Lincoln Square Post Acute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent a recurrence of a pressure injury (sores (ulcers) that happen on areas of the skin that are under pressure) for one of three residents (Resident 1) who had a history of a resolved pressure ulcer in the sacrococcygeal area (lower back/tailbone area), active moisture-associated skin damage (MASD - skin damage caused by prolonged exposure to moisture) to the right buttock, bowel and bladder incontinence, decreased bed mobility, and dependence on staff for repositioning, when Resident 1was not repositioned while in bed, resulting in Resident 1 remaining on her back in the same position for more than two hours despite complaints of back and buttocks pain. These failures placed Resident 1 at risk for recurrence of pressure injury and skin impairment, including MASD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) had access to water and fluids when Resident 1 complained of dry mouth, dry lips, and thirst and was unable to obtain fluids because the water pitcher was not within Resident 1's reach and no cup was available, which prevented Resident 1 from accessing and consuming fluids when needed. These failures had the potential to place Resident 1 at risk for dehydration (when the body does not get enough fluids to function properly), falls, and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely fully assess Resident 1's pain and provide non-pharmacological (non-medication) interventions, such as repositioning, to help relieve pain for one of three residents (Resident 1), when Resident 1, who required staff assistance to reposition in bed, complained of back and buttocks pain and remained lying flat in bed for more than two hours without a complete pain assessment or repositioning. These failures resulted in Resident 1 continuing to experience pain and discomfort and delayed identification and implementation of appropriate interventions to relieve the pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 63 residents who received meals from the kitchen when:1. Two open boxes with green lettuce and cheese were placed on the kitchen floor;2. Dietary staff did not fully cover the hair on the back of their head in the kitchen;3. One mesh bag of yellow onion was placed on the kitchen food storage room floor, and a bag of dry cereal and flour were not sealed in a container,4. Spinach was thawed in a sink next to two open chemical buckets; and5. A plastic food cover, an open box of gloves, and a grill cleaner was kept in a kitchen cabinet with cleaning supplies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly contained in the kitchen and outside dumpster areas for a total facility census of 64 residents, when one trash can inside the kitchen and one of two outside dumpster lids were observed not closed. This failure had the potential to expose the resident's environment to pests, odors, and disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 64 residents when:1. Resident 102's nebulizer tubing (plastic tubing used to deliver breathing treatments) was not stored in a protective bag after use.2. The facility did not implement their identified control measures ( an action aimed to eliminate a hazard or at least reduce the risk) in order to identify any potential growth of Legionella (a bacteria that can grow in water systems and cause a serious lung infection, especially in older adults and those with weak immune systems) in the water system. These failures had the potential to increase the risk of infection transmission to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS; an assessment tool) comprehensive assessments were completed for 4 of 30 sampled residents (Resident 52, Resident 68, Resident 76, and Resident 87), when comprehensive assessments were not performed within the required time frame for Resident 52, Resident 68, Resident 76, and Resident 87. This failure had the potential to result in failure to evaluate residents' overall health status, delayed or absent care plan initiation, and inappropriate interventions, placing residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' assessments were completed for 4 of 30 sampled residents (Resident 55, Resident 46, Resident 56, and Resident 84), when quarterly Minimum Data Set (MDS; an assessment tool used by the facility) assessments were not performed within the required time frame for Resident 55, Resident 46, Resident 56, and Resident 84. This failure had the potential to result in failure to identify changes in residents' status, delayed care plan updates, and inappropriate interventions, placing residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to accurately treat pain as ordered for six of thirty sampled residents (Resident 10, Resident 12, Resident 31, Resident 45, Resident 46, and Resident 47) when:1. Resident 10 received acetaminophen (an over-the-counter pain medication) for a documented pain level (using a numerical pain scale of 1 through 10 that measures the pain intensity and impact on daily life: 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 9 = severe pain, and 10 = the worst pain imaginable) rated as a 7 or 8 when the order was written for a mild pain level of 1-3; and,2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for 2 of 30 sampled residents (Resident 52 and Resident 101) when:Staff called Resident 52 a feeder during mealtime; and 2. Certified Nursing Assistant (CNA) 1 stood over Resident 101 while assisting with meals and did not position at Resident 101's eye level. These failures had the potential to negatively impact the psychosocial well-being (emotional and social functioning) of Resident 52 and Resident 101.