Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincoln Park Renaissance during CMS and state inspections, most recent first.
Failure to Provide Ordered Respiratory Care: A resident ordered continuous O2 had the flow set incorrectly and later found off, with an undated humidification bottle; another resident used a CPAP at bedside without a physician order or care plan documentation; and a third resident was observed on NC connected to an empty portable O2 tank. Staff confirmed the oxygen and CPAP issues during the survey, and the records showed respiratory diagnoses and ordered therapy that were not consistently supported by proper setup or documentation.
A resident with pain and cognitive impairment received PRN oxycodone despite a documented pain score of 0, and lidocaine patches were applied without a removal time in the order. Another resident with cardiac and fracture diagnoses had metoprolol given without time-specific BP/HR documentation, and PRN oxycodone was charted at pain levels below the ordered range. A third resident missed clonazepam doses, with family supplying medication and the DON acknowledging borrowed medication and delayed documentation. A fourth resident also had PRN pain meds documented at pain levels that did not match the order parameters.
A resident with moderate cognitive impairment, no upper body limitations, and fall risk had a call device clipped behind the bed and out of reach on repeated observations. During a wound tx observation, the call device was on the floor under the bed for the full 40-minute treatment before an RN placed it on the resident’s chest. The RN, DON, and Administrator confirmed the call bell should be within reach, and the facility policy stated it must be placed within the resident’s reach.
The facility failed to complete admission comprehensive MDS assessments within the required timeframe for two residents. Surveyors found that both assessments were signed late after the residents’ admission entries, and the RN/MDSC acknowledged the delay and stated that admission comprehensive MDS assessments should be completed within 14 days of admission.
Late MDS Transmission: The facility failed to timely complete and transmit MDS assessments for two residents after the assessments were signed as complete. The MDSC/RN said the delay occurred because another department’s assessment work had to be checked first, and if that department was late, the MDS submission was late as well.
MDS tobacco use coding was inaccurate for a resident with COPD who was observed stating they were going to smoke and was described by an RN as alert, oriented x3, and able to go to the smoking area independently. The resident had signed a smoking/vaping contract, was identified on a smoking safety screen as a smoker, and had a care plan focused on smoking, but the annual MDS was coded as no current tobacco use; the MDS/LPN said the smoking status was missed.
Failure to Document Fluid Restriction Non-Compliance: A resident with ESRD on dialysis had a 1000 ml/day fluid restriction, but the room contained multiple juices and water bottles, and the record did not document non-compliance with the restriction. The RN said the resident liked juices, milk, and coffee and that water was being given and entered on the eMAR, while the RD stated those fluids count toward the restriction and should be documented when the resident is non-compliant.
A resident who smoked and used a motorized wheelchair was observed going to the designated smoking area, but the area was covered with snow and ice around the walkway, table, and benches, and a fire extinguisher was also covered with snow. The resident, who had COPD and intact cognition, stated they had told administration the area was not safe and stayed near the doorway because the wheelchair could not maneuver through the slippery conditions. The RN had provided the vaping device, and cigarette butts were observed in the no-smoking area near the doorway.
A resident with an indwelling urinary catheter was observed in bed with the catheter bag lying on the floor outside the privacy bag while a roommate’s family member was present. The resident had obstructive/reflux uropathy, severe cognitive impairment, and an active order for catheter care every shift. Staff stated the bag should not be on the floor and should be covered for privacy and dignity.
Infection control was not followed during a wound treatment for a resident with moderate cognitive impairment and a sacral pressure ulcer. An LPN did not consistently perform hand hygiene for the required time, placed a pen on the clean treatment area, handled and stored used items and an open NS bottle without sanitizing them, did not sanitize the resident’s over-bed table before lunch, and placed the resident’s call device from the floor onto the resident’s chest without sanitizing it.
The facility failed to conduct regular pain assessments for a resident on palliative care, did not follow a physician's order for blood pressure monitoring before administering Losartan to another resident, and inaccurately documented the administration of Methadone for a cognitively impaired resident. These deficiencies highlight lapses in adherence to professional standards of practice and medication management.
The facility failed to assess and document vital signs and dialysis access site conditions for two residents returning from dialysis. One resident reported not being assessed promptly, and records lacked necessary documentation. Another resident's communication logs with the dialysis center were incomplete, missing vital information. The DON acknowledged these inconsistencies, which violated the facility's policy on dialysis care.
