Lincoln Park Care Center

Inspectors wroteBased on interviews, review of medical records, and review of other pertinent facility documents on 3/19/2026 and 3/24/2026, it was determined that the facility failed to maintain a safe environment to ensure adequate supervision to prevent the elopement of a resident (Resident #2). Resident #2, who was noted to exhibit in the presence of staff exit seeking behavior, was transferred to a secure unit on 03/04/2026. Resident #2 also had a Wander Guard in place since admission to the facility since 2024. This device would initiate an alarm and alert staff in the event of an attempt to leave the secured unit. This deficient practice was identified for 1 of 3 (Resident #2) reviewed for elopement. During the survey a finding that constituted an Immediate Jeopardy (IJ) was identified under CFR 483.12(a) (1) for F689. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to prepare resident meals in the proper consistency for 3 of 6 residents (Resident #53, #224, and #326) reviewed on a modified diet during dining observation. This deficient practice was evidenced by the following: 1. On 12/8/25 at 12:17 PM, the surveyor observed Resident #53 in the 2nd floor dining room. Certified Nursing Assistant (CNA#1) provided Resident #53 with their lunch tray. The surveyor observed the resident received whole French fries. Surveyor interviewed CNA#1, who stated Resident #53's diet is chopped consistency. CNA#1 cut Resident #53's French fries to the chopped consistency prior to eating. On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 5 of 5 residents (Resident #53, #134, #224, #326 and #501) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 12/8/25 at 12:17 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #53's tray, per the tray ticket, Resident #53 was supposed to receive an egg salad sandwich, 1/2 cup fortified mashed potatoes and 4 ounces (oz) sherbet, all three items were missing from the resident's tray. On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. On 12/04/25 at 9:24 AM, the surveyor in the presence of the Food Service Director observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed dietary aide (DA#1) and the Chef both wearing hooped earrings. DA#1 stated hooped earrings are ok as long as they do not hang down to your shoulders.2. In the walk-in freezer, the surveyor observed multiple items stored higher than 18 inches from the ceiling and a full tray of meatloaf labeled with a use by date of 12/2/25. Per the FSD the meatloaf was mislabeled and the 12/2/25 date was when the item was placed into the freezer and was not the use by date but would dispose of the meatloaf due to the mislabeling. 3. [...]

Inspectors wroteBased on observation, interviews, and review of facility policies, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. This deficient practice was observed and evidenced by the following:On 12/4/25 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area and found the following: There was garbage debris that included carboard, food wrappers, food containers, cups, gloves, paper products, plastic bottles, medication cups, and around the dumpster and surrounding areas. The FSD stated the maintenance department should have cleaned the area. On 12/4/25 at 1:24 PM, the FSD provided the surveyor with a facility policy titled, Refuse Receptacle/Dumpster Use with a revised date of December 2008. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 8 of the 35 residents (Resident #3, 6, 9, 13, 135, 209, 365, and #481) reviewed for reasonable accommodations of needs/preference. The deficient practices were evidenced by the following: 1. On 12/8/25 at 7:30 AM, the surveyor observed Resident #135 in bed. The surveyor observed that the call bell was wrapped around the light, on the wall above the bed, which was not within the resident's reach. A review of Resident #135's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and schizophrenia (a brain disorder that disrupts how a person thinks, behaves, and feels, leading to a distorted perception of reality). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment for residents on 4 of 13 units and was evidenced by the following. On 12/10/25 at 9:10 AM, the surveyor knocked on the door of room W218 and asked Resident #11 if he could inspect their bathroom. The surveyor entered the bathroom in W218 and observed approximately a 7-foot white trim molding, one urinal, and one bucket inside the bathtub. The bathtub which contained staining in the front near the faucet. On 12/10/25 at 11:30 AM, the surveyor showed the picture of the bathroom to the Licensed Nursing Home Administrator who stated that those items should not be inside the bathtub and that he was going to the room and have the items removed. The surveyor toured Unit 3 [NAME] on 12/04/2025 at 11:30 AM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed (a).to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 of 34 residents (Resident#7 and Resident #11) observed during the medication review and 1of 6 residents (Resident #584) observed during medication administration and b) accurate reconciliation and administration of narcotic medication with potential for drug diversion. Repeat deficiency The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a communication device for Resident #468 identified with a language barrier. This deficient practice was identified for one (1) of six (6) residents (Resident #468) observed during the medication administration and was evidenced by the following: Reference: According to the manufacturer's specifications for Breo Ellipta (fluticasone furoate and vilanterol trifenatate powder) section 2.3 Administration Information: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth, and the throat). [...]

