Inspection Reports for Lincoln Park Care Center
499 Pine Brook Road, NJ, 07035
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Inspection Report
Annual Inspection
Census: 516
Capacity: 547
Deficiencies: 14
Aug 26, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to medication administration, pharmacy services, infection control, immunizations, staffing ratios, life safety code violations including fire safety, sprinkler system maintenance, corridor door functionality, smoke barrier doors, elevator certification, electrical system maintenance, and emergency power generator performance.
Complaint Details
Complaint investigations were completed during this survey for complaint numbers NJ 158164, 159096, 159436, 160185, 162182, 164918, 165258, 165638, 166264, 168619, 170718, 172424, 173595, 173895.
Severity Breakdown
SS=D: 3
SS=E: 3
SS=F: 5
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure medication was administered in accordance with professional standards to Resident #112. | SS=D |
| Failed to provide pharmaceutical services in accordance with professional standards including medication storage and reconciliation. | SS=D |
| Failed to follow appropriate infection control practices and hand hygiene during meal service and resident care. | SS=E |
| Failed to ensure Resident #114 was offered pneumococcal immunization according to CDC and ACIP recommendations. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | — |
| Failed to provide night lights in all resident rooms. | — |
| Failed to provide exit discharge lighting in accordance with NFPA 101. | SS=E |
| Failed to provide instructional signage above Class K portable fire extinguishers in kitchen. | — |
| Failed to maintain fire sprinkler system sprinkler heads including missing escutcheon plates, corrosion, and gaps around heads. | SS=F |
| Failed to ensure corridor doors resisted passage of smoke and had proper latching and closing functionality. | SS=F |
| Failed to ensure smoke barrier doors closed into their door frame to resist passage of smoke. | SS=F |
| Failed to produce a valid certificate of occupancy/compliance for 1 of 2 elevators in the JDT building. | SS=F |
| Failed to ensure emergency power generator transfer time was within 10 seconds and failed to provide a remote emergency generator shut off. | SS=F |
| Failed to provide electrical policy, maintenance, and testing records for patient care related electrical equipment (PCREE). | SS=F |
Report Facts
Census: 516
Total Capacity: 547
Deficiencies cited: 13
Staffing ratios: 64
Staffing ratios: 516
Generator transfer time: 15
Inspection Report
Routine
Census: 481
Deficiencies: 12
Aug 9, 2022
Visit Reason
Standard routine survey conducted to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including call bell accessibility, resident privacy, bed hold policy notification, significant change assessments, medication administration, pressure ulcer care, incontinence care, dialysis communication, drug regimen review, medication storage, and hospice service coordination.
Severity Breakdown
SS=D: 9
SS=E: 3
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide access to a call bell for 1 of 35 residents for a 3-week period. | SS=D |
| Failed to provide full visual privacy when providing personal care for 1 of 35 residents. | SS=D |
| Failed to provide written notification of the facility's bed hold policy upon transfer to hospital for 4 of 4 residents reviewed. | SS=C |
| Failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set for 1 of 2 residents reviewed. | SS=D |
| Failed to provide care and services according to acceptable standards of clinical nursing practice including medication administration errors and improper cleaning of shared medical equipment. | SS=E |
| Failed to provide care to prevent deterioration of a pressure ulcer for 1 of 4 residents reviewed. | SS=D |
| Failed to provide care in a manner to reduce spread of infection related to improper positioning and use of urinary drainage bag for 1 of 4 residents reviewed. | SS=D |
| Failed to ensure appropriate response to oxygen desaturation for 1 of 2 residents reviewed for respiratory care. | SS=D |
| Failed to maintain ongoing complete communication notes and assessment of residents' condition upon return from dialysis for 3 of 4 residents reviewed. | SS=E |
| Failed to properly store medications requiring refrigeration in 2 of 13 medication carts inspected. | SS=D |
| Failed to consistently provide coordination between facility staff and hospice agency staff to meet resident's nursing needs for 1 of 2 residents reviewed. | SS=D |
| Failed to conduct routine drug regimen review and act on pharmacist recommendations for 3 of 38 residents reviewed. | SS=D |
Report Facts
Census: 481
Sample Size: 38
Medication administration errors: 37
Medication administration errors: 34
Medication administration errors: 19
Medication administration errors: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration and respiratory care findings |
| LPN #3 | Licensed Practical Nurse | Named in medication administration findings |
| LPN #4 | Licensed Practical Nurse | Named in medication administration findings |
| RN #2 | Registered Nurse | Named in medication administration findings |
| LPN #5 | Licensed Practical Nurse | Named in treatment and medication order findings |
| CN3 | Charge Nurse | Named in drug regimen review findings |
| RNCN | Registered Nurse Charge Nurse | Named in drug regimen review findings |
| Consultant Pharmacist | Named in drug regimen review and medication storage findings |
Inspection Report
Life Safety
Capacity: 547
Deficiencies: 13
Aug 9, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 8/4/22, 8/8/22, and 8/9/22 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of NFPA 101.
Findings
The facility was found to be in noncompliance with multiple Life Safety Code requirements including fire resistance-rated doors, egress door accessibility, emergency lighting, hazardous area door closures, smoke detection maintenance, sprinkler system coverage, corridor door smoke resistance, corridor door openings, smoke barrier door sealing, electrical panel accessibility, elevator firefighter service inspections, generator transfer time certification, and oxygen cylinder storage safety.