The facility failed to meet New Jersey's mandated staffing ratios, with deficiencies noted in CNA staffing on multiple day shifts. A resident was found with inadequate incontinence care due to the CNA's high workload, as observed by a surveyor. The DON acknowledged the staffing shortfall, which impacted resident care quality.
The facility failed to keep call bells within reach for two residents, both with severe cognitive impairments and requiring staff assistance. One resident's call bell was entangled with cords, and the other was similarly inaccessible. The CNA acknowledged the requirement but did not ensure compliance.
The facility failed to complete and transmit MDS assessments timely for two residents. One resident's Death in the Facility tracking discharge was 102 days overdue, and another resident's Discharge/Return Not Anticipated assessment was not completed within the required 14 days. The facility's policies did not adequately address these requirements.
The facility failed to accurately assess several residents' conditions in the MDS, leading to deficiencies. A resident's oral health issues, another's use of a hand splint, and a third's indwelling urinary catheter were not documented. Additionally, a resident with impaired cognition and a pressure ulcer was inaccurately assessed. These omissions indicate a lack of accurate documentation, crucial for ensuring appropriate care.
The facility failed to provide timely incontinence care to three residents, resulting in saturated briefs and strong odors. A resident was found with a saturated brief and pad, and the CNA admitted to providing care less frequently due to workload. Another resident was observed with a saturated brief and pad, and the CNA acknowledged the lack of recent care. A third resident was found in a similar condition, with the unit manager confirming the unacceptable state. Staffing issues contributed to the deficiency.
A facility failed to apply an orthopedic device as ordered for a resident with a right-hand contracture. The splint was observed on the over bed table instead of being applied during AM care, despite documentation indicating otherwise. Interviews confirmed that the documentation should have accurately reflected the splint's application.
Two residents in a facility were not administered oxygen therapy according to physician orders. One resident, with severe cognitive impairment, was observed with oxygen set at 1 LPM instead of the prescribed 2 LPM. Another resident, on palliative care, had their oxygen concentrator set at 1.5 LPM instead of 2 LPM. Staff confirmed the discrepancies and acknowledged the orders should have been followed.
A resident with chronic kidney disease and other conditions experienced a delay in treatment due to the facility's failure to promptly communicate an abnormal urine lab result to the physician. The lab report indicated a significant infection, but the resident was not evaluated and treated until four days later. The facility's policy required prompt notification of test results, which was not followed, leading to a delay in care.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide ordered respiratory care for multiple residents. One resident with diagnoses including pneumonia and acute respiratory failure had an order for oxygen via nasal cannula at 3 liters per minute continuously, but the surveyor observed the oxygen flow meter set at 0.5 liters per minute on one occasion and later at zero on another occasion, with the tubing connected but no oxygen flowing. The humidification bottle attached to the wall oxygen meter was also not dated as required by the physician's order and facility protocol. The RN confirmed the oxygen was not turned on at the prescribed rate and acknowledged that the humidification bottle should have been labeled with the start date. A second resident with COPD and obstructive sleep apnea had a CPAP machine at the bedside that the resident stated was used at night, but there was no physician's order for the CPAP machine and no care plan documentation addressing its use. Facility staff later obtained an order after the surveyor raised the concern, and the unit manager confirmed there had been no order in the record at the time of review. The resident's record did include notes indicating CPAP use at bedtime, but the ordered treatment had not been documented as a physician-directed therapy before survey inquiry. A third resident with diagnoses including osteomyelitis and shortness of breath was observed using a nasal cannula attached to a portable oxygen tank that was empty. The LPN replaced the tank after the surveyor pointed it out. The resident's record showed an order for oxygen at 2 liters per minute continuously every shift for shortness of breath, and nurses documented oxygen use each shift, but the surveyor found the portable tank empty during observation. Facility staff stated that oxygen tanks should be checked and full, and the facility policy reviewed by the surveyor did not address portable oxygen tank procedures.