Inspectors wroteComplaint #2561471 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 5 residents (Resident #302, #320, and # 275) observed for incontinence care on 1 of 2 units (3rd-floor North Nursing Unit). This deficient practice was evidenced by the following:On 12/8/25 at 7:30 AM, the surveyor completed an incontinence tour on the 3rd floor Nursing Unit and observed the following: 1. On 12/8/25 at 8:06 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA) observed Resident #302 in bed. The CNA exposed Resident #302's incontinence brief, and the surveyor observed that it was saturated with urine. The CNA confirmed that the brief was saturated with urine. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review, and review of facility policies it was determined that the facility failed to clarify the medication route for a resident from the Consultant Pharmacist (CP) monthly medication review for 1 of 6 Residents, (Resident #425). The deficient practice was evidenced by the following:On 12/4/25 at 11:19 AM, the surveyor observed Resident #425 in their bed with their eyes closed. The surveyor observed an enteral feeding machine (delivers liquid nutrition through a flexible tube directly into the stomach or small intestine) and enteral feeding (TF) products at bedside. On 12/4/25 at 11:45 AM, the surveyor reviewed Resident #425's electronic medical record (e-MAR) which revealed the following: [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 12/9/25, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of six (6) residents, (Resident #318 and #399), that were administered medications by two (2) of six (6) nurses that were observed. The deficient practices were evidenced by the following:1). On 12/09/25 at 8:40 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) entered the room of Resident #399. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 13 medication carts and 2 of 4 medication room refrigerators inspected. This deficient practice was evidenced by the following: a). On 12/11/25 at 10:15 AM, the surveyor inspected the 2nd floor east wing high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened multi-dose vial of Fluphenazine Decanoate 25 mg/ml (anti-psychotic) that had an opened date of 10/31/25 and was expired. At that time, the surveyor interviewed LPN#1 who acknowledge that the Fluphenazine Decanoate multi-dose vial once opened had a 28-day expiration date and that it was expired and should have been removed from active medication. b). [...]

Inspectors wroteBased on observations, interviews, record reviews, and other facility documentation, it was determined that the facility failed to follow infection control procedures on 3 of 3 nursing units. This deficient practice was identified with 5 of 13 staff members not wearing required personal protective equipment (PPE). On 12/4/25 at 10:50 AM, the surveyor conducted the initial tour of the JDT building. Per the Unit Manager (UM), the JDT building was having a Covid outbreak and surgical masks must be worn in common area such as the hallways, nursing station and non-Covid positive rooms. Currently Residents #1 and 2 were Covid positive. On 12/4/25 at 10:51 AM, the surveyor observed a laundry employee on the first floor unit without a surgical mask. The surveyor interviewed with housekeeper, who revealed they were unaware a surgical mask was required to be worn in the JDT building. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined the facility failed to a.) follow appropriate infection control practices and perform appropriate hand hygiene as indicated during meal service observation in 2 of 12 units (first floor JDT and 2 East) for 2 of 4 staff observed during meal service and, b.) follow appropriate infection control practices and perform hand hygiene as indicated for 1 of 1 Resident (Resident #139) observed during tracheostomy care. This deficient practice was evidenced by the following: A review of the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure an antipsychotic medication was administered in accordance with professional standards of clinical practice to Resident #112 who had episodes of auditory hallucinations. This deficient practice was observed for one (1) of four (4) nurses who administered to one (1) of six (6) residents during the medication administration observation and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) a refrigerator that contained prescription medications was lockable, b.) disposition (destruction) and reconciliation of controlled dangerous substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) was removed from active inventory when Unsampled Resident # 399 was discharged from the facility, c.) against borrowing medications from other residents to administer to a newly admitted resident (Unsampled Resident #1073), d.) a discontinued medication for Unsampled Resident #359 was removed from active inventory, and e.) a biological supply that required dating was dated. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure Resident #114 was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for one (1) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 2/13/23, included the following. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown . [...]

