Lincolnwood Place

In the surveyor’s words

From the most serious findings on record at Lincolnwood Place, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 1, 2024

  Based on interview and record review, the facility failed to maintain resident safety during a mechanical lift transfer, failed to ensure the mechanical lift sling was correctly applied during transfers, and failed to use a two person assist during a mechanical lift transfer. This affected one resident (R1) of three residents reviewed for safety and mechanical lift transfer. This failure resulted in R1 sliding from mechanical lift sling, sustaining a 3cm (centimeter) laceration to the posterior scalp, being sent to the local hospital where 3 staples were required to close the laceration. […]

• Actual harm, isolatedF689May 26, 2024

  Based on interview and record review, the facility failed to transfer a resident using a mechanical lift to ensure resident safety. This failure applied to one (R1) of three residents reviewed for resident injury and resulted in R1 sustaining a laceration to the leg while being transferred from wheelchair to bed; R1 required emergent hospital transfer and treatment with 12 sutures. Findings include: R1 is an [AGE] year-old woman with a medical history that includes but is not limited to generalized weakness, lymphedema with +4 edema present, chronic kidney disease, and coronary artery disease. Review of R1's medical record documents that R1 is alert, able to make her needs known with forgetfulness. […]

• Actual harm, isolatedF689Mar 15, 2023

  Based on observation, interview, and record review the facility failed to implement R1's care plan in providing assistance in transferring resident from bed to wheelchair and failed to follow its policy in transferring resident (R1). This failure caused a laceration of R1's right lower leg that required treatment at hospital of 18 staples to control bleeding. The facility failed to update R1's care plan after the laceration injury during transfer. The facility also failed to implement its fall prevention care plan, complete fall accurate assessment and update the fall care plan based on post fall investigation to prevent future falls. This deficiency affects all three ( R1, R2 and R3) residents reviewed for Resident safety. Findings include: 1. […]

• Actual harm, isolatedF684Feb 23, 2023

  Based on interview and record review, the facility failed to follow their Medication Administration policy and Narcotic/Controlled Medication Management policy, and physician orders. This affected 1 of 3 (R1) residents reviewed for physician orders and medication administration. This failure resulted in R1 received unscheduled opioid medication without doctor's order. R1 was transferred to local hospital due to hypotension and altered mental status in the wound clinic appointment. Hospital final diagnoses of Opioid overdose, accidental or unintentional, Anemia, Lupus, Antiphospholipid antibody positive and elevated BUN. […]

• Actual harm, isolatedF600Oct 24, 2022

  Based on interviews and record reviews, the facility failed to protect a resident from physical abuse during provision of care for one (R1) of five residents reviewed for abuse. This deficiency resulted in R1 feeling shocked and frustrated after being slapped on the face and sustained a bruise on the right side of lip. Findings include: R1 is a [AGE] year old, female, admitted in the facility on 06/04/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to progress notes dated 06/25/2022, R1 was found to have a bruise on the right side corner of her lips. R1 stated that a CNA (Certified Nurse Aide) was turning her in bed this morning during morning care and she (R1) screamed and CNA hit her right side of face. […]