Medication Administration Outside Ordered Parameters and Incomplete Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards for multiple residents by administering medications outside ordered parameters, failing to document required assessments at the time of administration, and allowing medication handling that was not supported by the record. For one resident with spinal stenosis, prior stroke, urinary tract infection, and moderate cognitive impairment, oxycodone 5 mg PRN was administered on two occasions even though the documented pain level was 0, and lidocaine 5% patches were applied without an order specifying when the patch should be removed or how long it should remain in place. The LPN confirmed the oxycodone was given despite the resident reporting no pain and stated the patch was removed in the evening without documentation of removal. For another resident with a compression fracture of the spine, humerus fracture, supraventricular tachycardia, and moderate cognitive impairment, metoprolol succinate was administered without documentation of blood pressure and heart rate at the time of administration. The same resident’s PRN oxycodone was documented with pain levels of 3, 2, and 0 even though the order allowed administration only for pain rated 4 through 7, and there was no additional documentation in the progress notes or MAR to support those administrations. Facility staff stated that vital signs and pain assessments should be documented in the MAR or progress notes, but the record reviewed did not contain those time-specific entries. A resident with anxiety disorder reported missing clonazepam doses and stated family brought medication from home after the nurse said no backup medication was available. The record showed clonazepam was not documented in the eMAR at the scheduled time, while the controlled drug record and later entries reflected handwritten and delayed documentation, including a dose signed after the surveyor’s inquiry. The DON stated one dose had been borrowed from another resident whose clonazepam had been discontinued, another dose came from family, and the facility did not have a policy for borrowing narcotics from one resident to another. For another resident with chronic pain syndrome, PRN Dilaudid and acetaminophen were documented with pain levels of 0 and 7, respectively, and the unit manager stated the system prompted nurses to enter pain levels, but the record showed PRN pain medication was given when the documented pain level did not match the order parameters.
Call Device Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure Resident #3’s call device was readily accessible. The resident, who had moderate cognitive impairment on the 11/19/25 significant change in status MDS assessment, no upper body limitations, and was at risk for falls, was observed in bed with the call device clipped to the sheet behind the head of the bed, with the cord hanging down behind the bed out of reach. On a later observation, the call device was again in the same position behind the bed. During a wound treatment observation, the call device was found on the floor under the resident’s bed for the entire 40-minute treatment, and at the end of the treatment the nurse picked it up and placed it on the resident’s chest. The nurse stated that call bells should always be accessible to the resident, and the Administrator and DON confirmed the call device should be in reach at all times. The facility’s Call Bell policy stated the call bell will be placed within the resident’s reach.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within the required timeframe for 2 of 35 residents reviewed. For Resident #19, the admission comprehensive MDS had an ARD of 1/17/26 and was dated and signed complete on 1/30/26, while the admission entry date was 1/11/26. For Resident #103, the admission MDS had an ARD of 12/17/25 and was dated and signed complete on 12/26/25, while the admission entry date was 12/11/25. During record review on 1/29/26, the surveyor identified that both admission comprehensive MDS assessments were completed more than 14 days after the residents’ admission dates. The RN/MDS coordinator stated that an admission comprehensive MDS assessment should be completed within 14 days of a resident’s admission entry and acknowledged that the identified MDS assessments were completed late. The facility later informed the surveyor, DON, and Regional DON of the concern, and no additional information was provided.
Late MDS Transmission
Penalty
Summary
The facility failed to complete and transmit MDS assessments in accordance with federal guidelines for 2 of 36 residents reviewed, identified as Resident #13 and Resident #18. The report states that the MDS is a federally mandated comprehensive assessment tool that must be electronically transmitted to the Quality Measure System within 14 days of completing the assessment. The deficiency was identified during interview and record review when the surveyor requested the final validation reports for the residents’ MDS transmissions. For Resident #13, the admission MDS had an ARD of 10/19/25, was signed as completed, but was not transmitted until 11/3/25. For Resident #18, the admission MDS had an ARD of 9/12/25, was signed as completed on 10/9/25, and was not transmitted until 10/13/25. The MDSC/RN stated the submissions were late because the facility needed to check whether another department had completed the assessment, and if that department was late, the MDS submission would also be late. The MDSC/RN also stated that the MDS should be completed within 14 days and submitted at least 21 days.
