Lincolnwood Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Lincolnwood Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760Jul 18, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who received Dilantin (a medication prescribed to treat seizures) in error on 18 occasions without a diagnosis of a seizure disorder, instead of receiving the intended medication, Diltiazem (a medication prescribed to treat high blood pressure) which was not transcribed. Additionally, the resident was transferred to the hospital where s/he received emergent hemodialysis (a medical treatment to remove waste and excess fluids that the kidneys are unable to perform this function adequately) for the Dilantin use, Resident ID #1.Findings are as follows:Record review of a community reported complaint… […]

• Immediate jeopardy, patternF880Jan 9, 2023

  Based on surveyor observation record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 2 of 2 residents observed, Resident ID #s 14 and 367 and 1 of 2 residents observed during a wound treatment, Resident ID #75. Findings are as follows: According to the facility's policy revised October 2019, titled, Blood Glucose Meter Cleaning, Disinfecting and Storage states in part, Blood Glucose Meter must be appropriately cleaned and disinfected between uses .4. After use, the blood glucose meter must [be] cleaned and disinfected per manufacturer guidelines .6. […]

• Immediate jeopardy, isolatedF710Jul 18, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's physician completed a medication reconciliation upon admission, failing to identify a medication transcription error, resulting in the resident receiving Dilantin (a medication prescribed to treat seizures) in error on 18 occasions without a diagnosis of a seizure disorder, instead of receiving the intended medication, Diltiazem (a medication prescribed to treat high blood pressure) which was not transcribed. […]

• Immediate jeopardy, isolatedF661Nov 25, 2024

  Based on record review and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 3 residents reviewed who were discharged from the facility, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 11/19/2024, alleges that Resident ID #1 was discharged home with Resident ID #2's medications. This resulted in one of the medications being taken by Resident ID #1 on two separate dates following his/her discharge. […]

• Immediate jeopardy, isolatedF689Jun 7, 2022

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident for 2 of 3 residents who are at risk for wandering and/or elopement, Resident ID's #1 and 2. Findings are as follows: 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2022, with diagnoses including, but not limited to, dementia, major depressive disorder and [CONDITION(S)]. Review of the hospital discharge paperwork dated 4/5/2022 revealed in part, that the resident presented .to the hospital for eloping from the apartment and wandering the streets . […]