Lincoln Park Manor Inc

Inspectors wroteThe facility identified a census of 34 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff followed appropriate Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and hand hygiene while providing wound care to Resident (R) 38 and R2. The facility failed to ensure R10's nasal cannula (NC- a hollow tube medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was properly stored when not in use. This placed R38, R2, and R10 at risk of infection development and possible respiratory complications.

Inspectors wroteThe facility had a census of 34 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility pharmacist consultant failed to provide the facility with a monthly Drug Regimen Review for February 2025, which placed all residents who received prescribed medications from the facility at risk for less supervision regarding their medication regimen. [...]

Inspectors wroteThe facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure medications were secure when a medication cart was left unlocked and unattended, failed to label and date insulin (a hormone that lowers the level of glucose in the blood) pens when opened, and failed to remove expired medication from use. This deficient practice placed residents at risk of receiving ineffective medication.

Inspectors wroteThe facility had a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R)1 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. This placed R1 at risk for improper use of medications and related side effects.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 24's medical record. This placed this resident at risk for impaired right to confidentiality.

Inspectors wroteThe facility had a census of 34 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 10's as needed (PRN) Ativan (an antianxiety medication class of medication that calms and relaxes people). The facility failed to ensure an appropriate indication for R17's Seroquel (an antipsychotic) and failed to document a physician's rationale and the risks versus benefits for the Seroquel use. The facility further failed to obtain a gradual dose reduction (GDR) for R6. This placed the residents at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38's care plan was revised with interventions to reflect his current level of staff assistance her required after a recent hospital stay and on hospice care. The facility failed to update R2's care plan with interventions related to the need for enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). This placed R38 and R2 at risk for delayed or missed care.

Inspectors wroteThe facility had a census of 34 residents. The sample included 13 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Resident (R) 10 when staff failed to store their oxygen tubing and cannula (a medical device used to deliver supplemental oxygen through the nostril) and nebulizer (a medical device that converts liquid medication into a fine mist, allowing it to be inhaled into the lungs) mask in a sanitary manner when not in use. This placed the resident at risk for an infection.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents, with two residents sampled for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 2 and R38's hospice provider and the facility which included the information on what hospice would provide the residents. This placed R2 and R38 at risk of inadequate end-of-life care.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the 32 residents who received their meals from the facility's kitchens when staff stored uncovered hamburger in two freezers. Kitchen staff failed to defrost the chest freezer and clean the outside of a chest and upright freezer. Kitchen staff failed to ensure the dishwasher sanitizing test strips were still effective. This placed the 32 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 32 residents. Based on observation, interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to include two sampled residents, Resident (R) 1 and R14, in the development and planning of the residents' care plan. This placed the residents at risk of impaired care and decreased autonomy.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had a physician's order and was assessed for the ability to safely self-administer medications left at the bed side. This placed R1 at risk for improper use of medication and related side effects.

Inspectors wroteThe facility had census of 32 residents. The sample included 14 residents with one reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a written notice for a facility-initiated transfer to Resident (R32) or her representative within a practicable time when R32 was transferred to the hospital. This placed the resident at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on record review and interview, the facility failed to provide Resident (R)32 or his representative with written information regarding the facility bed hold policy when R32 was transferred to the hospital. This placed R32 at risk for not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 30 to include the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for risperidone (antipsychotic medication) for staff direction to monitor for side effects from the antipsychotic medication. This placed the residents at risk due to uncommunicated care needs and adverse side effects.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with five reviewed for falls, Based on observation, record review, and interview, the facility failed to evaluate effectiveness of fall interventions and change or modify the interventions which were ineffective at preventing falls for Resident (R) 19. This placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents with one reviewed for hydration. Based on observation, record review, and interview, the facility nursing staff failed to consistently monitor Resident (R) 32's fluid intake related to a physician-ordered fluid restriction. This placed R32 at risk for fluid overload.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported that Resident (R) 26's as needed (PRN) Xanax (a sedative used for anxiety and panic disorder) lacked a 14-day stop date or specified duration which included a physician rationale. This placed the resident at risk for inappropriate use of medications.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify Resident (R) 30's allergy medication, Benadryl, with psychotropic (alters mood or thoughts) properties being used to treat anxiety and failed to apply the required 14-day stop date or obtain a specified duration for use with a physician rationale as required for as needed (PRN) psychotropic medications. The facility further failed to ensure an appropriate indication for R30's risperidone (an antipsychotic) or the required physician documentation and failed to ensure R30's PRN lorazepam (an antianxiety medication) had a physician's rationale for the extended use. [...]

