Avantara Lincoln Park

In the surveyor’s words

From the most serious findings on record at Avantara Lincoln Park, in the surveyor’s own words.

• Actual harm, patternF689Apr 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure that a fall intervention was in place for one resident (R2) who is high risk for falls; and failed to provide adequate supervision for five residents (R2, R3, R4, R6 and R7) who are high risk for falls. These failures resulted in R2 sustaining a fall which required R2 to go to the local hospital due to sustaining a acute right femoral fracture; R3 sustaining a fall which required R3 to go to the local hospital due to sustaining a left femur intertrochanteric fracture; R4 sustaining a fall which required R4 to go to the local hospital due to sustaining an acute fracture of T12 vertebral body; R6 sustaining a fall in the bathroom which required R6 to go to the local hospital due to sustaining a T12 (Thoracic)… […]

• Actual harm, isolatedF603May 21, 2026

  Based on interview and record review, the facility failed to ensure that residents were kept free from involuntary seclusion when staff tethered a bedsheet from the resident's room door handle to a hallway handrail, physically trapping the resident inside the room. This deficient practice affected one of four residents (R1) reviewed for abuse. A reasonable person reviewing these actions would conclude that tying a door shut with a bedsheet is a punitive, non-therapeutic mechanism used to involuntarily confine a resident.A reasonably prudent caregiver would recognize that blocking an exit in this manner completely strips the resident of their freedom of movement, creates an immediate fire and entrapment hazard, and serves strictly as a measure of staff convenience to manage the resident's… […]

• Actual harm, isolatedF689Dec 31, 2025

  Based on interview and record review, the facility failed to ensure that fall interventions were in place for one resident (R1) who was a high risk for falls. These failures resulted in R1 sustaining a fall which required R1 to go the local hospital due to sustaining an intracranial subdural hematoma. Findings include:R1's medical diagnoses include but are not limited to history of falling, type 2 diabetes mellitus, essential hypertension, obstructive sleep apnea, seizures, chronic kidney disease.R1's Minimum Data Set (MDS) dated [DATE] has R1's Cognitive Skills for Daily Decision Making scored at 3 Severely Impaired. R1's initial Reportable Incident to the state agency dated [DATE] documents in part, Resident was last seen by CNA (Certified Nursing Assistant) asleep approximately 2:30am. […]

• Actual harm, isolatedF692Aug 29, 2025

  Based on observation, interview and record review the facility failed to address a resident's significant weight loss for 1 (R1) of 4 residents reviewed for weight loss. This failure resulted in R1 having a 30-pound weight loss in 4 months, 34 pounds in 6 months and 44.5 pounds in 7 months.Findings Include:Findings Include:R1 was admitted to the facility on [DATE] with diagnoses not limited to Asthma, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only, Cervical Disc Degeneration, Atherosclerotic Heart Disease, Low Back Pain, Essential (Primary) Hypertension, Idiopathic Gout, Gastro-Esophageal Reflux Disease, Depression, Obstructive Sleep Apnea, Cervicalgia, Mood Disorder… […]

• Actual harm, isolatedF600Apr 19, 2024

  Based on interviews and records review, the facility failed to keep one resident (R4) free from abuse in a sample of three reviewed. This deficiency resulted in R4 being hit by R5 with a walker, and R4 sustained a laceration to the forehead requiring five sutures. Findings include: Facility Reported Incident Report (FRI) dated 3/20/2024 documents: -Physical abuse and documents R4 stated R5 picked up walker and pushed it towards his face. Investigations stated R4 sustained 5 sutures to right eyebrow, right hand skin tear and mid back abrasion. Hospital records dated 3/20/2024 document: -R4 assaulted by another resident with a walker. Patient c/o (complaining) of mild headache. Sustained laceration to forehead and skin tear to right hand. […]