Hall was secure when staff were not present. This had the potential to affect all residents on that hall or who were walking by the cart. As well as the facility failed to sure resident medication were secure at time of administration for one for 33 sampled resident (R37.)

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to follow infection prevention standards during a medication pass, which included not disinfecting glucometer's between residents, for two of two residents (Resident (R) 282, R135) observed. This created a potential for the transmission of blood borne illness to residents who had blood sugar checks.

Inspectors wroteBased on observation, interview, and record review the facility did not have evidence of preventing further abuse while the investigation was in progress for 1 of 2 facility self-reports (R7) reviewed for abuse, neglect, and mistreatment. * The facility's self-report dated 2/5/24 indicates on 2/4/24, R7 alleged a staff member yanked on R7's arm while performing cares. The facility self-report stated the alleged Certified Nursing Assistant (CNA) was sent to the rehab side of the building after the allegations on 2/4/24 to continue working with other residents. The facility did not protect residents from potential further abuse by allowing the CNA to continue working with other residents on another unit. Findings Include: Surveyor reviewed the facility's Policy and Procedure, Abuse, Neglect and Exploitation dated 9/2020, last reviewed 1/5/2024, noting the following as applicable: 1. [...]

Inspectors wroteBased on interview and record review the Facility did not provide a copy of R4's medical records in 48 hours after request. R4 was not provided copies of his medical record within 48 hours of his family members request who was acting on the request of R4. No follow up with R4 was made until 2/20/24 and the original written request was 2/6/24.

Inspectors wroteBased on interview and record review the facility failed to ensure the reporting of a reasonable suspicion of a crime, for 1 (R2) of 1 resident's with allegations of abuse, to law enforcement. On 2/8/2024 R2 was involved in an altercation while in the facility and was hit in the chest by roommate R3. Law Enforcement was not contacted immediately after the allegation of R2 being struck.

Inspectors wroteBased on observation, interview, and record review the facility did not revise 2 of 2 resident (R2 and R3) care plans after a resident to resident altercation occurred. * The facility's self-report dated 2/8/24 indicates that on 2/8/24 R2 alleged being hit in the chest by roommate (R3). The facility self-report stated the intervention was to transfer R2 to another room. The facility did not update R3's care plan to increase supervision when R3 was out of their room and around other residents including R2. The facility did not update R2's care plan to provide increased supervision of R2 should R2 and R3 encounter each other while outside their rooms.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and do not develop pressure ulcers for 2 (R37 and R71) of 7 residents reviewed for pressure injuries. * R37 was admitted from the hospital on [DATE] with multiple deep tissue pressure injuries from a medical device. On 11/17/23, the wound MD ordered treatment for the deep tissue pressure injuries which was not entered into R37's medical record until 11/20/23 with treatments not being signed out as completed until 11/27/23. The November and December Treatment Administration Record (TAR) indicated 8 of the 13 days where treatment was not signed as being completed. [...]

Inspectors wrote3. R43 was admitted to the facility on [DATE] on hospice care and had diagnoses including Vascular Dementia, unspecified severity, without behaviors; Parkinson's Disease; cognitive communication deficit and muscle weakness. R43's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, documented R43 had a Brief Interview for Mental Status of 3, indicating R43 had severe cognitive impairments; R43 required maximum staff assistance for transfers and was dependent on staff for toileting, and R43 had two or more falls with minor injuries since the last assessment date. R43's care plan, entitled R43 has high risk for falls r/t (related to) actual falls without injury r/t, weakness, confusion, hx (history) frequent falls, impaired balance, dementia, anxiety, Parkinson's disease, psychotropic medication use, dated 4/17/22 with interventions including; [...]

Inspectors wrote4. R32 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, hypertension, and cerebral vascular accident with aphagia and dysphasia. R32's annual Minimum Data Set (MDS) assessment dated [DATE] documented R32's Brief Interview for Mental Status was not completed due to R32 being rarely or never understood; R32 weighed 154 lbs (pounds) and had a 5% or more weight loss in last month or loss of 10% or more in the last 6 months not on a physician prescribed weight loss regime; R32 received more than 51% of nutrition via tube feeding while a resident and over the seven day look back period. [...]

