Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Little Sisters Of The Poor during CMS and state inspections, most recent first.
A resident with Parkinson's disease and mobility impairments, who was care planned for mechanical lift transfers, was manually transferred by two CNAs without a gait belt or lift. During the transfer, the resident's finger was caught on the wheelchair armrest, resulting in a fracture. Staff interviews confirmed that the required transfer method was not followed, leading to the injury.
The facility failed to follow proper food storage and sanitation practices, with unlabeled and spoiled food found in coolers, and dishwashing temperatures not reaching required levels for sanitization. Additionally, manual sanitizing processes were inconsistent, and a Cook was observed without a hair net. These deficiencies could affect all 43 residents receiving food from the facility's kitchen.
The facility failed to refer four residents with serious mental illnesses for Level II PASARR screenings. The Social Services Director did not update residents' diagnoses in the screening system, leading to incomplete assessments. Residents with conditions like major depressive disorder, bipolar disorder, and schizoaffective disorder were not properly reviewed, impacting their care and placement decisions.
A registered nurse in the facility was observed pre-cupping medications and documenting their administration before actually giving them to residents. This practice was confirmed by the Director of Nursing and another nurse as being against the facility's policy, which requires medications to be prepared and administered in the presence of the resident, with documentation occurring only after administration. The improper practice increases the risk of medication errors.
Expired medications were found in the medication cart and room of a facility, including geri-lanta, calcium, folic acid, centrum silver, vitamin C, and Glucerna. Staff confirmed that expired medications should not be present, as they may not be effective and could harm residents. The facility's policy prohibits storing expired medications with those available for administration.
The facility failed to ensure residents were offered pneumococcal vaccinations, as required by their policy and CDC guidelines. The DON, who manages immunization records, did not document offers of the vaccine for several residents, despite some having received their last dose years ago. One resident had no record of receiving the vaccine, and another's refusal of other vaccines was documented, but not the pneumococcal vaccine. The facility's 2017 policy requires offering the vaccine unless contraindicated or given within five years.
A resident's electronic medical record contained conflicting advance directive orders, with both CPR and DNR statuses active. The facility's staff, including the DON and a RN, were uncertain about the correct code status to follow. The discrepancy arose from a misplacement of the POLST form and failure to update the record, leading to confusion about the resident's wishes.
The facility did not complete a discharge assessment for a resident who was discharged to a hospital and subsequently passed away. The MDS coordinator believed no further action was needed after the resident's death, resulting in non-compliance with RAI requirements.
A facility failed to implement adequate fall prevention measures for three residents, resulting in multiple falls and injuries. One resident, assessed as high risk, experienced significant injuries due to inconsistent care plan implementation. Another resident fell due to improper bed positioning and lack of supervision. A third resident, with severe cognitive impairment, was left alone despite care plan instructions for close observation, leading to a fall during a transfer attempt.
Failure to Use Mechanical Lift During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and transfer protocols for a resident with significant mobility impairments and cognitive deficits. The resident, who had diagnoses including abnormalities of gait, mobility issues, and Parkinson's disease, was care planned to require a mechanical lift with the assistance of two CNAs for all transfers between bed and wheelchair. Despite this, two CNAs performed a manual pivot transfer without a gait belt or mechanical lift, contrary to the resident's care plan and facility policy. During the transfer, the resident attempted to grab the armrest of the wheelchair, resulting in her left fifth finger being bent against the armrest. The incident led to the resident sustaining a fracture of the distal shaft of the fifth metatarsal in her left hand, as confirmed by X-ray. The resident immediately reported pain, and subsequent assessments noted swelling and sensitivity in the affected area. Interviews with the involved CNAs revealed that they were aware the resident was care planned for mechanical lift transfers but chose not to use the required equipment, believing the resident could stand and transfer without it. Both CNAs described the resident's hand position during the transfer and acknowledged that the injury likely occurred as the resident's finger became caught on the wheelchair armrest. Further review of facility policies and staff interviews confirmed that the resident's care plan and Minimum Data Set (MDS) specified the use of a mechanical lift for transfers. The Director of Nursing and the resident's physician both stated that staff are expected to follow the care plan and use mechanical lifts for residents who require them. The failure to adhere to the established transfer protocol directly resulted in the resident's injury during the transfer process.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a kitchen tour. Several food items in the dairy, prep, and bread walk-in coolers were found without proper labeling, including missing open dates, expiration dates, or use-by dates. Additionally, the vegetable cooler contained multiple packages of produce that were spoiled, discolored, or moldy, such as radishes, shredded carrots, spinach, cucumbers, lettuce, grapes, garlic, ginger, and cauliflower. These deficiencies in food labeling and storage practices were acknowledged by the Dietary Manager, who confirmed that expired or moldy food items should not be stored and could pose a risk of foodborne illness to residents. The facility's dishwashing practices were also found to be deficient. The dishwasher's wash cycle temperature did not reach the required 160 degrees Fahrenheit, as evidenced by testing strips that failed to change color, indicating improper sanitization. Despite multiple attempts to test the dishwasher with different dishware, the temperature remained insufficient. The Dietary Manager and Dishwasher acknowledged the issue, noting that the facility had recently acquired a new dishwasher, but were unable to explain why the test strips did not indicate proper sanitization. Furthermore, the facility's manual sanitizing process in the three-compartment sink was not conducted correctly. The Dishwasher was observed testing the quaternary solution with test strips, but the immersion time was inconsistent, leading to inaccurate readings. Additionally, a Cook was observed preparing food without wearing a hair net, contrary to facility policy. These deficiencies in food preparation and sanitation practices have the potential to affect all 43 residents receiving food from the facility's kitchen.