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 30 sampled residents (Resident 18) when, Resident 18 had a call light (device used to contact staff for assistance) that was not within Resident 18's reach. This deficient practice placed Resident 18 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for 1 of 30 sampled residents (Resident 17) when, Resident 17 was provided a bathroom toilet that did not function. This failure negatively impacted Resident 17's homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (written plan that guides staff on daily care, safety, and interventions based on the resident's needs) for 1 of 30 sampled residents (Resident 63) when, Resident 63 refused to receive the COVID-19 (a contagious viral illness that affects the respiratory system) vaccine in April of 2025 and a care plan was not developed to help prevent Resident 63 from acquiring a COVID-19 infection. This failure resulted in Resident 63 acquiring a COVID-19 infection in the facility in September of 2025 and placed Resident 63 at risk of serious illness and complications related to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and treatment for 1 of 30 sampled residents (Resident 47) when, Resident 47 complained of shortness of breath and the facility staff failed to obtain oxygen saturation as ordered and failed to implement available interventions, including administration of oxygen or an albuterol treatment ( a quick-relief or rescue medication used to treat or prevent breathing difficulties), prior to Resident 47 being transferred to the hospital. This failure had the potential to delay timely assessment and intervention for respiratory compromise, placing residents at risk for decreased oxygen levels and worsening condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 30 sampled residents (Resident 63) ) was free from unnecessary medication administration when, Resident 63 received an antihypertensive medication (used to manage high blood pressure; BP) outside of the hold parameters (when a medication is not to given based on blood pressure readings) four times between February and March of 2026. This failure increased the potential for Resident 63 to experience side effects such as low BP, leading to further heart related complication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure antibiotic use was supported by ongoing reassessment and documented justification to determine if the antibiotic should be continued for 1 of 30 sampled residents (Resident 57) when, Resident 57 was prescribed an antibiotic for extended or long-term use. This failure placed Resident 57 at risk for unnecessary prolonged antibiotic exposure, adverse effects (harmful or unwanted side effects), antibiotic resistance (when bacteria no longer respond to the medication), and development and spread of MDROs (Multidrug-resistant organisms - germs that do not respond to multiple antibiotics) to other residents and staff in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of verbal abuse (harsh and insulting language directed at a person; also known as verbal attack, verbal aggression, verbal assault) for one of three sampled residents (Resident 1) when Resident 1 reported that a Licensed Nurse (LN) was rude to him and called him a thief on 1/10/26. This failure had the potential to a delayed investigation by the Department and the risk of negatively affecting Resident 1's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of two sampled residents (Resident 1) when Resident 1 exited the facility through an unlocked door on 3/22/25 and was missing from the facility for one and one-half hours before staff became aware. This failure resulted in Resident 1 falling out of her wheelchair sustaining injuries that included bruises (contusion, ecchymosis; skin discoloration from damaged, leaking blood vessels under the skin) and a facial laceration (cut) that required sutures (stitches). This failure had the potential to result in Resident 1 sustaining life-threatening injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident's rights to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 57 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 57 residents who ate facility prepared meals when: 1. Expired food was not thrown away; 2. Food was not labeled/dated properly; 3. Non food items were found in the dry food storage room; 4. A coffee water filter was expired; 5. A fan located in the food prep area was not clean; 6. Various tray line pans were stacked and stored wet; 7. The food processor bowel was ready to use wet; and 8. The ice machine was dirty. These failures had the potential to put residents eating facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain trash in a closed dumpster for a census of 57 residents. This failure had the potential to lead to insect and rodent infestation.