Inspectors wrote4. R43 was admitted to the facility on [DATE] on hospice care and had diagnoses including Vascular Dementia, unspecified severity, without behaviors; Depression, Anxiety, Parkinson's Disease; cognitive communication deficit and muscle weakness. R43's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, documented R43 had a Brief Interview for Mental Status of 3, indicating R43 had severe cognitive impairments; R43 had hallucinations and delusions, R43 did not exhibit any physical, verbal, or other behaviors; R43 had rejected of care one to three days during the look back period and R43 received antipsychotics on a routine basis only with no gradual dose reduction due to physician documenting contraindication. [...]

Inspectors wroteBased on interview and record review, the facility did not (1) implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for 2 (R288 and R21) residents; and (2) ensure that the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect 55 of 86 residents who resided in the facility that entered into the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review the Facility did not have an effective infection control program to help prevent the transmission of infections with residents on transmission based precautions with the potential to affect all residents residing on unit one which had a population of 14 residents. * R19 had a diagnosis of Clostridioides difficile (C.Diff) and was placed on contact isolation and who was taken off of contact isolation on 12/20/23. On 12/19/23, Licensed Practical Nurse (LPN)- H was observed using medical equipment on R19 and placing it in and on the medication cart without sanitizing it after use. The LPN was also observed to have placed her used personal protective equipment (PPE) in the garbage can on the medication cart. The LPN did not wash her hands with soap and water before coming of of R19's room. [...]

Inspectors wroteBased on interview and record review, the facility did not comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 (R288) of 19 residents reviewed for Advanced Directives. R288 was incapacitated at the time of admission and was unable to receive information or articulate whether or not he or she has executed an advance directive, the facility did not give advance directive information to the individual's resident representative in accordance with State law. R288's Power of Attorney (POA) was activated at the hospital prior to admission and the facility was unaware and had R288 sign his own admission paperwork.

Inspectors wroteBased on record review and interview, the facility did not complete a Preadmission Screening for individuals with a mental disorder as required for 1 (R51) of 3 residents reviewed for Preadmission Screening and President Review (PASARR). R51 was admitted to the facility with diagnoses of bipolar disorder, major depressive disorder, schizophrenia, and anxiety disorder. A Level I PASARR was not completed and submitted to the State Agency prior to admission that would have triggered a Level II PASARR to be completed.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R37) out of 19 residents sampled for care planning had a comprehensive care plan developed that included individualized approaches to care to maintain highest level of functioning and safety. The facility did not develop a comprehensive care plan identifying pain relieving measures for R37 who was admitted to the facility after being hospitalized for hemarthrosis of left knee and had chronic pain.

Inspectors wroteBased on interview and record review the facility did not provide care and services so that 1 of 2 sampled residents (R43) reviewed with a diagnosis of Dementia and was receiving multiple medications could reach their highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 2 of 5 resident (R33 and R287) investigated for proper medication administration. *R33 was observed to have her insulin pens dialed up and prepared by one Licensed Practical Nurse (LPN)-K and administered by another LPN-N. LPN-N who administered the insulin did not sign out that they administered it. LPN-K who prepared the medication signed it out. * R287 came in with orders for intravenous antibiotics every 12 hours and did not receive it until she went to the emergency room for administration.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R33 and R19) of 4 residents observed. Five medication errors were observed out of twenty-eight opportunities, for a total error rate of 17.85 %. * On 12/19/23, R33 received Lantus and Humalog insulin from an insulin pen and the needle was not primed before administration. *On 12/19/23, R19 was given Carvidilol, Hydroxine and Dicyclomine which are medications given more than once a day was given 2-3 hours after the written administration time.

Inspectors wroteBased on record review and interview, the facility did not offer the influenza immunizations for 1 (R32) of 5 residents reviewed for immunizations. * R32 was not given the influenza immunization as of the time of the survey and had an pintail admit date of 2/8/21.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of eight sampled residents (Resident (R) 5) whose drug regimen was reviewed was free from a significant medication error. R5 received two doses of short-acting insulin, administered by two different nurses, resulting in the potential for R5 to have a hypoglycemic (low blood sugar) reaction.