Lincoln Park Renaissance

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide ordered respiratory care consistent with professional standards of practice. This deficient practice was identified for 3 of 4 residents (Residents #13, #102, and #103) reviewed for respiratory care, and was evidenced by the following: 1. On 1/28/26 at 10:20 AM, the surveyor interviewed Resident #102. The resident was lying in bed and the surveyor observed a nasal canula connected to a wall oxygen outlet, which was was in use. The surveyor examined the wall oxygen meter and observed it was set at 0.5 liters/minute of flow. The humidification bottle attached to the wall meter had no date indicating start of use. The resident stated he was not short of breath and demonstrated no signs or symptoms of distress or difficulty breathing. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication (med) for 4 of 36 (Res. #14, #173, 205, 166 and 4) residents reviewed for medication regimen. 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 ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 32 residents (Resident #3) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: The surveyor observed Resident #3 on 1/28/26 at 10:02 AM in bed with eyes closed. The resident's call device was clipped to the sheet behind the head of the bed. The device cord hung down behind the bed out of the reach of the resident. The surveyor observed the resident on 2/4/26 at 9 AM in bed with eyes closed. The call device was in the same position as the previous observation, hanging down behind the head of the bed. The surveyor observed the wound treatment nurse perform a treatment to Resident #3 on 2/4/26 beginning at 11:38 AM. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the appropriate timeframe and in accordance with federal guidelines for 2 of 35 residents (Residents #19, and #103), reviewed for resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2025 indicated in Chapter 2, pages 2-8: .admission refers to the date a person enters the facility and is admitted as a resident.this date is considered the 1st day of admission .Under Chapter 2, Section 2.6-Required OBRA [Omnibus Budget Reconciliation Act] Assessments for the MDS revealed: .MDS Completion Date (Item Z0500B) No Later Than. [...]

