Landmark of Lincoln Park Rehabilitation and Nursin

In the surveyor’s words

From the most serious findings on record at Landmark of Lincoln Park Rehabilitation and Nursin, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 30, 2026

  Based on interview and record review, the facility failed to assure that a resident was free of unnecessary physical restraints; failed to identify the specific medical symptoms warranting the use of a physical restraint and failed to obtain physician orders with medical justification. This failure affected one resident (R4) out of five residents reviewed for abuse who was restrained by being placed in a Geri-chair with a sheet tied over the resident's body, restricting the residents ability to freely ambulate and causing bruising to the resident's body; with no physician order, no consent/permission, and no medical justification.Findings Include:R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Type 2 diabetes mellitus with hyperglycemia,… […]

• Actual harm, isolatedF600Oct 10, 2025

  Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 3 residents reviewed for physical abuse. This failure resulted in V4 (certified nursing assistant) physically attacking R1 by pulling R1's ear and dragging R1 out of his chair by his arms, resulting in R1 sustaining bruising on his upper arms, and R1 being scared to go to the dining room.Findings Include:The surveyor confirmed by observation, interview, and record review that the deficiency practice occurred 09/04/2025 and was corrected on 09/09/2025, prior to the start of this survey and was therefore Past noncompliance. […]

• Actual harm, isolatedF600Jul 12, 2024

  Based on interviews and record reviews, the facility failed to protect two (R1, R2) residents' rights to be free from physical and verbal abuse out of three sampled residents. This failure resulted in R2 experiencing right foot pain and sustaining subacute fracture of distal right fourth metatarsal. Findings Include: The facility's abuse reportable dated 6/28/24 documents that on 6/24/24, R1 and R2 had a verbal disagreement regarding the washroom in R1 and R2's room. R2 stated that contact was made to R1's face. R1 stated R2 did make contact with R1's face, but stated R1 was not physically harmed, not in pain, not mental or emotionally distressed. R1's clinical records show R1 went out on pass on 7/9/24. […]

• Actual harm, isolatedF684Jul 12, 2024

  Based on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy in maintaining a safe environment free of injury, failed to follow a resident's (R2) care plan, and failed to follow up on residents' complaints of pain for two (R2, R5) out of a sample of three residents. These failures resulted in R2 experiencing new onset of right foot pain which started on 6/24/24 and R2's physician was notified four days later on 6/28/24. X-Ray was obtained for R2 on 6/30/24 with findings revealed a new healing subacute fracture of distal right fourth metatarsal. These failures also resulted in R5 experiencing left knee pain for one week and a left femoral condyle fracture diagnosed on [DATE], 7 days after injury on 7/3/2024. […]

• Actual harm, isolatedF689Jul 12, 2024

  Based on observation, interview and record review, facility failed to ensure a resident (R3) with history of unsafe and self-harmful behaviors was supervised and monitored while in the day room. This failure affected one resident (R3) out of a sample of three residents resulting in R3 sustaining a nasal fracture. Findings: On 7/9/2024 at 10 AM, R3's Electronic Health Record was reviewed. R3's diagnoses with onset of 4/8/2024 included schizoaffective disorder, depressive type, autistic disorder, gastroesophageal reflux disease without esophagitis, pain in left shoulder, delirium due to known physiological condition, weakness and other abnormalities of gait and mobility. R3's additional diagnosis with onset date of 6/19/2024 was fracture of the nasal bones. […]