Inspectors wrote2. On 7/18/22 at 2:07 PM, the surveyor interviewed Resident #484. Resident #484 was seated in a wheelchair in their room. Resident #484 was pleasant and eager to speak with the surveyor. Review of Resident #484's Face Sheet (an admission summary) reflected that Resident #484 was admitted to the facility with diagnoses that included but were not limited to essential (primary) hypertension, Schizophrenia, and acquired absence of left leg below knee. The Quarterly MDS dated [DATE], revealed a BIMS score of 10 out of 15 which indicated that the resident's cognition was moderately impaired. Review of the resident's May, June, and July 2022 MAR revealed a physician's order dated 6/21/18 for Amlodipine 5 mg daily for hypertension (hold for blood pressure (BP) less than 120). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to: 1. maintain ongoing complete communication notes between the facility and the dialysis center and 2. maintain an assessment of a resident's condition and monitoring for complications upon return from dialysis. This deficient practice was identified for 3 of 4 residents reviewed for dialysis, Residents #138, #108 and #135). The deficient practice was evidenced by the following: 1. On 7/18/22 at 11:46 AM, the surveyor observed Resident #138 was not in their room. The unit's Assistant Director of Nursing (ADON) informed the surveyor that the resident was at hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) and had dialysis sessions every Monday, Wednesday, and Friday. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide access to a call bell for a 3-week period for 1 of 35 residents (Resident #320) reviewed. The evidence for the deficient practice is as follows: On 7/18/22 at 11:57 AM, the surveyor knocked on the door to room two South-206 window. Resident #320, in the window bed of the three bedded room, called out loudly come in. During the interview between the surveyor and the resident, Resident #320 stated they had no call bell access since moving to the room. The resident stated that they call out when needing assistance from staff. The resident stated staff routinely responded to their verbal calls for assistance. The surveyor was unable to locate a call bell in the vicinity of the resident's bed. On 7/19/22 at 1:30 PM, the surveyor again visited the resident in their room. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide full visual privacy when providing personal care for, 1 of 35 residents, Resident #247. The deficient practice was evidenced by the following: On 7/19/22 at 10:51 AM, the surveyor observed from hallway, standing outside the resident's room door, a Certified Nursing Assistant (CNA) providing hygiene care to Resident #247. The door to the room was open and the privacy curtain between Resident #247's bed and the room door was partially pulled back. Resident #247 could be seen lying in the bed from the hallway exposed from abdomen to feet. The resident was not covered with a blanket and their gown was pulled up to their abdomen. The surveyor observed the CNA providing hygiene care and changing the resident's incontinent brief. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 2 residents reviewed for hospice care, Resident #85 as evidenced by the following: According to the Resident Assessment Instrument (RAI) Manual Version 3.0 of CMS guidelines, updated October 2019 under Chapter 2 page 23, included that, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provide) or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide wound care in a manner that would decrease the possibility of the wound deteriorating. This was found with 1 of 4 residents reviewed for wound care, Resident # 9. The deficient practice was evidenced by the following: On 7/19/22 at 1:24 PM, the surveyor observed the resident in bed awake, the resident asked for food after trying for a few minutes to formulate the question. The resident was on a pressure relieving mattress. The resident was under a sheet and their legs appeared contracted. The resident was clean. The surveyor was able to visualize booties on the residents feet under the sheet. The resident was laying on their back. On 7/21/22 at 10:56 AM, the surveyor observed the resident in bed with eyes closed. The resident was clean and appeared comfortable. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide indwelling catheter care in a manner to reduce the spread of infection. The deficient practice was identified for 1 of 4 residents (Resident #120) reviewed for urinary catheters and evidenced by the following: On 07/18/22 at 12:07 PM, the surveyor observed Resident #120 awake in bed. The resident's indwelling urinary drainage collection bag was hanging from the bed frame. On 07/19/22 at 10:44 AM, the surveyor observed the resident seated at the bedside in a wheelchair. The surveyor inspected the resident's bathroom. A blue privacy bag was hung from the hand-rail next to the toilet. A used large urinary drainage collection bag was stored in the privacy bag. The tubing of bag was uncapped and open to air. [...]