Failure to Refer Residents for Level II PASARR
Penalty
Summary
The facility failed to refer four residents with newly evident or possible serious mental illness to the appropriate state-designated authority for review. The Social Services Director, identified as V3, was responsible for ensuring that all residents had a Level I Pre-Admission Screening and Resident Review (PASARR) in their records. However, V3 admitted to not updating the residents' diagnoses in the new screening system, which could lead to incorrect PASARR screenings. This oversight resulted in the failure to generate necessary Level II PASARR screenings for residents with severe mental illnesses. Resident 1, a female with major depressive disorder, generalized anxiety, and bipolar disorder, had an initial Level I PASARR dated 2002, but there was no documentation of a Level II PASARR. Similarly, Resident 30, with major depressive disorder, anxiety disorder, psychotic disturbance, and unspecified psychosis, had an initial Level I PASARR dated 2020, but lacked a Level II screening. Resident 23, diagnosed with bipolar disorder with psychotic features, had a Level I PASARR from 2017, but no Level II screening was documented. Resident 35, with anxiety disorder and schizoaffective disorder, was referred for a Level II PASARR, but the facility could not provide documentation of the outcome. The Social Services Director acknowledged the importance of entering accurate information into the screening system to determine the need for a Level II PASARR. However, there was a lack of awareness and understanding of the need to update residents' PASARR information to ensure accurate screenings. This deficiency highlights the facility's failure to comply with the requirements for referring residents with serious mental illnesses for appropriate reviews, potentially impacting the residents' care and placement decisions.
Improper Medication Administration Practices
Penalty
Summary
The facility failed to adhere to nursing standards of practice by preparing and pre-cupping medications in advance of administration for four residents. During an observation in the second-floor medication room, a registered nurse (V5) was found with medication cups labeled with resident names, containing both whole and crushed medications mixed with applesauce. The nurse had documented the administration of medications for two residents in the electronic medical record before the medications were actually given, which is against the standard practice of ensuring the resident takes the medication before documentation. The Director of Nursing (V2) and another registered nurse (V4) confirmed that pre-pouring medications is not allowed as it increases the risk of medication errors. The practice of pre-pouring medications removes them from their original packaging, which identifies the medication and the intended recipient, thus increasing the risk of errors. The facility's policy requires that medications be prepared and administered in the presence of the resident, ensuring the right medication, dose, time, and resident, and that documentation occurs only after the medication is administered and taken by the resident.