MDS Tobacco Use Coding Error
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for Resident #15, who was reviewed for MDS accuracy. During observation, the resident was seated in a motorized wheelchair and stated they would go down to smoke. An RN stated that the resident was alert and oriented x3 and could go by themselves to the smoking area. The resident’s admission record listed chronic obstructive pulmonary disease (COPD) among the diagnoses. Review of the annual MDS dated 9/19/25 showed a BIMS score of 15 out of 15, indicating intact cognition, but Section J - Current Tobacco Use was coded as 0. No. Additional records showed a Smoking/Vaping contract signed by the resident, a Smoking Safety Screen identifying the resident as a smoker, and a comprehensive care plan initiated with the focus that the resident is a smoker. The MDS/LPN stated she was aware the resident was smoking either vape or tobacco and said she must have missed coding the smoking status in the MDS assessment.
Failure to Document Fluid Restriction Non-Compliance
Penalty
Summary
The nursing facility failed to document non-compliance with a resident’s ordered fluid restriction. Resident #11 had diagnoses including end-stage renal disease and dependence on dialysis, and the annual MDS indicated intact cognition with a BIMS score of 15 and that the resident was receiving dialysis. The resident’s care plan identified a 1000 ml daily fluid restriction related to ESRD and included an intervention to monitor compliance daily and document all episodes of non-compliance. The order summary specified a 1000 ml/day restriction with allotted amounts for nursing and dietary intake, and the January 2026 eMAR showed total fluids documented by nursing that exceeded the 280 ml nursing allotment. During observation, the resident was off the unit at dialysis, and the room contained multiple beverages, including 8 unopened cups of cranberry juice, 4 empty cups, 5 unopened 500 ml bottles of water, 2 half-empty bottles of water, and one full 120 ml bottle of water. Review of the nursing progress notes found no documentation that the resident was receiving more than 1000 ml daily or that fluid restriction non-compliance occurred. The RN stated the resident liked juices, milk, and coffee and that water was being given and documented on the eMAR, while the RD stated that fluids such as coffee, milk, tea, juices, and soup count toward the restriction and that nurses should document non-compliance. The DON stated there was an incorrect documentation error for the January shifts but did not explain why non-compliance was not documented in the medical record.
Smoking Area Left Covered in Snow and Ice
Penalty
Summary
The facility failed to ensure the resident smoking area was free from accident hazards when snow and ice were left uncleared in the designated smoking area after a snowfall. On 1/29/26, a surveyor observed Resident #15, who was seated in a motorized wheelchair and stated they went to smoke at the first-floor back patio. The RN stated the resident was alert and oriented x3 and could go to the smoking area independently, and the RN gave the resident a vaping device. When the surveyor accompanied the resident to the back patio, the surveyor observed cigarette butts in front of the doorway in the no-smoking area. Resident #15 stated they had informed administration that it was not safe to go into the designated smoking area and that they stayed near the doorway because they could not maneuver the motorized wheelchair through the area due to a layer of snow and ice. The surveyor and team coordinator observed the smoking area was full of snow and ice around the walkway, on top of the table, and on two benches, and the fire extinguisher behind a bench was covered with snow. The resident’s record showed diagnoses including COPD, and the annual MDS dated 9/19/25 showed a BIMS score of 15 out of 15, indicating intact cognition. The care plan identified the resident as a smoker, and the facility’s Smoking Safety policy stated smoking and/or vaping is permitted only in the designated resident smoking area.
Indwelling Catheter Bag Left Outside Privacy Cover
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had the catheter bag kept inside a privacy bag for dignity. Resident #18 was observed in bed asleep with yellowish urine draining from the catheter bag, which was lying on the floor outside the privacy bag. The surveyor observed this condition while a family member of the roommate was inside the room, and the catheter bag remained on the floor during a later observation the same morning after an LPN had entered the room to administer medication. Resident #18’s record showed diagnoses including obstructive and reflux uropathy, a quarterly MDS dated 12/13/25 with a BIMS score of 7 indicating severe cognitive impairment, and an active order for indwelling catheter care every shift. The care plan addressed the resident’s indwelling catheter due to obstructive uropathy. Facility staff interviewed by the surveyor stated that the catheter should not be touching the floor and should be inside the privacy bag, and that the bag should be covered for privacy and dignity because a family member was visiting the roommate.