Inspectors wroteBased on observation, interview, and review of facility records, it was determined that the facility failed to ensure that a resident's low oxygen saturation (the amount of oxygen circulating in the blood) was responded to appropriately for 1 of 2 residents (Resident #159) reviewed for respiratory care. This deficient practice was evidenced by the following: On 7/19/22 at 1:20 PM, the surveyor observed Resident #159 awake in bed and observed that the resident was wearing a nasal cannula (a device to provide supplemental oxygen therapy) attached to an oxygen concentrator. The surveyor observed that the flow rate on the oxygen concentrator was set to two liters per minute (LPM). At the same time the surveyor interviewed Resident #159. Resident #159 stated that they always wear the oxygen and that ordinarily the flow rate is set to 2 LPM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that 1.) the Consultant Pharmacist failed to identify the need for routine pain management medication review for 1 of 38 residents reviewed, Resident #108, and 2.) the facility failed to respond to the Consultant Pharmacist recommendations for 2 of 38 residents reviewed, Resident #211 and Resident #484. The deficient practice was evidenced by the following: 1. On [DATE] at 10:30 AM, the surveyor interviewed Resident #108 in the resident's room. The resident informed the surveyor that they attend dialysis on Tuesday, Thursday, and Saturday each week. Resident #108 informed the surveyor that due to a previous fall prior to their facility admission and arthritis, they suffer from regular knee pain. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly store medications meant to be refrigerated in 2 of 13 medication carts inspected. The deficient practice is evidenced by the following: 1. On 7/26/22 at 9:41 AM, the surveyor inspected the 3rd floor JDT high side medication cart in the presence of Licensed Practical Nurse (LPN) #1. The surveyor observed a bag labeled Refrigerate. Inside the bag, the surveyor observed a Frivanq (an antibiotic used to treat infections) Solution 50 milligrams/ milliliter bottle labeled, Must Be Refrigerated. The surveyor observed that the Firvanq bottle felt room temperature. At that time, the surveyor interviewed LPN #1 who stated that her shift started at 7 AM and that she did not take the Firvanq out of the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident # 9) reviewed for hospice/end of life care. The deficient practice was evidenced by the following: On 7/19/22 at 1:24 PM, the surveyor observed Resident # 9 in bed and awake. The resident asked for food after trying for a few minutes to formulate the question. The resident was on a pressure relieving mattress. The resident was under a sheet. The resident was clean. On 7/20/22 at 9:15 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) who was assigned to the resident. [...]

Inspectors wroteBased on interview and review of the medical record, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy upon transfer to the hospital for 4 of 4 residents (Resident #50, # 135, #467, # 479) reviewed for hospitalizations. The deficient practice was evidenced by the following: 1. On 7/25/22 at 1:32 PM, the surveyor reviewed the medical record of Resident # 50 which revealed the following: A New Jersey Universal Transfer Form (NJUTF) indicated the resident was sent to the hospital on 5/12/22 at 8:55 AM due to a change in speech and an asymmetrical smile. A Nurses Note dated 5/14/22 indicated the resident was re-admitted to the facility on that day. 2. On 7/25/22 at 10:00 AM, the surveyor reviewed the medical record of Resident # 135 which revealed the following: [...]