Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration and food safety standards in the facility.
Findings
The facility failed to label a multi-dose jar of petroleum jelly with the open date, affecting one resident. Additionally, the facility did not properly store and label refrigerated foods, including rotten lettuce and unlabeled items, potentially affecting all 31 residents.
Deficiencies (2)
F 0761: The facility failed to label a multi-dose jar of petroleum jelly with the open date as required by Medication Administration Policy.
F 0812: The facility failed to remove rotten lettuce and did not label, date, or monitor refrigerated foods in accordance with food safety standards.
Report Facts
Residents affected: 1
Residents affected: 31
Lettuce count: 5
Gelatin portions: 5
Lettuce box count: 24
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 7, 2025
Visit Reason
The visit was conducted as a complaint investigation related to complaint number 2593814/IL 191327.
Complaint Details
Investigation unable to be completed due to the subject of the complaint not residing in the assisted living area of the facility.
Findings
The investigation was unable to be completed because the subject of the complaint did not reside in the assisted living area of the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 15, 2025
Visit Reason
Complaint investigation IL00186955 was conducted on 2/15/2025.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 13, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident safety, medication storage, food handling, and immunization policies at Lincolnwood Place nursing home.
Findings
The facility was found deficient in supervising a high fall risk resident, monitoring medication refrigerator temperatures, labeling food products with dates, and administering immunizations to residents. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
F 0689: The facility failed to adequately supervise a high fall risk resident (R26) during toileting, leaving the resident unattended contrary to care plan and staff expectations.
F 0761: The facility failed to monitor the temperature of two medication refrigerators, missing temperature logs on multiple dates, potentially affecting medication efficacy for six residents.
F 0812: The facility failed to label food products with cook or open dates, risking food safety for 36 residents on oral diets.
F 0883: The facility failed to administer influenza and pneumococcal vaccines to 3 of 5 residents reviewed, despite documented consents and vaccine availability.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 36
Residents affected: 3
Sample size: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Observed leaving high fall risk resident unattended (V15) | |
| Interim Director of Nursing | Provided interview statements on supervision expectations (V2) | |
| Registered Nurse | Observed medication storage and vaccine stock (V13) | |
| Chef | Observed unlabeled food items and provided statements on food labeling (V6) | |
| Dietician | Provided statements on food labeling responsibilities (V7) | |
| Cook | Provided statements on food labeling (V8) | |
| Infection Prevention | Provided statements on immunization policies and vaccine administration (V4) |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving a resident who fell during a mechanical lift transfer, resulting in injury.
Complaint Details
The complaint investigation found that one resident (R1) fell from a mechanical lift due to improper sling application and lack of two-person assist. The fall caused a 3 cm laceration requiring 3 staples. The incident was substantiated with detailed interviews and documentation.
Findings
The facility failed to maintain resident safety during a mechanical lift transfer by not correctly applying the lift sling and not using a two-person assist. This failure caused one resident to slide from the sling and sustain a laceration requiring hospital treatment.
Deficiencies (1)
F 0689: The facility failed to maintain resident safety during mechanical lift transfers by incorrectly applying the sling and not using two-person assist, resulting in a resident falling and sustaining a 3 cm laceration to the posterior scalp.
Report Facts
Length of laceration: 3
Staples required: 3
Date of incident: Aug 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Agency CNA | Named in mechanical lift transfer incident causing resident fall |
| V8 | Agency CNA | Named as requested for assistance during transfer but did not assist |
| V2 | Director of Nursing | Responded to incident and conducted interviews |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 26, 2024
Visit Reason
The inspection was conducted following a complaint regarding a resident injury during transfer at the nursing home.
Complaint Details
The investigation was triggered by a complaint regarding an incident on 2/11/24 where resident R1 was injured during a transfer. The complaint was substantiated as staff failed to use the mechanical lift as required, leading to the injury.
Findings
The facility failed to transfer a resident (R1) using a mechanical lift as required, resulting in R1 sustaining a laceration to the leg that required 12 sutures and emergency hospital transfer. Staff did not follow the prescribed transfer protocol, and the resident's care plan did not reflect the mechanical lift requirement prior to 5/20/24.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. Staff did not use a mechanical lift for resident R1 during transfer, resulting in a leg laceration requiring 12 sutures and emergency hospital transfer.
Report Facts
Sutures required: 12
Resident weight: 193
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V8 | Certified Nursing Assistant | Named in interview and CNA Occurrence Report regarding the transfer incident with resident R1. |
| V9 | Registered Nurse | Interviewed regarding resident R1's transfer needs and incident. |
| V6 | Certified Nursing Assistant | Interviewed confirming previous injury incidents and transfer practices for resident R1. |
| V2 | Director of Nursing | Confirmed transfer incident details and mechanical lift usage policy. |
| V10 | Registered Nurse | Completed Incident Detail report and interviewed about the transfer incident. |
| V3 | Physical Therapist | Provided therapy progress and discharge summary for resident R1 and confirmed transfer recommendations. |
| V1 | Administrator | Provided facility transfer policy and confirmed transfer procedures. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint or allegation regarding infection prevention and control practices at the facility.
Complaint Details
The complaint investigation found that staff did not follow isolation procedures for resident R5, who was on contact isolation precautions for ESBL in the urine. The failure was substantiated with observations and interviews.
Findings
The facility failed to follow isolation procedures and proper use of Personal Protective Equipment (PPE) for one resident on contact isolation precautions, posing a potential risk to the entire facility.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff did not consistently wear required PPE and failed to perform hand hygiene when entering and exiting a resident's room under contact isolation precautions.
Report Facts
Facility census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Provided census information during inspection |
| V7 | Housekeeper | Observed not wearing gown while cleaning contact isolation room |
| V8 | Maintenance staff | Observed entering isolation room bathroom without PPE or hand hygiene |
| V9 | Registered Nurse | Provided information about resident R5's isolation status |
| V2 | Director of Nursing/Infection Preventionist | Explained required PPE and hand hygiene protocols |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nursing home regulations, focusing on resident safety, care plan implementation, and fall prevention following incidents and complaints.
Findings
The facility failed to implement proper transfer procedures for resident R1, resulting in a laceration requiring hospital treatment. The facility also failed to update care plans and fall prevention protocols for residents R1, R2, and R3 after incidents, and did not maintain adequate documentation or supervision consistent with their policies.
Deficiencies (1)
F 0689: The facility failed to ensure safe transfer of resident R1, causing a laceration requiring 18 staples and hospital treatment. The care plan was not updated after the injury, and fall prevention plans for residents R1, R2, and R3 were incomplete or not updated following incidents.
Report Facts
Staples placed: 18
Incident report submission date: Feb 15, 2023
Incident date: Feb 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 RN | Registered Nurse | Completed post-incident investigation and provided care for resident R1's laceration |
| V5 CNA | Certified Nursing Assistant | Transferred resident R1 alone without gait belt, causing injury |
| V2 DON | Director of Nursing | Fall coordinator and involved in post-fall investigations and care plan updates |
| V7 Physical Therapy | Physical Therapist | Provided expert opinion on transfer procedures and wheelchair safety for resident R1 |
| V10 Maintenance Supervisor | Maintenance Supervisor | Responsible for wheelchair safety checks and maintenance |
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