Infection Control Breaks During Wound Treatment
Penalty
Summary
The facility failed to provide services in a manner to prevent or limit the spread of infection during a wound treatment observation for a resident with moderate cognitive impairment and a sacral pressure ulcer. The resident’s record showed a significant change MDS assessment dated 11/19/25 indicating moderate cognitive impairment with a brief interview for mental status score of 8 and one pressure ulcer. A physician’s order dated 1/22/26 directed application of Santyl ointment to the sacrum after cleansing with normal saline, packing with calcium alginate, and covering with a dry dressing. During observation of the full-thickness sacral pressure ulcer treatment, the LPN washed hands 8 times but did not consistently follow the facility’s handwashing technique, including lathering for the required 20 seconds; observed lathering times were 15, 13, 11, 10, 10, 7 seconds, and one instance of placing hands under running water immediately after applying soap. The LPN removed a pen from a uniform pocket, dated a bottle of normal saline and the cover dressing, and placed the pen on the clean drape with treatment supplies. After the treatment, the used pen, scissors, and open normal saline bottle were placed on the resident’s over-bed table and then on the treatment cart; the unsanitized pen was returned to the uniform pocket and the unsanitized normal saline bottle was returned to the treatment cart. The LPN did not sanitize the resident’s over-bed table before lunch was to be served, and when the resident’s call device was found on the floor, it was picked up and placed on the resident’s chest without sanitizing it.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in pain management for Resident #14. The resident, who was on palliative care due to a poor prognosis, had a history of chronic pain related to a non-healing right hip surgical wound, impaired mobility, and diabetic neuropathy. Despite the care plan indicating the need for regular pain assessments, the facility did not conduct these assessments every shift as required. The Unit Manager acknowledged the inconsistency in pain level documentation, which did not reflect assessments done every shift, as confirmed by the Director of Nursing. In another instance, the facility did not follow a physician's order for Resident #131 regarding the administration of Losartan, a medication for hypertension. The Registered Nurse (RN) failed to take the resident's systolic blood pressure immediately prior to administering the medication, as required by the physician's order. The RN admitted to taking the blood pressure earlier but not immediately before the medication administration, which is a deviation from the prescribed protocol. Additionally, there was a discrepancy in the administration of Methadone for Resident #367. The RN signed the Individual Patient's Controlled Drug Record (IPCDR) indicating the medication was administered, but it was not given to the resident. The resident, who was cognitively impaired, reported having pain every day and believed she had taken her Methadone that morning. The RN later acknowledged the error and administered the medication after the surveyor's intervention. The facility's records, including the electronic Medication Administration Record (eMAR), did not accurately reflect the administration of the medication, highlighting a failure in medication management and documentation.
Inadequate Post-Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for two residents, as observed by surveyors. Resident #90, who is cognitively intact and has renal disease, reported not being assessed promptly upon returning from dialysis appointments. The facility's electronic medical records lacked documentation of vital signs and assessments of the resident's dialysis access site, as confirmed by the Unit Manager and Director of Nursing. Resident #134, also cognitively intact and diagnosed with end-stage renal disease and congestive heart failure, was observed to have incomplete post-dialysis assessments. The facility's communication logs with the dialysis center were often left blank, missing critical information such as pre- and post-dialysis weights and treatment complications. The facility staff documented the AV fistula assessment but failed to record vital signs consistently after the resident's return from dialysis. The Director of Nursing acknowledged the inconsistencies in documentation and assessment practices. The facility's policy on end-stage renal disease care requires thorough documentation of dialysis-related care and communication between the facility and the dialysis center, which was not adhered to in these cases.
Deficient Staffing Ratios and Resident Care in LTC Facility
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. Specifically, the facility was deficient in Certified Nurse Aide (CNA) staffing for residents on 13 of 14 day shifts during the two weeks prior to the standard survey conducted on October 10, 2024. The staffing levels were consistently below the required ratios, with instances such as having only 18 CNAs for 170 residents when at least 21 were required. Similar deficiencies were noted during the week of complaint investigations from May 5, 2024, to May 11, 2024, where the facility was deficient in CNA staffing on 5 of 7 day shifts. The deficiency in staffing ratios was further evidenced by the care provided to a resident observed on October 1, 2024. The resident was found in bed on a specialty mattress with a strong unpleasant odor in the room. The CNA assigned to the resident's care had 10 residents on her assignment and stated that she could only provide incontinence care twice during her shift due to time constraints. Upon inspection, the resident's incontinence brief and absorbency pad were saturated with urine, indicating inadequate care due to insufficient staffing. The Director of Nursing (DON) acknowledged that despite the number of residents assigned to CNAs, incontinence care should be provided every two hours on the day shift. The report highlights the facility's failure to meet the mandated staffing requirements, which directly impacted the quality of care provided to the residents, as evidenced by the observations and interviews conducted by the surveyor.
