Lincoln Square Post Acute Care

In the surveyor’s words

From the most serious findings on record at Lincoln Square Post Acute Care, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 22, 2021

  Based on interview and record review, the facility failed to provide necessary care and services to prevent a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (tissue rubbing together in opposite directions) and/or friction) from developing and/or worsening for one out of two residents (Resident 1), when Resident 1's sacrococcyx (tail bone and lower back) was not monitored by a licensed nurse every shift over a period of at least four days ([DATE], [DATE], [DATE], and [DATE]) following the identification of blanchable redness (a reddened area of skin which turns white when pressed with a fingertip and then turns red again when pressure is removed a warning sign that a… […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 63 residents who received meals from the kitchen when:1. Two open boxes with green lettuce and cheese were placed on the kitchen floor;2. Dietary staff did not fully cover the hair on the back of their head in the kitchen;3. One mesh bag of yellow onion was placed on the kitchen food storage room floor, and a bag of dry cereal and flour were not sealed in a container,4. Spinach was thawed in a sink next to two open chemical buckets; and5. A plastic food cover, an open box of gloves, and a grill cleaner was kept in a kitchen cabinet with cleaning supplies. […]

• No harm, potential for more than minimal, widespreadF814Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly contained in the kitchen and outside dumpster areas for a total facility census of 64 residents, when one trash can inside the kitchen and one of two outside dumpster lids were observed not closed. This failure had the potential to expose the resident's environment to pests, odors, and disease.Findings:During an observation on 3/24/26 at 8:56 a.m. with the Dietary Supervisor (DS) in the kitchen, a trash can was observed with the lid propped open.During a concurrent observation and interview on 3/24/26 at 8:57 a.m. with the [NAME] (CK) in the kitchen, the CK confirmed the trash can was not closed. […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 64 residents when:1. Resident 102's nebulizer tubing (plastic tubing used to deliver breathing treatments) was not stored in a protective bag after use.2. The facility did not implement their identified control measures ( an action aimed to eliminate a hazard or at least reduce the risk) in order to identify any potential growth of Legionella (a bacteria that can grow in water systems and cause a serious lung infection, especially in older adults and those with weak immune systems) in the water system.These failures had the potential to increase the risk of infection transmission to residents, staff, and visitors.Findings:1. […]

• No harm, potential for more than minimal, widespreadF583Dec 18, 2024

  Based on observation, interview, and record review, the facility failed to maintain a resident's rights to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 57 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records. Findings: During an observation on 12/15/24, at 9:45 AM, with the Dietary Aide (DA) 1 in the dishwashing area, DA 1 was observed throwing uneaten food, used napkins, and residents' meal tickets left on the meal trays into the garbage bin. DA 1 confirmed the observation. […]