Lincoln Park Nursing and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Lincoln Park Nursing and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF867Mar 11, 2021

  Based on interview and record review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies to prevent a legionella outbreak. This has the potential to affect all 65 Residents residing within the facility. Facility was aware of having positive legionella in their water supply from tests in 2018 and 2019 and starting again on [DATE]. The facility failed to implement corrective actions to prevent a legionella outbreak, resulting in a Resident's hospitalization and death due to Legionella. Facility failure to develop and implement corrective actions to prevent a legionella outbreak, created a finding of immediate jeopardy that began on [DATE]. […]

• Immediate jeopardy, widespreadF880Mar 11, 2021

  Based on observations, interviews and record reviews, the facility's water management program (WMP) is inaccurate, incomplete and is not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, the CDC Toolkit and the Wisconsin State Plumbing Code SPS 382.50, creating a potential for all 65 facility residents to be infected by Legionella. The facility's Water Management Program failed to: Include water management team members who were knowledgeable about the facility's water system Describe the building water system using text and an accurate flow diagram of the system Identify all locations where Legionella could grow and spread, Identify where control measures should be applied based on where Legionella could grow and… […]

• Immediate jeopardy, isolatedF600May 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure 2 of 4 residents (R1 and R5) was free from physical abuse. R2 is known to have physical aggression towards residents and staff and was observed to have escalating behaviors. The facility did not ensure R1 was free from abuse by another resident (R2) residing in the facility. On 4/17/25, at 6:45 AM, facility staff observed R2 strike R1 in the arm twice while in the common area. On 4/20/25, facility staff observed R2 strike R1 in the back with a wet floor sign. R2 and R1 were separated by facility staff and escorted to separate units within the facility. Approximately 10 minutes later at 12:50 AM, R2 sought out R1, and R2 hit R1 multiple times in the head with the wet floor sign. […]

• Immediate jeopardy, isolatedF745May 28, 2025

  Based on observation, interview, and record review, the facility did not ensure 4 (R1, R2, R5, and R6) of 6 residents reviewed received medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1 has a diagnosis of Alzheimer's Disease, alcohol abuse, and impaired cognitive function with behaviors demonstrated upon admission. The facility did not obtain information prior to admission that would have been pertinent to understanding R1's behaviors and how to address them. The facility failed to assess R1's behaviors. […]

• Actual harm, isolatedF689Apr 22, 2026

  Based on interview and record review the facility did not ensure 1 (R86) of 3 sampled residents at risk for falls had interventions in place to prevent a fall with major injury. On 5/23/25 R86 sustained a fall out of bed and was sent to the hospital due to R86 being on a blood thinner and R86 being unable to vocalize if she hit her head. At the hospital R86 was found to have a left subacute infarct of left parietal and frontal lobe with petechial hemorrhage along acute infarct (brain bleed). R86 was at high risk for falls, had right sided weakness from a stroke, had contradictory assessments regarding bed mobility and interventions to be used, was on an anticoagulant and was on an air mattress which are risk factors for a fall. […]