Inspectors wroteREPEAT DEFICIENCY Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 of 36 residents (Resident #13 and #18) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 of 36 residents (Resident #15), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, who is seated in a motorized wheelchair, and stated that they would go down to smoke. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. On 2/4/26 at 9:39 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #15, which revealed the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility polices, it was determined that the facility failed to document the non-compliance of the resident's fluid restriction. This deficient practice was identified for 1 (one) of 1 resident (Resident #11) reviewed for dialysis. The deficient practices were evidenced by the following: On 2/5/26 at 9:07 AM, the surveyor observed that the resident was not in the room. The staff stated that Resident #11 was on dialysis. The surveyor observed that the residents had 8 unopened cups of cranberry juice and 4 empty cups, for a total of 12 cups, on top of the overbed table. There are also 5 unopened bottles of bottled water (500 ml (milliliter) each) on top of the windowsill, 2 half-empty bottles of bottled water, and one 120 ml full bottle of water on top of the bedside table. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure the resident's designated smoking area was free from accident hazards, specifically by failing to clear snow and ice from the smoking area after the snow, to prevent slips and falls for 1 (one) of 2 residents (Resident #15), who were reviewed for smoking. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, seated in a motorized wheelchair, who stated that they would go down to smoke to the 1st floor of the facility at the back patio. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. The surveyor observed that the RN gave the vaping (handheld electronic device) device to Resident #15. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified in 1 (one) of 3 residents (Resident #18) who were reviewed for urinary catheter use. This deficient practice was evidenced by the following: On 1/28/26 at 9:50 AM, the surveyor observed Resident #18 in bed, asleep. It was observed that the resident's indwelling catheter, draining yellowish urine, was lying on the floor outside the privacy bag. The surveyor observed that there was a family member of the roommate inside the room. On the same day at 10:00 AM, the surveyor observed that the Licensed Practical Nurse (LPN) went inside the resident's room to give the resident's medication. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide services in a manner to prevent or limit the spread of infection during a wound treatment observation. The deficient practice was observed for 1 resident (Resident #3) of 3 reviewed for pressure ulcers and other skin conditions and was evidenced by the following: The surveyor observed Resident #3 in bed with eyes closed on 1/28/26 at 10:02 AM and on 2/4/26 at 11:38 AM. A review of the resident's medical record revealed the following information. The 11/19/25 significant change in status Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment (brief interview for mental status score of 8). The MDS also indicated the resident had one pressure ulcer. The resident had a 1/22/26 physician's order for a sacral pressure ulcer as follows. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility's documentation, it was determined that the facility failed to ensure a.) the Professional Standards of Practice to assess a resident's pain at least each shift for significant changes in levels of chronic pain, b.) a physician order for administration with parameters was followed (Resident #131) and c.) a narcotic medication for pain was administered when documented as administered (Resident #367). The deficient practice was identified for one (1) of one (1), Resident #14, reviewed for pain management, one (1) of (4) four residents administered by one (1) of four (4) nurses observed during the medication administration, and for one (1) of (5) medication carts observed during the medication storage and labeling inspection. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to assess residents' vital signs and dialysis access site for complications upon return from the renal dialysis (RD) center for 2 of 2 residents reviewed for dialysis care, Resident #90 and 134. Evidence of the deficient practice is as follows. 1. The surveyor interviewed Resident #90 on 10/1/24 at 1:09 PM. The resident stated they had RD appointments on Monday, Wednesday, and Friday at 5:30 AM. The resident stated they are not assessed promptly when returning from RD. A review of the electronic medical record revealed the following information. The 8/15/24 quarterly Minimum Data Set (MDS) assessment tool, Section C - Cognitive Patterns, indicated the resident was cognitively intact (Brief Interview for Mental Status score 15 of 15). Section I - Active Diagnoses triggered for renal disease. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 38 residents reviewed for accommodation of needs (Resident #59 and #127), and was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was intertwined with their roommates call bell cord and entangled in the bed electrical cords, not within his/her reach. The surveyor reviewed the medical record for Resident #59. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to start, complete and transmit the Minimum Data Set (MDS) for a Death in facility and a Discharge Return not Anticipated in accordance with federal guidelines. This deficient practice was identified for two (2) of 38 residents reviewed for Resident Assessment (Resident #144, and 54) and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #144. A review of the resident's admission Record (an admission summary) reflected that Resident #144 was admitted to the facility with diagnoses that included but was not limited to heart failure. On [DATE] at 10:14 AM, the surveyor reviewed the electronic Medical Record, Minimum Data Set (MDS) tab that reflected a Death in the facility tracking discharge was not completed and was 102 days overdue. [...]

Inspectors wrote4. On 10/1/24 at 11:45 AM, during the initial tour, Resident #25 was not in their room. A staff member identified Resident #25 in the dayroom asleep, not roused by the surveyor's voice, seated on a geri chair (geriatric chair or medical recliner; a large, padded chair with wheels, designed to assist seniors with limited mobility) with legs elevated and heels off-loaded (practice of reducing or removing pressure on a part of the body to help with healing or prevent wounds). The surveyor reviewed the medical record for Resident #25 According to the electronic Medical Record, Resident #25 had diagnoses which included, but were not limited to, unstageable pressure ulcer of unspecified site. Review of the quarterly Minimum Data Set, an assessment tool dated 6/28/24, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated a severely impaired cognition. [...]

Inspectors wroteBased 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 10 residents (Resident #59, #82 and #29), observed for incontinence care on 1 of 2 units (B1 Unit). This deficient practice was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed a strong unpleasant odor in the resident's room. On 10/1/24 at 11:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been assigned to Resident #59's care for the 7AM-3:00 PM shift. [...]

