Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincolnwood Place during CMS and state inspections, most recent first.
Surveyors found that food items such as salads, gelatin, onions, and prosciutto were stored in refrigerators without proper covering, labeling, or dating, and rotten lettuce was kept in a leaking bag above other produce. Staff confirmed these practices did not follow facility policy, and all residents consuming food from dietary services were potentially affected.
A nurse administered petroleum jelly from a multi-dose jar that was not labeled with the open date, as required by facility policy. Both the nurse and the DON confirmed that staff are responsible for labeling multi-dose medications with the open date to track expiration, but this was not done in this instance.
The facility failed to label and date various food items in the kitchen, including cooked vegetables, sauces, and uncooked fish, as required by their food storage policy. This oversight was noted during a survey, and dietary staff confirmed the importance of labeling to track food handling and shelf life. The deficiency could potentially affect 36 residents on oral diets.
The facility failed to monitor the temperature of two medication refrigerators, potentially affecting six residents. A surveyor found missing temperature log entries for the patient medication fridge and the house stock control substance fridge. The DON and an RN confirmed that the night shift is responsible for checking temperatures, which should have been done. The facility lacked a policy on medication refrigerator temperature monitoring.
A high fall risk resident was left unattended on the toilet by a CNA who left to retrieve gloves, despite the resident's care plan indicating the need for extensive assistance due to dementia and other conditions. The facility's policies require staff to gather supplies beforehand and not leave residents unattended, highlighting a failure to provide adequate supervision.
The facility failed to administer influenza and pneumococcal vaccines to three residents who had consented to receive them, despite having the vaccines in stock. The DON and Infection Preventionist acknowledged the oversight, which was contrary to the facility's policies requiring vaccine status checks and administration upon admission.
A resident sustained a head laceration during a mechanical lift transfer due to a CNA's incorrect application of the sling and failure to use a two-person assist, as required by the facility's procedures. The CNA attempted the transfer alone after initially asking for help, leading to the resident sliding from the sling and requiring hospital treatment.
A resident sustained a leg laceration requiring 12 sutures due to staff failing to use a mechanical lift during a transfer, despite the care plan indicating its necessity. The incident revealed lapses in communication and adherence to care protocols.
Failure to Properly Store, Label, and Remove Unsafe Food Items
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's kitchen. Uncovered and unlabeled single-serve garden salad and red gelatin portions were found in the refrigerator, along with covered but undated ranch dressing containers. Staff interviews confirmed that these items should have been covered and labeled according to facility policy. In the walk-in refrigerator, peeled white onions and an opened package of prosciutto were found without covers or dates. Additionally, five rotten lettuce heads, described as dark brown, yellow, soggy, and moist, were stored in a transparent bag that was dripping fluid and placed on top of a box containing individual romaine lettuce heads in an unsealed bag. Staff acknowledged that these practices did not comply with facility policy and that the rotten lettuce should not have been stored in the refrigerator. A review of the facility's food safety policy confirmed requirements for labeling, dating, and covering refrigerated foods, as well as inspecting food upon delivery and removing any damaged or questionable items from use. The invoice review verified that the lettuce was recently delivered, and staff stated that the rotten lettuce arrived in the shipment and should have been reported to the vendor and removed from storage. All 31 residents in the facility consume food prepared by dietary services, making them potentially affected by these deficiencies in food storage and handling.
Failure to Label Multi-Dose Medication with Open Date
Penalty
Summary
A deficiency occurred when a registered nurse applied petroleum jelly from a multi-dose jar for a resident without an open date labeled on the container. The surveyor observed this during medication administration and confirmed with the nurse that the jar lacked the required open date. Both the nurse and the Director of Nursing acknowledged that it is the responsibility of the staff member who opens a multi-dose medication to label it with the open date, as per facility policy. The facility's Medication Administration Policy, revised in February 2024, specifies that the date must be recorded on the container when opening a multi-dose medication. This lapse was identified during a review of medication practices for one of twelve residents reviewed.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to its food storage policy by not labeling food products with the dates they were cooked or opened. This deficiency was observed during a survey when various food items, including cooked mixed vegetables, meat sauce, marinara, barbeque sauce, beef base, uncooked tilapia, lasagna, dinner rolls, tortellini, tater tots, sweet potato fries, raisin bran, and wheat cereal, were found without labels or dates. The surveyor noted that the chef immediately began labeling the food items upon discovery of the oversight. Interviews with the dietary staff, including the chef, dietician, and cook, revealed that all dietary staff are responsible for labeling food items to track when the food was handled and determine its shelf life. The facility's food storage policy, revised in 2016, mandates that all products be dated upon receipt and use, with leftovers dated according to the leftovers policy. The deficiency has the potential to affect 36 residents on oral diets, as documented in the dietary spreadsheet.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperature of two medication refrigerators, which has the potential to affect six residents reviewed for medication storage. During a tour of the medication storage room, a surveyor observed that temperature logs for the patient medication fridge and the house stock control substance fridge were missing entries on specific dates. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the night shift is responsible for checking the refrigerator temperatures at the end of their shift, and acknowledged that the temperatures should have been checked. The facility was unable to provide a policy on medication refrigerator temperature monitoring.