Inspectors wroteThe facility had a census of 32 residents. The sample had 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed ensure a medications error rate of less than five percent (%) when staff incorrectly administered medications to Resident (R)1. This placed the resident at risk for improper use of medication and related side effects and resulted in a medication error rate of 27 %.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attended to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 26. This placed R26 at risk for inappropriate and/or unmet end of life cares.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents with one reviewed for bladder and bowel incontinence. Based on observation, record review, and interview, the facility staff failed exercise appropriate hand hygiene when providing Resident (R)31 incontinent and catheter (tube inserted directly into the bladder to drain urine) cares. This placed the resident at risk for infection.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents reviewed for care plan. Based on observation, interview and record review, the facility failed to revise and update Resident (R)29, R22, R30 and R31s' care plan with interventions aimed to prevent falls and fall related injuries. This placed the residents at risk for ineffective care and monitoring.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to complete a root cause analysis to identify causative factors and failed to implement meaningful, resident centered interventions for five sampled residents, Resident (R) 22, R30, R31, and R29, who were at risk and had falls. This placed the residents at increased risk for falls and fall related injury.

Inspectors wroteThe facility identified a census of 32 residents. Based on observation, record review and interview, the facility failed to ensure staff followed infection control standard of practice. The facility failed to practice proper hand hygiene while serving residents their meals in the dining room. The facility failed to provide a clean barrier under the glucometer (instrument used to calculate blood glucose) while obtaining blood glucose reading. The facility failed to ensure staff sanitized the facility glucometer after each use. The facility failed to properly store the scoop for the ice chest in a sanitary manner. This placed the residents at risk for increased infection and transmission of communicable disease.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents, with four reviewed for neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)22 remained free from neglect when staff failed to provide the necessary care and services during a transfer as directed by R22's plan of care. This deficient practice placed R22 at risk for injury and impaired physical and psychosocial well-being.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility staff failed to report an injury of unknown origin to administration staff for one sampled resident, Resident (R) 30, who had a bruise with swelling on top of her forehead. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury of unknown origin for one sampled resident, Resident (R) 30, who had a bruise with swelling on top of her forehead. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents. One resident (R)9 was reviewed for transfer and discharge. Based on record review and interview, the facility failed to provide written notice of discharge when R9 was discharged to an acute care facility.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents, with one reviewed for change of condition. Based on observation, record review, and interview, the facility failed to follow up with care in a timely period consistent with standards of nursing care after Resident (R) 31 developed increased weakness in her right arm. This placed R31, who had a history of a stroke at increased risk for physical decline and delay in treatment.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents. Based on observations, record review and interview, the facility failed to ensure resident (R)9 and R4's oxygen (O2) tubing was dated and stored in a plastic bag when not in use. This deficient practice left R9 and R4 at risk for respiratory complication and increased risk for bacteria formation.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility's failed to ensure the Consultant Pharmacist (CP)followed up with monthly with recommendations to change R31's inappropriate diagnosis for the Seroquel (antipsychotic medication) [medication used to treat psychosis and other mental emotional conditions]). The facility further failed to ensure staff followed up on the CP recommendation from June 2021. This deficient practice placed R31 at risk for adverse side effects related to antipsychotic use.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents, with five residents' reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one sampled resident, Resident (R) 31, who had a history of constipation (difficulty in emptying the bowels) This placed the resident at risk for complications related to constipation.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 31's Seroquel (antipsychotic medication [medication used to treat psychosis and other mental emotional conditions]). placing R31 at risk for adverse side effects.