Failure to Maintain Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, as observed by surveyors for two residents. Resident #59 was found in bed with a call bell that was intertwined with their roommate's call bell cord and entangled in bed electrical cords, making it unreachable. This resident had a history of hemiplegia, hemiparesis, dysphagia, and severe cognitive impairment, requiring staff assistance for personal hygiene and being non-verbal. The resident's care plan specifically included the intervention to keep the call light within reach, which was not adhered to. Similarly, Resident #127 was observed with a call bell that was also intertwined with their roommate's call bell and twisted in bed electrical cords, rendering it inaccessible. This resident had diagnoses of dementia, insomnia, and dysphagia, with a severe cognitive impairment indicated by a BIMS score of 3 out of 15. The resident required supervision and contact guard from staff for transfers and toileting, and their care plan included encouraging the use of the call bell for assistance. The CNA responsible for these residents acknowledged the requirement to keep call bells within reach but could not explain why this was not done.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to adhere to federal guidelines for the timely completion and transmission of the Minimum Data Set (MDS) assessments for two residents. Resident #144, who was admitted with diagnoses including heart failure, passed away in the facility. However, the required Death in the Facility tracking discharge was not completed and was found to be 102 days overdue. The MDS-Director confirmed that the facility had 14 days to submit this tracking, but it was not started within the required timeframe. The facility's policy on Resident Assessment Instrument (RAI) indicated that assessments should be conducted within 14 days of admission, upon significant changes, quarterly, and annually, but this was not followed in this case. Similarly, Resident #54 was discharged to home and was not expected to return. The MDS Discharge/Return Not Anticipated assessment for this resident was not completed within the required 14 days post-discharge. The RN Assessment Coordinator acknowledged that the assessment was late. The facility's policies did not specifically address discharge assessments, although the RN Assessment Coordinator stated that the facility follows the RAI 3.0 guidelines. These oversights were discussed with the survey team, the Licensed Nursing Home Administrator, the Regional Nurse, and the DON.
Inaccurate MDS Assessments Lead to Deficiencies
Penalty
Summary
The facility failed to accurately assess several residents' conditions in the Minimum Data Set (MDS) assessment tool, leading to deficiencies in care. Resident #88 was observed with multiple broken and missing teeth, which were noted in a Speech Therapy evaluation but not recorded in the Admission MDS assessment. Resident #77 had a physician's order for a hand splint, but the use of the splint was not documented in the Annual MDS assessment. Resident #129 was admitted with an indwelling urinary catheter, but this was not identified in the Admission MDS assessment. These omissions indicate a lack of accurate documentation in the MDS, which is crucial for ensuring appropriate care. Additionally, Resident #25, who had a severely impaired cognition and an unstageable pressure ulcer, was inaccurately assessed in the MDS. The Admission MDS incorrectly documented the presence of a deep tissue injury upon admission, which was not the case. The RN/MDS Director confirmed the inaccuracies upon review with the surveyor. The facility's policy requires all personnel completing any portion of the MDS to certify its accuracy, yet these errors were present, highlighting a significant lapse in the assessment process.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to three residents, leading to saturated incontinence briefs and unpleasant odors in their rooms. Resident #59 was observed in bed with a strong odor, and upon examination, their incontinence brief and pad were found to be saturated with urine. The CNA assigned to Resident #59 admitted to providing incontinence care less frequently than required due to a heavy workload. Resident #59's care plan indicated a need for incontinence care every two hours, which was not adhered to. Similarly, Resident #82 was found with a saturated incontinence brief and pad, emitting a strong urine odor. The CNA acknowledged that the resident had not received recent incontinence care, as evidenced by the extent of saturation. Resident #82's care plan required extensive assistance for personal hygiene, which was not provided. The resident's cognitive impairments and dependency on staff for personal hygiene were documented in their records. Resident #29 was also observed with a saturated incontinence brief, gown, and bed pad, indicating a lack of timely care. The unit manager confirmed the unacceptable condition of the resident. The facility's policy required residents to be cleaned after each episode of incontinence, which was not followed. The deficiency was further compounded by staffing issues, as one CNA left their shift early, leaving only one CNA to care for residents during a critical time.