Inspectors wroteComplaint NJ 177694, NJ 176286 Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure an abnormal urine lab result was communicated to the physician, received treatment and care, in a timely manner, and in accordance with professional standards of practice that meet the resident's physical, mental and psychosocial needs. This deficient practice was identified for one (1) of two (2) residents reviewed for abuse and neglect, (Resident #319) and was evidenced by the following: The surveyor reviewed the closed record for Resident #319. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently follow a physician's order for placement of an orthopedic device for 1 of 3 residents reviewed for positioning and mobility, Resident #77. The deficient practice is evidenced by the following. The surveyor observed the door to Resident #77's room was closed on 10/1/24 at 11:19 AM. The surveyor knocked and entered the room to see the resident had completed receiving morning care from the Certified Nursing Assistant (CNA). The CNA stated she was done with care and left the room. The surveyor observed a blue hand splint placed on the over bed table. The surveyor returned to the resident's room later the same day at 1:03 PM. The splint was observed on the over bed table. The resident was seated in a geri-chair (a reclining lounge-type chair) at the bedside. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 2 of 4 residents, (Resident #29 and #136). This deficient practice was evidenced by the following: 1. On 10/1/24 at 12:46 PM, the surveyor observed Resident #29 in bed. The resident did not respond to the surveyor. The surveyor observed Resident #29 wearing a nasal cannula (NC) with a portable oxygen tank on and the gauge was set at 2 liters per minute (LPM). On 10/4/24 at 7:38 AM, the surveyor observed Resident #29 in bed with the head of the bed positioned at approximately 45 degrees with a tube feeding running via a machine at 65 mililiters (mls) per hour. The resident did not respond to the surveyor. [...]

Inspectors wroteBased on interview, review of facility documents and review of facility policy, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This failure had the potential to affect all 175 residents who currently live in the facility.

Inspectors wroteBased on observations, interview, record review, and policy review the facility failed to provide a safe, clean, and homelike environment for its residents. Specifically, two residents (Resident (R)106 and (R)40) windows were found to be dirty and broken and a request for bed replacement for R40 had not been fulfilled; and R23's room was found to have leaking insulated ceiling pipes. This deficient practice had the potential to affect three out of 175 residents. In addition, the facility failed to exercise reasonable care for the protection of a resident's (R40) property from damage or theft for one out of one resident sampled for missing items. The deficiency had the potential to significantly impact the residents' quality of life, safety, and overall well-being. The lack of a safe, clean, and homelike environment compromised the residents' sense of dignity and comfort.

Inspectors wroteComplaint #NJ165572, NJ155763 Based on interview, record review, and facility policy review the facility failed to report timely, within two hours and not later than 24 hours for initial notification to the state survey agency (SSA), a witnessed resident to resident altercation for one of one sampled resident (R)21 and an injury of unknown origin for R122 reviewed for facility reported incidents (FRIs). Failure to report resident to resident altercations or injuries of unknown origin could potentially lead to continued abuse and neglect.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the Resident Representative and two residents (Resident (R)122 and R154) of two residents reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information required on the transfer notice. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R)150), reviewed for not having a Minimum Data Set ([MDS) discharge assessment transmitted to Centers for Medicaid and Medicare Services (CMS) in a timely manner, in that the MDS was not transmitted until 120 days after the resident was discharged from the facility This failure has the potential to have Medicare or Medicaid services denied due to the payment system having the R149 as being a nursing facility resident.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately assess] and encode the Minimum Data Set [MDS] related to the presence of an indwelling catheter for one of six residents reviewed for urinary catheters. for one of six residents (Resident (R)15) reviewed for urinary catheter or urinary tract infection (UTI). This failure could lead to inaccurate care planning and/or care provision for the resident.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide assistance with facial grooming, and preserve and promote the dignity of two (Residents (R)84 and R117) of two residents reviewed for activities of daily living out of 39 sampled residents. This failure resulted in residents' appearing in a manner that failed to preserve the residents' dignity.

Inspectors wroteBased on review of facility policy, observations, and staff interviews, the facility failed to follow appropriate infection control practices for hand hygiene and glove wearing for one (Resident (R120) of one resident observed during resident care.

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure that five of five residents (Resident (R) R8, R9, R113, R117, and R132) reviewed for pneumococcal vaccinations were up to date with their pneumococcal vaccines per CDC guidelines out a total sample of 39. This practice had the potential to increase the risk for these residents to contract pneumonia.

Inspectors wroteBased on record review, interview, facility policy review and review of facility assessment, the facility failed to ensure three Certified Nurse Aides (CNAs) (CNA1, CNA2, and CNA3) of three CNAs and one Registered Nurses (RN)1 of one RN reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated on the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present.