Warren Barr Lincoln Park

In the surveyor’s words

From the most serious findings on record at Warren Barr Lincoln Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 25, 2024

  Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff. This failure affected one resident (R1) who was handled roughly and was hit on the arm and the back by a facility CNA (Certified Nursing Assistant) as she attempted to redirect R1. This was identified as an Immediate Jeopardy which began on 06/30/24 when V20, Certified Nursing Assistant, physically abused R1. The immediacy was removed on 07/22/24. On 07/17/24, V1 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 07/17/24 at 2:41pm. The facility provided an acceptable removal plan on 07/22/34 at 5:34pm. […]

• Immediate jeopardy, isolatedF689Jun 23, 2023

  Based on interview and record review, the facility failed to monitor R2, a cognitively impaired resident who was a known wanderer with an electronic monitoring safety device on R2's right wrist and left ankle; failed to respond to a stairwell door alarm; failed to identify R2, who was assessed at risk for elopement, on the facility's elopement risk list; failed to check the placement of R2's electronic monitoring safety device every shift per facility policy; and failed to weekly test the functioning of R2's electronic monitoring safety device per facility policy. […]

• Actual harm, isolatedF689Mar 14, 2026

  Based on observation, interview, and record review, the facility failed to supervise a resident with a history of falls. This failure affected one resident (R2)out of 3 residents reviewed for accidents and supervision in the facility. As a result, R2 fell and sustained a laceration of the head requiring sutures.Findings Include:On 11/29/25 at 8:24 pm, an initial Facility Reported Incident was submitted to Illinois Department of Public health (IDPH) that documented, Around 11:25 am, a resident (R2) was observed lying on his back on the floor in the bathroom of his room. (R2's) fall was unwitnessed and resulted in (R2) having a laceration to the right forehead, that required (R2) to get two sutures. (R2) can stand and ambulate with a walker, cues, and standby assist. […]

• No harm, potential for more than minimal, widespreadF575Nov 21, 2025

  Based on observation, interview, and record review, the facility failed to display [NAME] information in a public and accessible location, informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition.These failures have the potential to affect all 85 residents in the facility. Findings include: On 11/18/2025 at 2:36 PM, V5 (Social Service Director) stated V30 ([NAME] agent) is the agent that works for [NAME] program. V5 submitted a list of six (6) residents with two (2) residents crossed out. V5 stated the 2 residents that were crossed out were already discharged , not through [NAME] program. V5 was asked if residents included on the list were being coordinated to V30 ([NAME] Agent). […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2025

  Based on observation, interview, and record review, the facility failed to properly label and store food. These deficient practices have the potential to affect all 85 residents receiving food prepared in the facility kitchen. Findings include: On 11/18/2025 at 10:03AM, a tour of the kitchen was conducted with V20 (Food Service Manager). V20 and surveyor observed in the walk in-cooler, the following food items: - *1 open box of multiple heads of romaine lettuce that is wet and discolored a dark black color, with a receive date of 11/17/25.- * 1 open box of multiple heads of cabbage with discolored black spots on different areas of the cabbage leaves, with a receive date of 11/10/25.- * Multiple packages of ground beef meat inside a gray bin with a receive date of 11/17/2025, no use by date… […]