Warren Barr Lincoln Park: Care Plan Failures - Chicago, IL
The resident, identified in inspection records as R3, was admitted on August 1, 2025, with a sacral ulcer, the kind of deep pressure wound that forms at the base of the spine. The infection had spread. An infectious disease doctor and a general surgeon were both consulted. On August 6, surgeons debrided the sacral bone and took a biopsy. The culture came back polymicrobial, meaning multiple types of bacteria had taken hold in the tissue and bone.
He had also developed a urinary tract infection. His mental status had deteriorated, a condition the records described as altered mental status, and physicians believed the confusion was likely driven by the combination of the UTI and the wound infection. After antibiotics and surgery, his mental status improved.
The wound, and everything that had gone into treating it, was serious enough to require two surgical specialists, an operating room procedure, and a course of antibiotics. What it did not have, for months, was a care plan.
Inspectors reviewed R3's care plan on September 24, September 26, September 30, and again on November 14, 2025. Each time, they found nothing addressing the Stage IV pressure ulcer on his sacrum. Not a goal. Not an intervention. Not a note that the wound existed.
On November 17, one day after inspectors had flagged the gap to facility staff, a care plan appeared. It contained information and documentation that had not been present in any of the records previously provided to and reviewed by the surveyor. Inspectors noted the discrepancy directly.
The facility's own care plan policy, dated June 30, 2025, states that after a required assessment is completed, a person-centered care plan outlining care for the resident must be in place within seven days. R3 had been a resident since August 1. Inspectors were still looking for his wound care plan in November.
Warren Barr Lincoln Park is a skilled nursing and rehabilitation facility on Chicago's North Side. The violation was cited under F0656, which covers the requirement that facilities develop and implement comprehensive care plans for each resident. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
The classification matters less than what it describes. A man underwent bone surgery for an infected wound. Surgeons scraped tissue from his sacrum and sent it to a lab. The lab found multiple strains of bacteria. His mind had clouded and then cleared after treatment. And through all of it, from August into November, the nursing home responsible for his daily care had produced no written plan for managing the wound at the center of all of it.
The care plan that finally appeared on November 17 came after inspectors spent weeks asking for it. What changed between November 14, when no care plan existed, and November 17, when one did, the inspection record does not say. The facility offered no explanation that appears in the report.
R3's treatment administration record for July was reviewed and showed no concerns. That is the one clean finding in the record. Everything after his August 1 admission, the bone infection, the surgery, the months without a care plan, sits in a different category.
A Stage IV pressure ulcer is the deepest classification for this type of wound. It extends through the skin and tissue to expose muscle, tendon, or bone. They are painful, slow to heal, and carry serious risk of systemic infection. They are also among the conditions nursing homes are most specifically required to plan around, because managing them requires consistent, coordinated care across every shift and every staff member who enters the room.
The plan that coordinates that care was not there. Then inspectors arrived. Then it was.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Warren Barr Lincoln Park from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
WARREN BARR LINCOLN PARK in CHICAGO, IL was cited for violations during a health inspection on November 18, 2025.
An infectious disease doctor and a general surgeon were both consulted.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.