Failure to Apply Orthopedic Device as Ordered
Penalty
Summary
The facility failed to consistently follow a physician's order for the application of an orthopedic device for a resident with a right-hand contracture. The surveyor observed that the blue hand splint, which was supposed to be placed on the resident during AM care and removed during PM care, was left on the over bed table instead of being applied to the resident. This observation was made twice on the same day, once at 11:19 AM and again at 1:03 PM, indicating that the splint was not applied as per the physician's order. The electronic medical record showed a physician's order dated 4/26/24 for the application of a right-hand roll with wrist support during AM care. However, the Treatment Administration Record (TAR) for 10/1/24 inaccurately indicated that the splint was placed during AM care and removed during PM care, despite the surveyor's observations to the contrary. Interviews with the nursing Unit Manager and the Regional Registered Nurse confirmed that the documentation should have reflected the actual application of the splint, which was not done in this case.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for two residents, leading to a deficiency. Resident #29 was observed on multiple occasions with the oxygen tank set at 1 liter per minute (LPM) instead of the prescribed 2 LPM. The resident, who has severe cognitive impairment and a history of Alzheimer's disease, acute kidney failure, psychosis, and major depressive disorder, was non-responsive during these observations. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the discrepancy and acknowledged that the physician's order for 2 LPM should have been followed. Similarly, Resident #136 was observed with an oxygen concentrator set at 1.5 LPM instead of the prescribed 2 LPM. This resident, who is on palliative care and has a history of altered respiratory status, was also non-responsive during the surveyor's observations. The Licensed Practical Nurse (LPN) assigned to the resident confirmed the incorrect setting and acknowledged the need to adhere to the physician's order. The resident's medical record indicated a requirement for continuous oxygen therapy at 2 LPM, which was not being met. The facility's policy for oxygen administration, revised in May 2024, outlines guidelines for safe oxygen administration, which were not followed in these instances. Both residents had documented physician orders for oxygen therapy that were not adhered to, resulting in a failure to provide the prescribed level of care. The surveyor's observations and interviews with facility staff highlighted these deficiencies in the administration of oxygen therapy.
Delayed Communication and Treatment of Abnormal Urine Lab Result
Penalty
Summary
The facility failed to ensure timely communication and treatment of an abnormal urine lab result for a resident with chronic kidney disease, heart failure, and hyperparathyroidism. The resident, who had severely impaired cognition and occasional incontinence, was not monitored for signs and symptoms of a urinary tract infection (UTI) as part of their care plan. A urinalysis and culture were ordered, and the preliminary report indicated a significant infection, but there was a delay in notifying the physician and initiating treatment. The abnormal urine lab report, which showed a high colony count of Pseudomonas Aeruginosa, was available on December 2, 2023, but the resident was not evaluated and treated until December 6, 2023. The Licensed Practical Nurse/Infection Preventionist stated that abnormal labs should be reported to the physician and documented in the electronic medical record, but there was no evidence that this was done. The Licensed Practical Nurse/Unit Manager was unable to provide documentation of communication with the physician regarding the lab results. The Nurse Practitioner involved stated that it was not acceptable for the resident to go untreated for four days after the lab results were available, but noted that the timing of the infectious disease prescriber's evaluation was beyond their control. The facility's policy required prompt notification of test results to attending physicians, but this was not adhered to in this case, leading to a delay in the resident receiving appropriate care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,279 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lincoln Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Park Care Center | 0.1 mi | ★★★★★ | 44 | 1 |
| Atrium Post Acute Care Of Wayneview | 2.8 mi | ★★★★★ | 1 | 0 |
| Careone At Wayne | 3.4 mi | ★★★★★ | 8 | 0 |
| Atrium Post Acute Care Of Wayne | 3.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At West Caldwell Llc | 4.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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