Inspectors wroteBased on interview, and record review, the facility did not consistently implement an antibiotic stewardship program (to ensure medications used to treat infections are used only when necessary and appropriate) for a census of 57 residents when, Loeb (a set of minimum signs and symptoms that indicate a resident in long-term care likely has an infection and may need antibiotic) and/or McGeer criteria (a set of definitions used to identify infection after an antibiotic is started) were not consistently used to assess the initiation and/or the appropriateness of continued use of an antibiotic, including accurate documentation of the correct indication for use. This failure had the potential to result in antibiotics being prescribed when not indicated and the development of multi- drug resistant organisms (MDRO; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 119 was treated with dignity for a census of 57 when staff did not cover resident's genital area with a sheet while he was sleeping in bed. These failures had the potential to negatively impact Resident 119's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to submit a new Level I PASRR (Preadmission Screening and Resident Review- a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services appropriate to their needs) for 1 of 18 sampled residents (Resident 2) when, a level II Mental Health Evaluation was not completed for Resident 2 due to Resident 2 being on isolation as a health or safety precaution which required the facility to submit a new Level I screening for Resident 2. This failure had the potential to place Resident 2 at risk for not receiving the necessary care or services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 269) received quality care when staff administered rapid-acting insulin to Resident 269 (Lispro-medication which starts to lower blood sugar within 10-15 minutes) on 12/17/24 based on a medication order that did not include parameters (a fixed limit that establishes how something must be done) defining when to hold/not administer the insulin; and staff did not notify the physician when Resident 269 did not eat her scheduled meal after the rapid-acting insulin was administered. These failures led to Resident 269 experiencing a hypoglycemic event (when the body's blood sugar level drops too low for the body to function properly) with a blood glucose (BG) of 36 (a BG below 70 is considered low BG; hypoglycemic) and needing emergent medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 57 residents when, narcotic medications (used for pain) were not accurately documented in the Medication Administration Record (MAR, a document listing medications and monitoring parameters) when removed from the Controlled Drug Record (CDR, a paper record that kept track of opioid medication use for accountability) for Resident 55. This failure resulted in the inaccurate documentation of Resident 55's pain medication dosages and had the potential to result in decreased well-being for Resident 55.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 56) was free from unnecessary medications when, Resident 56 received an antibiotic (medication used to treat infection) even though Resident 56 did not meet the criteria established for use of an antibiotic medication through the facility's antibiotic stewardship program (a set of efforts to ensure that antibiotics are used appropriately and only when necessary). This failure had the potential to result in unnecessary medication side effects for Resident 56 and had the potential to result in the development of multi-drug resistant organisms (MDRO; germs that have developed the ability to survive antibiotics that were previously used to kill them; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were free from significant medication errors when Resident 55 received more than the prescribed dose of a narcotic pain medication (a controlled medication that is used for pain that is severe) for more than one month. This failure had the potential for a decreased quality of life and well-being for Resident 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 57 residents when: 1. An opened, unlabeled container of a psyllium fiber supplement (helps to bulk and soften poop, making it easier to pass) was stored in the medication cart; 2. An opened, unlabeled bottle of cough medicine was stored in the medication cart; and, 3. Medications for a discharged resident were stored in the medication cart. These unsafe medication storage practices could contribute to medication errors and unsafe medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention practices were used for a census of 57 when: 1. Resident 171 was placed in a room with another resident who tested positive for RSV (Respiratory Syncytial Virus, a virus (germ) that causes infection (invasion and growth of germs in the body) of the lung and the respiratory tract) with no Droplet Isolation Precautions (hand hygiene, wearing a surgical mask, eye protection, and a gown and gloves (if contact with blood/bloody fluids is possible) are used when in contact with a person who has an infection with germs that can be spread to others by coughing, talking, or sneezing) in place on 12/15/24; and, 2. Resident 9 tested positive for RSV on 12/11/24 but was not in Droplet Isolation Precautions on 12/15/24. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the influenza vaccine (also known as a flu shot, a safe and effective way to protect against the influenza virus) to 1 of 5 sampled residents (Resident 11) when, there was no documented evidence in Resident 11's medical record that the vaccine had been offered, given, and/or refused. This failure had the potential to result in Resident 11 acquiring, transmitting, or experiencing complications from influenza.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route) on post- discharge medications for one of three residents (Resident 1) when Resident 1 was discharged home with a discontinued (no longer provided) medication. This failure had the potential for Resident 1 to take an unprescribed medication in error which could negatively affect his health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a kitchen free of potential hazards for food borne illnesses (nausea, vomiting, and diarrhea) for 55 residents who received and ate food from the kitchen when: 1. Perishable food items in the kitchen were not properly labeled; and, 2. The inside of the ice machine contained a black like substance. These failures had the potential to result in food borne illnesses for 55 of the residents who ate food from the kitchen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 2 of 18 sampled residents (Resident 3 and Resident 17) based on standards of practice when: 1. Resident 3's medical record was marked with schizoaffective disorder (a mental health disorder marked by a combination symptom, such as hallucinations or delusions, and mood disorder symptoms) as a diagnosis for use of quetiapine (or Seroquel, an antipsychotic [mind altering] medication used to treat mental disease) with no prior history of such diagnosis; and, 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain an accurate and complete medical record for 3 of 18 sampled residents (Resident 11, Resident 19, and Resident 165) when: 1. Resident 11 and Resident 19's COVID immunization records was not readily available in their medical record, 2. Resident 165's Interdisciplinary (IDT- a care team consisting of different disciplines) care conference record was inaccurate and incomplete; and, 3. Resident 165's speech screening evaluation was not available in his record. This failures resulted in an incomplete and inaccurate medical documentation for Resident 11, Resident 19, and Resident 165.