Expired Medications Found in Facility Storage
Penalty
Summary
The facility failed to ensure that expired medications were not available for administration to residents, as observed during a survey. On March 4th, a review of the first-floor medication cart by a registered nurse revealed several expired medications, including geri-lanta antacid/antigas, calcium 600mg, folic acid 400mcg, and centrum silver, all with expiration dates prior to the survey date. Similarly, on March 5th, a review of the second-floor medication room uncovered expired vitamin C and five bottles of Glucerna with past expiration dates. These findings indicate that expired medications were stored in areas where they could be readily administered to residents. Interviews with the registered nurses and the Director of Nursing confirmed that expired medications should not be present in the medication carts or rooms, as they may not be effective and could potentially harm residents. The facility's policy on Medication Storage and Administration, dated August 2022, mandates that no expired or discontinued medications should be stored with medications available for administration. The presence of expired medications in the facility's storage areas represents a failure to adhere to this policy, posing a potential risk to all residents receiving medications from these locations.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to have an appropriate policy and procedure in place to ensure residents are offered a pneumococcal immunization. This deficiency was identified during an interview and record review, where it was found that five residents out of a sample of twelve were not offered the pneumococcal vaccine. The Director of Nursing, who also serves as the infection preventionist nurse, stated that the facility manages residents' immunization records through their electronic medical record (EMR) system. However, there was no documentation indicating that residents were offered the pneumococcal vaccine, despite some having received their last dose several years ago. Specifically, one resident received a pneumococcal vaccine in 2015, another in 2019, and a third in 2022, with no subsequent offers documented. Additionally, one resident had no record of receiving the vaccine, and another resident's refusal of the influenza and COVID-19 vaccines was documented, but not their refusal or offer of the pneumococcal vaccine. The facility's existing policy from 2017 states that the pneumococcal vaccine should be made available to all residents unless contraindicated or previously administered within five years. The CDC guidelines recommend specific vaccination schedules, which the facility failed to follow, leading to the deficiency.
Conflicting Advance Directive Orders for a Resident
Penalty
Summary
The facility failed to clearly document the code status for a resident, identified as R35, leading to conflicting orders in the electronic medical record. R35's record contained three active advance directive orders: one for full code, one for CPR, and one for DNR. Upon review, the IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form indicated a DNR status, but no form designating full code was found. The Director of Nursing (V2) acknowledged the presence of conflicting orders and was uncertain about the resident's current code status, as the electronic record near the resident's picture indicated CPR, but the POLST form supported DNR. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed confusion and uncertainty regarding which order to follow in the event of a code. The Director of Nursing later found a POLST form designating CPR in the miscellaneous section of the electronic record, indicating a misplacement and failure to update the record by removing the DNR form and discontinuing the DNR order. The Social Service Director confirmed that R35 was currently a full code, highlighting the discrepancy between the orders and the resident's or their power of attorney's wishes. The facility's policy on advance directives emphasizes the importance of respecting residents' wishes and maintaining current documentation in the medical record, which was not adhered to in this case.
Failure to Complete Discharge Assessment for Deceased Resident
Penalty
Summary
The facility failed to adhere to the Resident Assessment Instrument (RAI) requirements concerning the discharge assessment within the mandated timeframe for one resident, identified as R39. R39 was admitted to the facility and later discharged to a hospital where they passed away. The records indicate that no discharge assessment was completed for R39 after their discharge date. The last assessment recorded for R39 was prior to their discharge, and no subsequent assessments were conducted. During an interview, the MDS coordinator, V11, who has been with the facility for several years, stated that the completion of the MDS discharge assessment varies depending on the resident's circumstances. V11 mentioned that in cases where residents are discharged back to the community, the facility has 14 days to complete the assessment. However, in R39's case, since the resident was sent to the hospital and died there, V11 believed no further action was required, and the resident's chart was closed without completing the necessary discharge assessment.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that the care plan for a resident was consistent with their fall risk assessment and did not implement adequate fall prevention interventions. This resident, who was assessed as high risk for falls, experienced two unwitnessed falls resulting in significant injuries, including a laceration to the leg and a C1 fracture. The care plan inaccurately categorized the resident as medium risk, and interventions such as ensuring the call light was within reach were not consistently implemented. Another resident, who required substantial assistance for transfers and was at moderate risk for falls, fell while attempting to transfer from a wheelchair to bed. The resident's bed was not in the low position as required, and the resident was left alone without adequate supervision. This oversight contributed to the resident's fall and subsequent injury. A third resident, with a history of multiple unwitnessed falls and severe cognitive impairment, was left alone in their room despite care plan instructions for close observation during specific hours. The resident fell while attempting to transfer from bed to a wheelchair, highlighting a failure to adhere to the care plan's specified interventions. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of direct observation and failure to ensure the call light was within reach.
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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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Lincoln Park | 0.1 mi | ★★★★★ | 9 | 0 |
| Landmark Of Lincoln Park Rehabilitation And Nursin | 0.9 mi | ★★★★★ | 4 | 0 |
| Warren Barr Lincoln Park | 1.1 mi | ★★★★★ | 10 | 0 |
| Alden Lincoln Rehab & H C Ctr | 1.3 mi | ★★★★★ | 4 | 0 |
| Winston Manor Cnv & Nursing | 1.5 mi | ★★★★★ | 11 | 1 |
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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.