Inadequate Supervision of High Fall Risk Resident
Penalty
Summary
The facility failed to adequately supervise a high fall risk resident, identified as R26, during a toileting activity. On December 10, 2024, a Certified Nursing Assistant (CNA), V15, was observed leaving R26 unattended on the toilet to retrieve a pair of gloves, leaving the resident without supervision. V15 stated that he did not consider R26 a fall risk, despite the resident's documented high fall risk score of 13 and a history of a fall incident noted in the progress notes dated June 12, 2024. The facility's policy requires staff to gather all necessary supplies before providing care and to not leave residents unattended during care tasks. R26's care plan, revised on November 22, 2024, indicated that the resident requires extensive assistance from one staff member for toileting due to a self-care performance deficit related to diagnoses of dementia, cerebral infarction, depression, and adult failure to thrive. The Minimum Data Set (MDS) assessment dated November 18, 2024, also indicated that R26 needs supervision or touching assistance with toileting hygiene and partial/moderate assistance with toilet transfer. The facility's policies on Activities of Daily Living and Falls Program emphasize the need for appropriate supervision and assistance based on the resident's assessed needs to prevent accidents.
Failure to Administer Vaccines to Consenting Residents
Penalty
Summary
The facility failed to administer immunizations to three residents who had consented to receive them. Resident 15 had a consent for an influenza vaccine dated November 22, 2024, but had not received the vaccine by December 11, 2024. Similarly, Resident 28 consented to a pneumococcal vaccine on November 13, 2024, and Resident 132 consented for an influenza vaccine on December 4, 2024, yet neither had received their respective vaccines by December 11, 2024. During a medication storage inspection, it was observed that the facility had a stock of 20 pre-filled influenza vaccines available in the fridge. The Director of Nursing (DON) and the Infection Preventionist acknowledged that the vaccines should have been administered. The DON stated that the nurse who obtained the consent was responsible for administering the vaccines. The facility's policy requires that residents' vaccine status be checked upon admission and that vaccines be administered if they have not been received. The Infection Preventionist, who assumed the role nine months prior, is responsible for ensuring residents' immunizations are up to date upon admission. The facility's policies outline the procedures for offering influenza and pneumococcal vaccines, but these were not followed in the cases of the three residents.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to maintain resident safety during a mechanical lift transfer, which resulted in a resident sliding from the lift sling and sustaining a 3 cm laceration to the posterior scalp. The incident occurred when an agency CNA attempted to transfer the resident from bed to wheelchair using a mechanical lift. The CNA incorrectly applied the sling, failing to crisscross the leg straps, which is necessary to prevent the resident from sliding out. Additionally, the CNA conducted the transfer alone, despite the requirement for a two-person assist. The resident involved in the incident required extensive assistance with activities of daily living due to generalized weakness, as noted in their care plan. The care plan specified the need for two staff members to assist with transfers. On the day of the incident, the CNA initially asked another CNA for help, but the second CNA left the room to attend to another resident, instructing the first CNA to prepare the resident for transfer and to call for assistance when ready. However, the first CNA proceeded with the transfer alone, leading to the resident's fall and injury. The facility's procedure for using mechanical lifts clearly states that at least two staff members are required for safe operation. Instructions attached to the lift machine also emphasized the need for a two-person assist and provided detailed steps for correctly applying the sling. Despite these guidelines, the CNA's failure to adhere to the procedure and the lack of proper supervision during the transfer resulted in the resident's injury and subsequent hospitalization for treatment.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to transfer a resident using a mechanical lift, resulting in the resident sustaining a laceration to the leg during a transfer from a wheelchair to a bed. The resident, who has a medical history including generalized weakness, lymphedema, chronic kidney disease, and coronary artery disease, required emergent hospital transfer and treatment with 12 sutures. The incident occurred when two staff members attempted a manual pivot transfer, despite the resident's care plan indicating the need for a mechanical lift and two-person assistance for transfers. The staff involved were not aware of the resident's updated transfer requirements, leading to the injury. Interviews with staff revealed that the regular CNA on duty was assisting agency CNAs who were unfamiliar with the residents. The regular CNA did not check the resident's transfer status in the binder at the nurse's station before attempting the transfer. The resident's care plan and therapy notes indicated that a mechanical lift was necessary for safe transfers, but this information was not communicated effectively to the staff performing the transfer. The incident report and staff interviews confirmed that the resident's leg did not pivot during the transfer, causing the laceration when the leg scraped against the wheelchair. The facility's policies on transfers and activities of daily living were not followed, as the staff did not use the mechanical lift as required. The resident's care plan was updated after the incident to include the use of a mechanical lift for all transfers, but there was no documentation of the transfer status in the care plan prior to the incident. The failure to follow the prescribed transfer method directly led to the resident's injury, highlighting a lapse in communication and adherence to care protocols within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincolnwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Astoria Place Living & Rehab | 0.6 mi | ★★★★★ | 4 | 0 |
| Peterson Park Health Care Ctr | 0.9 mi | ★★★★★ | 5 | 0 |
| Buckingham Pavilion | 1.3 mi | ★★★★★ | 6 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 1.5 mi | ★★★★★ | 3 | 0 |
| Elevate Care Chicago North | 1.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.