Inspection Reports for Lincoln Park Manor Inc
922 N 5TH ST PO BOX 466, KS, 67455-466
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 29, 2016, found no deficiencies after a follow-up visit verified correction of prior issues. Earlier inspections showed a pattern of deficiencies related mainly to resident care practices, infection control, and safety measures, including failure to notify physicians, inadequate meal assistance, unsecured hazardous materials, and unsanitary kitchen conditions. Complaint investigations included unsubstantiated abuse allegations and some failures in abuse reporting and investigation procedures. Enforcement actions such as immediate jeopardy findings and payment denials occurred in 2015 but were followed by corrective plans and subsequent compliance. The facility’s inspection history indicates improvement over time, with recent reports showing resolution of previously cited deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
29 residents
Based on a June 2016 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jun 29, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.15(a), 483.25(c), 483.25(h), 483.35(i), and 483.65 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Jun 29, 2016
Visit Reason
This document is a Plan of Correction submitted by Lincoln Park Manor addressing deficiencies cited during a prior survey inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including fluid restriction monitoring, dining assistance practices, footwear safety, locked storage for hazardous materials, kitchen flooring maintenance, and updated infection control policies with staff re-education.
Severity Breakdown
D: 4
F: 1
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident #3's fluid restriction monitoring and physician notification | D |
| Nurse Aide re-education on Dining with Dignity and seating arrangements | D |
| Removal of tight shoes for Resident #8 and root cause analysis for foot sores | D |
| Locked cabinet below sink in activity room and staff re-education on safety policy | D |
| Kitchen flooring maintenance and plans for replacement with county involvement | F |
| Updated infection control policies and staff re-education on medication pass guidelines | E |
Report Facts
Complete Date: Jun 29, 2016
Fluid restriction amount: 2000
Flooring project completion estimate year: 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Re-educated about safety policy and locked cabinet incident | |
| Staff A | Re-educated on chemical product kill claim and infection control guidelines | |
| Staff G | Educated on medication pass guidelines and pill dropping procedures | |
| Staff H | Educated on medication pass guidelines and pill dropping procedures |
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 14, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter and referenced as contact for questions regarding the survey. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 7
Jun 14, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #99688 and #99839 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician of fluid intake exceeding orders, failure to maintain resident dignity during meal assistance, inadequate prevention and treatment of pressure ulcers, unsafe environment hazards, unsanitary food preparation conditions, and infection control lapses including improper cleaning and medication administration practices.
Complaint Details
The visit was complaint-related as it included Complaint Investigations #99688 and #99839. Substantiation status is not explicitly stated.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to notify Resident #3's physician regarding fluid intake exceeding the physician ordered 2000 cc daily during March, April, May 2016. | SS=D |
| Failure to provide an environment that maintains or enhances dignity for residents requiring extensive assistance with meals. | SS=D |
| Failure to implement interventions to ensure appropriate footwear to prevent pressure ulcers for Resident #8. | SS=D |
| Failure to adequately assess an air mattress for Resident #1 who had a fall with minor injury. | SS=D |
| Failure to maintain a safe environment by leaving hazardous chemicals unsecured in an unlocked activity room cabinet. | SS=D |
| Failure to prepare, store, distribute and serve food under sanitary conditions, including missing floor tiles and greasy buildup in kitchen areas. | SS=F |
| Failure to establish and maintain an infection control program to prevent disease transmission, including improper cleaning of shower areas and administering a contaminated medication to Resident #35. | SS=E |
Report Facts
Resident census: 29
Sample size: 15
Fluid intake: 3500
Fluid intake: 4650
Fluid intake: 4225
Fluid intake: 2552
Blood blister size: 3.5
Blackish purple hard area size: 1
Blackish purple hard area size: 1.9
Dark scab size: 1.5
Dark scab size: 0.9
Dark spot size: 1
Dark spot size: 0.5
Fall date: 2016
Chemical container size: 2.5
Chemical container size: 2.5
Chemical container size: 10
Chemical container size: 10
Chemical container size: 8
Chemical container size: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Administrative Nurse | Verified failure to notify physician of fluid intake, improper meal assistance, failure to assess air mattress, and medication administration practices. |
| Nurse Aide E | Nurse Aide | Observed assisting residents with meals in a manner that failed to maintain dignity. |
| Dietary Manager F | Dietary Manager | Verified kitchen floor deficiencies and cleaning practices. |
| Maintenance Staff B | Maintenance Staff | Verified missing tiles and greasy buildup in kitchen floor areas. |
| Nurse Aide A | Nurse Aide | Observed improper cleaning of shower area with disinfectant. |
| Medication Aide G | Medication Aide | Observed administering contaminated medication to Resident #35. |
| Nurse H | