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 Warren Barr Lincoln Park during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of falls, syncope, abnormal gait, and Alzheimer’s disease was identified in assessments and the care plan as needing supervision or touching assistance for toileting and ambulation, frequent monitoring, and use of bed/chair alarms. Despite this, fall risk evaluations later documented the resident as low risk, staff were unsure if the bed alarm was in place, and one CNA reported the alarm was too faint to hear in the hallway. The resident, known to be impulsive and to get up unassisted to toilet, was found on the bathroom floor after an unwitnessed fall without his walker, sustaining a forehead laceration requiring sutures. At surveyor observation, the call light was on the floor out of reach, and staff reported only one nurse with three CNAs caring for 38 residents, which they described as a staffing problem that limited adequate supervision and contributed to the fall.
A facility failed to post [NAME] program information in a public, accessible location for residents. The SS DOR stated the only bulletin board checked did not have the required posting, and no other posting locations existed. The SS DOR was not aware of providing educational materials to residents, and the ADM stated he did not know whether educational material or discharge paperwork was accessible through the online system. Requested [NAME] policy and supporting documentation were not provided.
Improper food labeling and storage in kitchen coolers and freezers. Surveyors observed spoiled and discolored produce in the walk-in cooler, including romaine lettuce and cabbage, along with ground beef stored without a use-by or expiration date. In the dry storage freezers, open bags of carrots and cauliflower and an open box of sausage were also found without required dating. The FSD stated food items should be dated and labeled, and items without an expiration or use-by date should be discarded.
Failure to offer flu and pneumococcal vaccines to 3 of 5 residents reviewed for infection prevention. One resident had no documentation that either vaccine was offered for the current year, another had prior flu and PCV13 records but no evidence of updated pneumococcal vaccination per the facility’s guidance, and a third resident had no pneumococcal vaccine documented. The IP RN stated she had just started and that residents without immunization documentation had not yet been offered vaccination.
A resident with bipolar disorder with psychotic features and major depression was not referred for a new level I PASRR screening. The Admissions Director stated the PASRR should have been completed before admission, but the facility did not follow up after the hospital incorrectly completed it. The facility policy requires level I PASRR screening for all residents to determine whether they have a mental disorder or ID.
A resident with a G-tube and gastrostomy malfunction diagnosis was found with tube feeding disconnected and not running despite an order for Osmolite 1.5 at 70 mL/hour to deliver 1540 mL daily. Staff stated the feeding was started in the evening and taken down when the bottle emptied by morning, even though the ordered rate and volume required a longer run time. The DON confirmed the resident was not receiving the full ordered amount, and the facility policy required staff to verify the ordered formula, rate, and duration.
Discontinued Tramadol was administered to a resident without an active order. An RN dispensed the narcotic from the med cart without verifying the EMR, and the DON later confirmed the order had been discontinued. Record review showed the medication was given on multiple later occasions after discontinuation, despite the resident having no active order.
Discontinued narcotic remained in the med cart. During med pass, an RN left the med cart unlocked and unattended, then opened the narcotic bin and dispensed a Tramadol 50 mg tablet before checking the MAR. The RN later confirmed the order was no longer active, and the DON verified there was no active order for the medication. The DON stated discontinued controlled substances are removed from the cart after med reconciliation.
Failure to document offering COVID-19 vaccination to a resident. A resident's immunization record did not show that the COVID-19 vaccine was received or offered, and the IP RN stated some residents still had not been addressed for vaccination because documentation was missing. The facility policy required offering the vaccine and documenting it in the resident record.
Failure to care plan a Stage IV sacral pressure ulcer. A resident with multiple comorbidities, including DM2, HTN, dementia, and incontinence, had a documented Stage IV sacral wound with exposed tissue and heavy drainage, yet survey review found no individualized care plan for the wound despite staff stating that skin impairment and pressure ulcers should be care planned with goals and interventions. The resident later required hospital care for sacral wound infection, including surgical debridement and bone biopsy.
The facility failed to properly account for and administer narcotic medications, with discrepancies found in narcotic counts and improper documentation by nursing staff. Additionally, a nurse did not follow protocols for administering medications via gastronomy tube, and expired insulin was nearly administered to a resident, causing a delay in treatment. These incidents reflect a lack of adherence to medication administration and accountability policies.
The facility failed to properly label and store medications, including insulins and controlled substances. Insulin vials for several residents were not dated when opened, and some were expired but still in use. A controlled substance was found in an unlocked refrigerator, and a discontinued medication was not destroyed as per guidelines. These issues affected multiple residents.
A CNA allowed another CNA to document resident care under her login credentials, leading to inaccurate medical records for several residents. Despite facility policies against sharing login information, this practice occurred, compromising the integrity of resident documentation.
A facility failed to accurately complete a resident's comprehensive annual assessment, submitting a quarterly MDS instead. The error was linked to the absence of a current MDS Coordinator and was identified on the last day for annual assessment completion. The resident had been admitted to the hospital and returned as a dual Medicaid and Medicare payor, complicating the MDS sequence.
A resident's PASARR screening was not updated after their exemption expired, as required by facility policy. The administrator admitted the oversight and showed a lack of understanding of the DON score ranges necessary for determining the need for further screening.
A resident with diabetes had a high blood sugar level of 333, which required physician notification per orders, but there was no documentation of such notification. The resident's blood sugar later increased to 397, and the resident was pronounced expired by EMS. Interviews revealed a lack of communication and documentation among staff, including the DON and NP, regarding the elevated blood sugar levels and necessary actions.
The facility failed to follow pressure ulcer prevention protocols for two residents on low air loss mattresses. Observations showed improper use of fitted and folded flat sheets, contrary to guidelines that recommend minimal layering to prevent pressure injuries. The Wound Care Manager confirmed the protocol breach, highlighting the deficiency in care.
A resident repeatedly received eggs for breakfast despite expressing a dislike for them, as documented in her food preference form. The Dietary Manager acknowledged the oversight, which was due to the resident's preference not being updated on her dietary meal ticket, contrary to the facility's policy.
The facility failed to ensure proper PPE use for a resident with shingles, as staff entered the room without gowns and gloves, despite contact isolation precautions. Additionally, during a bed bath for another resident, a CNA used the same washcloth for multiple body areas without changing gloves, contrary to infection prevention practices. These actions did not align with the facility's infection control policies, leading to deficiencies in care.
A resident with dementia was physically abused by a CNA in a LTC facility, leading to an Immediate Jeopardy situation. The CNA admitted to hitting the resident, and another CNA witnessed the incident but no immediate action was taken. The facility's policy prohibits abuse, and staff acknowledged the incident as abuse, although the facility's investigation was inconclusive.
The facility failed to secure medication carts, leaving them unlocked and unattended on the 2nd and 3rd floors, contrary to policy. An RN and an LPN acknowledged the carts should have been locked to prevent resident access, but they were left unsecured, posing a potential hazard.
A resident with dementia was roughly handled and hit by a CNA, which was witnessed by another CNA who reported it to the nurse on duty. However, no action was taken until the surveyor's visit. The facility's policy requires immediate reporting of abuse to the administrator and IDPH, which was not followed in this case.
A resident with dementia was physically abused by a CNA, who admitted to hitting the resident but did not report it. Another CNA witnessed the incident and reported it to the nurse on duty, but no investigation was initiated. The facility's policy requires immediate reporting and investigation of abuse, which was not followed.
A resident was administered Potassium chloride on an incorrect day, contrary to the prescribed schedule. The RN failed to document the correct administration time and left medications at the bedside without proper assessment. The facility's policies on medication administration were not adhered to, leading to this deficiency.
The facility failed to label the date and time on enteral feeding bottles for two residents, leading to potential health risks. Both residents had severe cognitive impairment and were on specific enteral feeding regimens. The LPN on duty was unaware of when the feedings were started, which is against the facility's policy.
Failure to Supervise High-Risk Resident and Maintain Effective Fall-Prevention Measures
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and implement effective fall-prevention measures for a resident with a known history of falls and severe cognitive impairment. The resident had diagnoses including syncope, collapse, falling, transient cerebral ischemic attack, hypertension, abnormal gait and mobility, chronic fatigue, and Alzheimer’s disease. An MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, and showed the resident required supervision or touching assistance for toileting hygiene and walking 10 feet with a walker. The care plan identified the resident as at high risk for falls related to dementia, behavioral and mood disturbances, anxiety, poor awareness, decreased comprehension, impulsivity, and memory deficits, and documented that the resident required assistance with all ADLs, including toileting and walking, and demonstrated movement behaviors such as wandering, pacing, or roaming. Despite these identified risks, the facility did not maintain accurate fall risk assessments or ensure consistent implementation of fall precautions. A fall risk assessment completed on the date of the fall scored the resident as high risk with a score of 13, but subsequent fall risk evaluations in December and January documented a score of 0, categorizing the resident as low risk for falls, which the DON later stated was not accurate. The resident’s orders allowed use of bed and chair alarms, and the care plan included use of a chair/bed alarm related to potential falls and frequent monitoring. However, staff interviews revealed uncertainty about whether the bed alarm was in place at the time of the fall, and one CNA reported that the bed alarm in use had a very faint sound, suggesting low battery, and could not be heard in the hallway. The DON stated that only residents at high risk for falls should have bed alarms and that any resident who has fallen is automatically considered high risk, indicating a discrepancy between policy and the documented low-risk scores. On the day of the incident, the resident was found lying on his back on the bathroom floor with a laceration to the forehead after an unwitnessed fall. The resident reported having walked to the bathroom, used it, and then only remembered waking up on the floor. The resident did not have his walker with him in the bathroom at the time of the fall. Staff reported that the resident was impulsive, would get up by himself when he had the urge to use the bathroom, and required frequent monitoring and supervision when ambulating or going to the bathroom. The LPN and CNA assigned to the resident stated that he should have been supervised for toileting and ambulation and that if he had assistance with toileting, the fall could have been prevented. At the time of surveyor observation, the resident’s call light was found on the floor at the head of the bed, out of reach, despite staff acknowledging that the call light should always be within reach. Staffing on the unit consisted of one nurse and three CNAs for 38 residents, and both the DON and floor staff described this as a staffing problem that affected the ability to provide quality care and adequate supervision, contributing to the failure to prevent the resident’s fall and resulting head laceration requiring sutures.
[NAME] Program Information Not Posted for Residents
Penalty
Summary
The facility failed to display [NAME] information in a public and accessible location that would inform residents of their right to explore or decline community transition and their right to be free from retaliation regardless of their decision on transition. During observation on 11/18/2025, the Social Service Director stated that V30 was the agent for the [NAME] program and provided a list of six residents, with two crossed out because they had already been discharged and were not through the [NAME] program. When asked whether the residents on the list were being coordinated to V30, the Social Service Director stated she communicated with V30, including by email, but no email correspondence or other supporting documents were provided. The Social Service Director was taken to the second-floor bulletin board in front of the elevator, where she checked the posted materials and stated that no [NAME] program information was posted, adding that it was not there and may have been taken out. She stated there were no other places where the information was posted. On 11/19/2025, the Social Service Director stated she would follow up on the request for documents and was not aware of providing educational information to residents regarding the [NAME] program. On 11/20/2025, the Administrator stated the [NAME] program was for residents to be able to get housing and be notified of their ability to get housing through the program, and that the [NAME] agent could access the online system. The Administrator also stated he did not know whether educational material and discharge paperwork were accessible through the online system, and the facility did not provide [NAME] information posted for resident referral. Requests for the facility’s [NAME] policy and procedure and related documentation were not provided.
Improper food labeling and storage in kitchen coolers and freezers
Penalty
Summary
The facility failed to properly label and store food in the kitchen and storage areas. During a kitchen tour with the Food Service Manager, surveyors observed an open box of romaine lettuce in the walk-in cooler that was wet, discolored dark black, and had a receive date of 11/17/25. An open box of cabbage was also observed in the cooler with discolored black spots on different areas of the leaves and a receive date of 11/10/25. Multiple packages of ground beef were stored inside a gray bin with a receive date of 11/17/2025, but the bin had no use-by date or expiration date labeled on it. The Food Service Manager stated the lettuce looked bad and believed it was already molded, and she removed it from the cooler. She also removed and discarded the outer cabbage leaves with black spots. In the dry food storage room, surveyors observed two deep freezers, one used for vegetables and one for meat. Inside the vegetable freezer, there was an open bag of carrots and an open bag of cauliflower, both without a receive date and without a use-by date or expiration date labeled on the bags. Inside the meat freezer, there was an open box of sausage with no use-by date or expiration date labeled on the box. The Food Service Manager stated all food items stored in coolers and freezers should have an open date and expiration date written on the packaging, and that food without an expiration date or use-by date should be discarded and not stored for resident use. Facility records showed there were 85 residents receiving food prepared in the kitchen, and the facility policy stated refrigerated food should be covered, dated, labeled, and shelved to allow air circulation, and open containers or leftover potentially hazardous food should be dated and used within 3-5 days in the refrigerator.
Failure to Offer Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to 3 of 5 residents reviewed for infection prevention. One resident’s immunization history showed the last influenza vaccine was received on 11/13/2022, and the pneumococcal vaccine had not been administered since refusal on 07/21/2023; no documentation was available showing that either vaccine was offered for 2025. Another resident’s record showed influenza vaccination on 01/04/2025 and a PCV13 pneumococcal vaccine on 01/22/2020, while the facility’s Clinical Management/Infection Prevention document dated 03/04/2025 stated that adults 50 years and older should receive PCV15, PCV20, or PCV21. A third resident’s immunization record did not document receipt of pneumococcal vaccination. The Infection Preventionist stated on 11/19/2025 that she had just started in the role, still needed to address vaccination for some residents, and that residents without immunization documentation had not yet been offered vaccination.
Failure to Complete Required PASRR Screening
Penalty
Summary
PASARR screening for Mental disorders or Intellectual Disabilities was deficient because the facility failed to refer one resident with a known mental illness for a new level I PASRR screening. R64 was admitted with diagnoses of bipolar disorder with psychotic features and major depression. During interview, the Admissions Director stated that R64's level I PASRR should have been completed before admission on 4/23/24 to determine whether the nursing facility could meet the resident's needs, and stated that the PASRR level I had been incorrectly completed by the hospital in 2024, but the facility did not follow up until 11/18/25. The facility policy stated that the Medicaid-certified nursing facility will ensure level I PASRR is completed by the transferring hospital/facility, upon admission, or as soon as practicable thereafter for all residents to determine whether they have a Mental Disorder or Intellectual Disability.
G-tube feeding not administered per physician order
Penalty
Summary
A deficiency was identified involving a resident with a gastrostomy tube and physician-ordered enteral nutrition. The resident’s physician order sheet directed evening G-tube feeding with Osmolite 1.5 at 70 mL/hour, starting at 5:00 PM and continuing until a total daily volume of 1540 mL was reached. During observation, the resident’s G-tube was found not connected to tube feeding and not running. The resident’s face sheet listed a diagnosis of gastrostomy malfunction. Interview and record review showed the nurse assigned to the resident stated the evening nurse starts the feeding at 5:00 PM and that when the bottle is empty by morning, it is taken down and the next feeding is hung by the evening nurse again. The nurse also stated that one Osmolite bottle is 1200 mL and that, based on the ordered rate and total volume, the feeding should run for 22 hours, ending around 3:00 PM if started at 5:00 PM. The nurse stated the resident was not getting the full nutritional amount. The DON also stated the feeding should run until 3:00 PM based on the ordered rate and total amount, and that not receiving the required tube feeding amount had the potential to lead to poor nutritional intake and weight loss. The facility’s enteral tube feeding care policy directed nurses to check the physician order sheet or MAR for feeding formula, type, rate, and duration.
Discontinued Tramadol Was Administered Without an Active Order
Penalty
Summary
The facility failed to ensure a discontinued controlled medication was not administered and properly destroyed for one resident. During a medication pass, an RN opened the medication cart on the third floor, unlocked the narcotic bin, and dispensed a Tramadol 50 mg tablet for the resident even though the electronic medical record did not show an active order for Tramadol. When questioned, the RN stated she did not verify the order in the EMR because she remembered the resident had Tramadol in the narcotic bin. The DON later verified the resident had no active physician order for Tramadol 50 mg tablet and stated the medication would have to be discarded and removed from the cart. Record review showed Tramadol had originally been ordered for the resident on October 13, 2025, then discontinued on October 21, 2025, yet nurses administered it on multiple later dates, including 10/23/25, 10/26/2025, 10/28/2025, 11/7/2025, 11/10/2025, 11/12/2025, 11/15/2025, 11/16/2025, and 11/18/2025. The DON stated the nurse should complete a pain assessment, verify the EMR for an active order, and confirm the right patient, medication, dose, route, and time.
Discontinued narcotic remained in medication cart
Penalty
Summary
The facility failed to ensure discontinued narcotics were removed and disposed of from the medication cart for one resident, R72, out of a sample of 3 residents reviewed for medication storage and labeling. During observation on 11/20/2025 at 10:32 AM, V24, the RN, was leaving the medication cart on the third floor unlocked and unattended. At 10:34 AM, V24 opened the third-floor medication cart, unlocked the narcotic medication bin, and dispensed a Tramadol 50 mg tablet before checking whether the medication was still active on the MAR. When asked to verify the order, V24 logged into the EMR and stated that the Tramadol 50 mg tablet was no longer an active order. V24 stated that if a medication that had been discontinued remained in the medication cart, the nurse could administer it to the resident. Later that morning, the DON logged into the EMR and confirmed there was no active order for Tramadol 50 mg tablet for R72, stating it would have to be discarded and removed from the medication cart. On 11/19/2025, the DON stated that once an order is discontinued, the nurse gives the medication and sheet to the DON, medication reconciliation is completed, and then the DON removes it from the medication cart. The facility policy titled Controlled Substance Disposal states that controlled substances remaining in the facility after discharge or discontinuation are to be disposed of according to federal and state laws and regulations.
Failure to Document Offering COVID-19 Vaccination
Penalty
Summary
The facility failed to document offering COVID-19 vaccination to 1 of 5 residents reviewed, identified as R87. R87's immunization record did not document that the resident received or was offered the COVID-19 vaccine. During an interview on 11/19/2025 at 10:34 AM, the Infection Preventionist/Registered Nurse stated she had just started in the role and still needed to address vaccination for some residents. She stated that residents without immunization documentation had not yet been offered vaccination and that vaccination was a priority to protect residents and people around them from infection. The facility's COVID-19 Vaccination Policy, dated 07/16/2024, states the facility will comply with applicable CMS, CDC, and/or IDPH guidance on COVID-19 vaccination and will offer the vaccine to residents and document administration in the resident's record.
Failure to Care Plan Stage IV Sacral Pressure Ulcer
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident with a Stage IV pressure ulcer to the sacrum. The resident’s record showed diagnoses including pressure ulcer of the sacral region stage 4, type 2 diabetes mellitus, essential hypertension, disorder of prostate, and unspecified dementia. The MDS dated 7/7/25 showed the resident had intact cognition, required substantial to maximal assistance with eating, oral and personal hygiene, was dependent for toileting hygiene, showering, dressing, and chair/bed transfers, and was always incontinent of bowel and bladder. The MDS also indicated one Stage IV pressure ulcer present on admission/entry. Interview and record review showed the wound care coordinator and DON stated that pressure ulcers and skin impairment should be care planned and that the care plan should include the resident’s problems, goals, and interventions. However, surveyor review of the resident’s care plan on 9/24/25, 9/26/25, 9/30/35, and 11/14/25 found no care plan for the Stage IV pressure ulcer to the sacrum. The resident’s wound records documented a community-acquired Stage IV sacral pressure ulcer with measurements and exposed subcutaneous tissue, muscle/fascia, tendon/ligament, and bone, and later wound notes described a heavy amount of serous exudate. The resident was also hospitalized on 8/1/25 with a sacral ulcer, and hospital records showed infectious disease and general surgery consultations for stage IV sacral wound infection, with sacral bone debridement and bone biopsy on 8/6/25.
Medication Administration and Accountability Failures
Penalty
Summary
The facility failed to ensure proper accounting and administration of narcotic medications, as well as adherence to medication administration protocols. During a shift change, a registered nurse (V10) did not sign the narcotic record documents, and discrepancies were found in the count of R23's Pregabalin 75 MG. Similarly, a licensed practical nurse (V11) found discrepancies in the narcotic counts for two residents, with missing tablets of Oxycodone and Morphine Sulfate. Both nurses admitted to forgetting to sign the records, which is a violation of the facility's policy requiring accurate documentation and accountability for controlled substances. Additionally, the facility failed to follow proper procedures for administering medications via gastronomy tube. A licensed practical nurse (V12) prepared multiple medications for R69 without separating them into individual cups, contrary to the policy that requires each medication to be flushed independently with water. V12 also failed to maintain cleanliness by touching high-touch areas and the enteral tube with the same gloves used for medication administration, which could compromise the sterility of the procedure. The facility also did not ensure the availability of insulin as per physician orders, leading to a delay in administration. A licensed practical nurse (V13) attempted to administer expired Humalog insulin to R11, realizing the error only after being questioned. The insulin had been opened beyond its 28-day expiration period, and V13 was unable to find a non-expired insulin vial, resulting in a delay until a one-time dose was authorized by the physician. This incident highlights the facility's failure to adhere to medication labeling and expiration protocols, as outlined in their policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, including insulins and controlled substances, as per their policy and professional standards. During an inspection, it was observed that several insulin vials for residents were not dated when opened, and some were found to be expired but still stored in the medication cart. Specifically, insulins for residents were either missing open dates or were past their expiration dates, yet remained in use. Additionally, an eye drop medication was found without a date in the medication cart. Controlled substances were not stored according to the required double-lock protocol. A Lorazepam vial, a controlled substance, was found in an unlocked refrigerator at the nurse station, which was supposed to be secured. Furthermore, this medication had been discontinued but was still present in the storage area. The Director of Nursing confirmed that all narcotics should be double-locked and that discontinued medications should be destroyed per pharmacy guidelines. These lapses in medication management affected six residents reviewed for drug storage.
Improper Documentation Practices by CNAs
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for eight residents. This deficiency was identified through interviews and record reviews. A Certified Nursing Assistant (CNA), identified as V14, was found to be allowing another CNA, V15, to document resident care under her login credentials. V15, who works through an agency and occasionally at the facility, stated she was unable to log into her account and thus documented care under V14's account. This practice was confirmed by V14, who mentioned that the documentation of care was what mattered, regardless of who logged it. The Assistant Director of Nursing, V3, stated that all agency staff are provided with individual electronic login access to document their work, and another CNA, V32, confirmed that staff are not allowed to share login information. Despite this, the facility's floor assignment records showed that V15 was responsible for several residents, yet documentation for these residents was completed under V14's login. This included tasks related to bowel and bladder management, as well as behavior monitoring and intervention. The facility's policy emphasizes the importance of safeguarding resident information and maintaining accurate medical records, which was not adhered to in this instance.
Inaccurate Completion of Resident's Annual Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive annual assessment for a resident, identified as R29. The issue arose when the Minimum Data Set (MDS) was incorrectly submitted as a quarterly assessment instead of an annual one. This error was identified during an interview with the MDS Consultant, who noted that the resident's census line contained an error due to the resident's hospital admission and subsequent return to the facility as a dual Medicaid and Medicare payor. The MDS was scheduled in sequence, but the quarterly assessment was mistakenly submitted in place of the required annual assessment. The facility did not have a current MDS Coordinator, and someone from another facility was covering the MDS responsibilities, contributing to the oversight. The error was recognized on the last day to complete the annual assessment, prompting the inactivation of the quarterly assessment and the initiation of the annual assessment process.
Failure to Conduct Timely PASARR Screening
Penalty
Summary
The facility failed to initiate a new Level I PASARR screening for a resident, identified as R70, who was reviewed for Pre-Admission Screening and Record Review (PASARR). R70 was admitted to the facility with an exempted hospital discharge, which allowed for a 30-day length of stay without a new PASARR screening. However, this exemption expired, and the facility did not conduct a new Level I PASARR screening as required. The administrator, V1, acknowledged that the resident's PASARR screening had expired and that a new screening was necessary but had not been completed. The facility's policy mandates that residents with mental disorders or intellectual disabilities receive PASARR screenings within the allowed timeframe. Despite this policy, the facility did not adhere to the requirement for R70, whose exemption status had lapsed. The administrator also demonstrated a lack of understanding regarding the determination of needs (DON) score ranges and their implications, which are crucial for deciding if a resident requires a Level II PASARR screening for severe mental illness. This oversight resulted in a deficiency related to the facility's failure to ensure appropriate PASARR screenings were conducted in a timely manner.
Failure to Address High Blood Sugar in Resident with Diabetes
Penalty
Summary
The facility failed to address a high blood sugar result for a resident with diabetes mellitus, leading to a deficiency in care. The resident, who was receiving Paxlovid for Covid-19, had a physician's order to monitor blood sugar levels and notify the doctor if results were below 60 or above 300. On the day of the incident, the resident's blood sugar was recorded at 333, which required physician notification according to the order. However, there was no documentation indicating that the physician or nurse practitioner was informed of this elevated result. Later, the resident's blood sugar further increased to 397, and the resident was pronounced expired by EMS at 3:15 PM. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's elevated blood sugar levels. The Director of Nursing was not present at the time and was unsure if the physician was notified, while the Restorative Director stated she was not informed of the elevated levels. The Nurse Practitioner acknowledged being informed of the initial high result but was unaware of the subsequent increase to 397. He admitted to not documenting the elevated blood sugar or any actions taken to address it, highlighting a failure in following the physician's order and ensuring proper care for the resident.
Failure to Adhere to Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to ensure proper pressure ulcer preventative measures for two residents, R4 and R62, who were both on low air loss mattresses as per their physician orders. R4's physician order summary indicated the need for a low air loss mattress for pressure reduction, yet observations revealed that R4 was lying on a mattress with a fitted sheet and a flat sheet folded twice, which is against the facility's protocol. Similarly, R62, who required the mattress due to active wounds, was found with a fitted sheet and a folded flat sheet, contrary to the guidelines that specify only a single sheet, a blue pad, and a brief should be used. The Wound Care Manager confirmed that the facility's protocol does not allow for both a fitted and a flat sheet, nor the use of a folded flat sheet as a draw sheet, as this creates excessive layers. The Proactive Medical Products Operation Manual and the Med-Aire 8 Alternating Pressure Mattress Replacement System User Manual both recommend minimal layering to prevent pressure injuries. The facility's failure to adhere to these guidelines resulted in a deficiency in providing appropriate pressure ulcer care and prevention for the residents involved.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy on accommodating resident food preferences, specifically for one resident, R70, who was part of a sample of 21 residents reviewed. R70's Nutrition Progress Note indicated that her diet should include food preferences and alternatives as needed. Despite this, the facility served eggs to R70 for breakfast on multiple occasions, even though she had explicitly informed the staff, including the Dietary Manager (V8), that she disliked eggs. R70's food preference interview form, which documented her preference against eggs, was not reflected on her dietary meal ticket, leading to repeated servings of eggs. The Dietary Manager, V8, acknowledged awareness of R70's preference against eggs and admitted to completing a food preference interview form for R70. However, the form was initially misplaced and later found in a storage clipboard. The oversight was attributed to the failure to document R70's no-egg preference on her dietary meal ticket, which should have been updated according to the facility's policy. This lapse resulted in R70 refusing her breakfast meal tray when eggs were served, highlighting a breakdown in the communication and implementation of dietary preferences within the facility.
Infection Control Deficiencies in PPE Use and Bed Bath Practices
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) by staff caring for a resident with a known infectious disease. A resident diagnosed with shingles was placed on contact isolation precautions, requiring staff to wear gowns and gloves before entering the room. However, observations revealed that staff members, including a CNA Supervisor and a CNA, entered the resident's room without donning the required PPE, despite being aware of the resident's condition and the posted contact precautions. Both staff members acknowledged their failure to adhere to the PPE requirements and recognized the potential risk of cross-contamination and spreading the infection to other residents. Additionally, the facility did not maintain clean technique and infection control practices during a bed bath for another resident. The resident, who required substantial assistance for bathing, reported inadequate cleaning by certain CNAs, particularly in the perineal area. During an observed bed bath, a CNA used the same washcloth for multiple body areas, including the perineal area, without changing gloves or washcloths, contrary to best practices for infection prevention. The CNA acknowledged that the observed procedure was not her usual practice, and the facility lacked a specific bed bath procedure policy. The facility's infection prevention and control policy required the use of gowns and gloves for contact precautions and emphasized maintaining clean techniques during hygienic care. However, the staff's actions during the observed incidents did not align with these policies, leading to deficiencies in infection prevention and control practices for the residents involved.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA), which was identified as an Immediate Jeopardy situation. The incident involved a resident with dementia who was handled roughly and hit on the arm and back by the CNA while attempting to redirect the resident. The abuse occurred on 06/30/24, but the facility's video recording system did not retain footage from that date, as it only stored recordings for seven days. The resident, who does not speak English and has a history of dementia with agitation, was unable to recall or speak of the abuse incident. The CNA admitted to hitting the resident after the resident allegedly hit her first. Another CNA witnessed the incident and reported it to a nurse on duty, but no action was taken until the surveyor's investigation. The facility's policy clearly states that abuse, including hitting, is not acceptable under any circumstances. Despite the facility's investigation concluding that the allegation of abuse could not be substantiated, multiple staff members, including the Director of Nursing and the Social Services Director, acknowledged that hitting a resident is a form of abuse. The Medical Director suggested that the incident might be considered self-defense but emphasized that staff should de-escalate situations without resorting to aggression. The facility's policy mandates immediate reporting of any abuse allegations to the administrator.
Removal Plan
- V20 suspended.
- R1 is no longer residing at the facility. R1 has been discharged to another Long-Term Care.
- R1 full skin assessment conducted.
- R1 seen by psychotherapist.
- R1 evaluated by Physiatrist.
- R1 screened for abuse/neglect.
- V21 was suspended for not reporting to V1, pending investigation.
- Staff are being educated on Abuse, with quiz to monitor effectiveness.
- Abuse in-service completed.
- Abuse in-service on Handling Aggressive Behaviors with quiz for 5 staff members three times per week for 12 weeks on-going.
- Social Work outside consultation group initiated monthly in-service on de-escalation techniques and handling aggressive residents.
- Staff training on facility code gray for aggressive behavior/violence, initiated and completed.
- QA (Quality Assurance) audit on 3 times weekly times 12 weeks to ensure direct staff care staff (Nurses and CNA's).
- Thirteen residents R1, R7, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22, were reviewed for abuse and aggressive behaviors. List of residents with behaviors provided and posted at the nurse's station inside a closed cupboard.
- V27 (Medical Director) interviewed and was aware of the removal plan with V27's approval.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked and within the visual proximity of licensed nurses when not in use, posing a potential hazard to residents. On the 3rd floor, a treatment cart was observed unlocked and unattended in the hallway. The RN on duty, V16, acknowledged the facility's policy that medications should be locked when not in use but stated that they were not responsible for the cart. The Wound Care Nurse, V18, confirmed that the cart should have been locked to prevent resident access. Similarly, on the 2nd floor, a medication cart was found unlocked and unattended. The LPN, V24, admitted that the cart should have been locked when not in visual proximity, explaining that they had left it to administer medication in the dining room. The facility's policies on hazards and medication storage clearly state that medications must be secured to prevent resident access, yet these protocols were not followed, creating a potential risk for all residents on the affected floors.
Failure to Report Abuse Incident Timely
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required time frame. This incident involved a resident with dementia, who was handled roughly and hit on the arm and back by a Certified Nursing Assistant (CNA) in an attempt to redirect the resident. The incident was witnessed by another CNA, who reported that the resident was hit multiple times and handled roughly, which was not appropriate even if the resident was combative. Despite the witness reporting the incident to the nurse on duty, no action was taken until the surveyor's visit. The facility's policy on abuse and neglect, revised in June 2024, mandates that all allegations of abuse must be reported immediately to the administrator, who is the Abuse Coordinator, and to the IDPH. The policy defines abuse as willful infliction of mistreatment, including physical actions such as hitting and grabbing. The failure to report the incident promptly and the lack of immediate action by the staff on duty contributed to the deficiency identified by the surveyors.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to immediately initiate an investigation into an alleged physical abuse incident involving a resident, identified as R1, who was handled roughly and physically hit by a Certified Nursing Assistant (CNA), V20. R1, who has dementia and other medical conditions, was reportedly hit on the arm and back by V20 in an attempt to redirect R1 from sitting on the floor. V20 admitted to hitting R1 after being elbowed by the resident, but did not report the incident to the facility's Abuse Coordinator, V1, as V20 did not initially perceive it as abuse. The incident was captured on a hallway camera, but no action was taken until the surveyor's visit. Another CNA, V21, witnessed the incident and confirmed that V20 hit R1 multiple times and handled the resident roughly. V21 reported the incident to the nurse on duty, V10, but no investigation was initiated. The facility's policy on abuse and neglect mandates immediate reporting and investigation of such incidents, which was not followed in this case. The policy outlines that abuse includes hitting and rough handling, and all staff are required to report any alleged abuse immediately to the Abuse Coordinator.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure medication was administered as ordered for a resident, identified as R3, who was reviewed for medication administration. R3's Medication Administration Record (MAR) and Physician Order Sheet (POS) indicated an order for Potassium chloride crys ER 20 meq tablet extended release to be given by mouth once a day every Monday, Wednesday, and Friday. However, R3 was administered this medication on a Thursday, which was not in accordance with the prescribed schedule. On the day of the incident, R3 was observed in bed with two plastic medication cups containing pills, including a large whitish pill identified as potassium. R3 expressed stress and confusion about the medication, stating that the nurse had not provided assistance in identifying the pills. The Registered Nurse (RN), identified as V16, was unaware that R3 had not taken the medication and proceeded to administer the potassium despite the error in timing. V16 did not document the administration of potassium at the correct time and signed off the scheduled medication as given at 9:00 am, although it was administered later. The facility's Director of Nursing (DON), identified as V2, confirmed that medications should be administered as ordered and not left at the bedside unless the resident is assessed to self-administer safely. The facility's policies on medication pass and physician orders emphasize adherence to federal and state regulations and following physician orders as written, which were not followed in this instance.
Failure to Label Enteral Feeding Bottles
Penalty
Summary
The facility failed to follow their policy on enteral tube feeding care by not labeling the date and time the feeding was started for two residents. Resident 2 (R2) had severe cognitive impairment and was on a Jevity1.5 enteral feeding at 75ml/hour. During an observation, it was noted that the nutritional supplement bottle was not labeled with the date and time it was started. The LPN on duty was unaware of when the feeding was initiated, which is against the facility's policy. Similarly, Resident 3 (R3), who also had severe cognitive impairment, was on a Jevity1.2 enteral feeding at 60ml/hour. The nutritional supplement bottle for R3 was also found without a date and time label, and the LPN did not know when it was started. Both residents' nutritional supplements were running at the prescribed rates, but the lack of labeling posed a risk for potential gastrointestinal issues and infections due to the possibility of using the supplement beyond the recommended 24-hour period. The Registered Dietitian and the Director of Nursing confirmed that the facility's policy requires the date and time to be labeled on the feeding bottles to ensure they are changed within 24 hours to prevent infections and ensure the residents receive fresh feedings. The failure to label the feeding bottles as per the policy was observed during the survey, and it was acknowledged by the staff that this oversight could lead to significant health risks for the residents, including gastrointestinal issues and potential infections due to compromised health conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,653 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Lincoln Park Rehabilitation And Nursin | 0.3 mi | ★★★★★ | 4 | 0 |
| Alden Lincoln Rehab & H C Ctr | 0.4 mi | ★★★★★ | 4 | 0 |
| Little Sisters Of The Poor | 1.1 mi | ★★★★★ | 0 | 0 |
| Avantara Lincoln Park | 1.2 mi | ★★★★★ | 9 | 0 |
| Carlton At The Lake, The | 2.1 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.