Severity Breakdown
SS=F: 6
SS=E: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide two-hour fire resistance-rated doors between main building and newer building. | SS=F |
| Exit doors in means of egress were obstructed or locked with devices restricting emergency use. | SS=F |
| Emergency lighting above generator transfer switches was missing or nonfunctional. | SS=F |
| Failed to maintain self-closing devices and hardware on doors to hazardous areas. | SS=E |
| No preventative maintenance program for battery-operated smoke detectors in resident rooms. | SS=E |
| Missing sprinkler head in HVAC closet. | SS=E |
| Corridor doors failed to resist passage of smoke and did not latch properly. | SS=E |
| Door to HVAC closet had an open transfer grille allowing smoke passage into corridor. | SS=F |
| Smoke barrier doors did not fully close and seal, leaving a gap allowing smoke passage. | SS=E |
| Electrical panels were obstructed by combustible materials and ladders, delaying emergency access. | SS=E |
| Elevators' firefighter service was not operated monthly with written records; annual inspections were expired. | SS=F |
| Generator transfer times were not properly documented for 7 of 12 months. | SS=F |
| Oxygen cylinders were stored unsecured, risking tipping and damage. | SS=E |
Report Facts
Certified beds: 547
Waivers utilized: 1135
Deficiency count: 13
Elevators: 4
Transfer times missing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to fire safety, emergency lighting, elevator service, and oxygen cylinder storage | |
| Regional Plant Operations Director | Named in multiple findings related to fire safety, emergency lighting, elevator service, and oxygen cylinder storage |
Inspection Report
Complaint Investigation
Census: 467
Deficiencies: 3
Jun 24, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and COVID-19 vaccination requirements for staff.
Findings
The facility failed to maintain the required minimum direct care staff to resident ratios for 14 out of 42 shifts reviewed and failed to ensure that all eligible staff received their COVID-19 booster vaccination by the required deadline, with 243 of 490 staff not up to date on boosters. The facility also did not provide evidence that all eligible staff were contacted regarding booster vaccination.
Complaint Details
The visit was complaint-related, focusing on COVID-19 infection control and vaccination compliance. The facility was found non-compliant with staffing ratios and COVID-19 booster vaccination requirements for staff.
Deficiencies (3)
| Description |
|---|
| Failure to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 14 out of 42 shifts reviewed. |
| Failure to ensure all staff eligible for COVID-19 booster vaccination received it by the required deadline, with 243 of 490 staff not up to date. |
| Failure to provide evidence that all eligible staff were contacted to receive their COVID-19 booster vaccination. |
Report Facts
Census: 467
Staff not boosted: 243
Staff eligible for booster: 490
Shifts with staffing deficiency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to staffing deficiencies and COVID-19 vaccination compliance responsibilities |
| Infection Preventionist | Infection Preventionist/Registered Nurse (IP/RN #1) | Responsible for COVID-19 vaccination efforts and infection control |
| Infection Preventionist | Infection Preventionist/Registered Nurse (IP/RN #2) | Responsible for ensuring vaccination mandates were followed |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Present during entrance conference and involved in infection control oversight |
Inspection Report
Complaint Investigation
Census: 467
Deficiencies: 0
Jun 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on NJ Complaint #155648.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint investigation related to NJ Complaint #155648; the facility was found in substantial compliance.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 466
Deficiencies: 0
Jul 9, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145973, NJ145477, and NJ144409.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ145973, NJ145477, and NJ144409 were investigated and found to be in compliance.
Report Facts
Sample Size: 10
Inspection Report
Routine
Census: 458
Deficiencies: 0
Mar 30, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 420
Deficiencies: 0
Dec 3, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00133870.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint number NJ00133870 was investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 4
Inspection Report
Routine
Census: 430
Deficiencies: 0
Nov 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Annual Inspection
Census: 430
Deficiencies: 2
Nov 16, 2020
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to develop a person-centered comprehensive care plan addressing nutrition for one resident, and failure to ensure proper infection control practices during wound treatment for another resident.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop a person-centered comprehensive care plan to address nutrition status for Resident #400 for 7 months. | SS=E |
| Failure to ensure proper infection control practices during treatment observation for Resident #245, including inadequate hand hygiene and improper handling of treatment supplies. | SS=D |
Report Facts
Sample size: 36
Weight loss days: Resident #400 had weight loss over unspecified days (exact number redacted)
BIMS score: Resident #400 and Resident #245 had BIMS scores indicating cognitive status (exact scores redacted)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietician | Named in nutrition care plan deficiency and re-education | |
| Registered Nurse/MDS Coordinator (RN/MDSC) | Discussed responsibility for nutrition care plan initiation and updates | |
| Director of Nursing (DON) | Acknowledged deficiencies and discussed concerns with survey team | |
| Licensed Practical Nurse (LPN) | Observed failing to follow proper infection control during wound treatment | |
| Assistant Director of Nursing/Designee | Responsible for conducting random observations of treatments and hand hygiene audits |
Inspection Report
Life Safety
Deficiencies: 0
Nov 16, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with the emergency preparedness requirements and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and to describe their rights related to this information.
Findings
The notice explains the types of information covered, the circumstances under which health information may be used or disclosed, the legal duties of NJDHSS to protect privacy, and the rights of individuals to access, amend, and restrict their health information.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | Listed as NJDHSS Privacy Officer and contact person for privacy practices. |
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