Inspectors wroteBased on interview, and record review, the facility failed to accurately assess 2 of 18 sampled residents (Resident 3, and Resident 17) when Resident 3 and Resident 17's documentation of a mental health diagnosis in the medical record was not accurately assessed. This failure resulted in Resident 3, and Resident 17's medical record with an inaccurate mental health diagnosis which could affect the care provided.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 26) received proper vision treatment when Resident 26 was not seen by an ophthalmologist (a medical doctor who specializes in eye and vision care) as referred. This failure had the potential to delay care and treatment for Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment and supervision for one of two residents (Resident 2) at risk of elopement (resident leaves the premises without the facility's knowledge and supervision) when: 1. Resident 2 eloped from the facility, falling out of her wheelchair and sustaining a fractured left ankle; and, 2. Resident 2's Elopement/Wandering Risk Assessment was not assessed accurately. These failures resulted in Resident 2 not receiving additional monitoring which allowed Resident 2 to exit the facility unnoticed and sustain an accidental injury while outside the facility's premises without supervision from staff. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary services and assistance were provided to maintain bowel and bladder continence (the ability to control movements of the bowels and bladder) for 1 of 18 sampled residents (Resident 4), when: 1. A bowel and bladder training program (a schedule of urinating and defecating to improve continence) was not developed and initiated for Resident 4 as indicated by her bowel and bladder assessment; and, 2. Resident 4's bowel and bladder assessments were not completed accurately. These failures resulted in Resident 4 using briefs (adult diapers) for urination, had the potential to not provide adequate care and a risk for further decline to Resident 4's bowel and bladder control.

Inspectors wroteBased on interview, and record review, the facility failed to provide the services of a full time (working 40 or more hours a week) Director of Nursing (DON) onsite to fulfill the job duties of the DON. This failure had the potential to result in the needs of the residents not being adequately assessed and met in a timely manner and could potentially impact the quality of care delivered by licensed and non-licensed nursing staff for a census of 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and accountable medication use, documentation, and the timely availability of medication with a census of 57 when: 1. There was a discrepancy between the Controlled Drug Record (or CDR, an accountability record for opioid use) removal and the respective Medication Administration Record (or MAR referred to as a drug chart that serves as a legal record of the drugs administered to a resident) documentation for two residents (Resident 163 and Resident 999); and, 2. Diabetic medication (medication to lower blood sugar) was not available for Resident 113. These failures had the potential risk for diversion (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use) and could negatively impact Resident 113's blood sugar control.

Inspectors wroteBased on interview, and record review, the facility failed to ensure insulin (a medicine to control blood sugar levels) use was documented and blood sugar monitoring was performed as ordered for 1 of 5 residents (Resident 45). These failures had the potential to negatively impact Resident 45's blood sugar control and monitoring.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a psychotropic (mind-altering drug) medication called lorazepam (or Ativan, an [NAME]-anxiety medication) ordered for PRN (means as needed) use had a duration and clear direction for use in 1 out of 18 sampled residents (Resident 2). This failure could result in unsafe medication use and contribute to medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stores resident's medication and supplies) with a census of 57 when: 1. One emergency kit (or Ekit- a box that stored medication for emergency use) was opened and unsealed with no documentation of its use, 2. The medication refrigerator was frosted when medications sensitive to freezing were stored in proximity, 3. Extra supplies were placed under the sink-based cabinet in the medication storage room, 4. Staff's personal belongings were stored in the active medication storage room; and, 5. [...]

Inspectors wroteBased on interview, and record review, the facility's quality assessment and assurance (QAA) committee failed to meet quarterly with all the required members, when the Interim Director of Nursing (IDON) did not attend the second and third quarter meetings for the year of 2023. This failure had the potential for quality care improvement activities not to be evaluated and revised as needed with a possible decline in residents' quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention measures were followed for a census of 57 when: 1. The shared glucometer (a device used to measure blood sugar) and blood pressure devices (or BP, Blood Pressure, measures the pressure of blood pushing against the walls of arteries) were not cleaned and sanitized in-between resident care based on manufacturer recommendation and standards of practice; and, 2. Hand hygiene was not performed in-between resident care during the medication administration task. These failures could pose health safety risks and spread of infection in the facility.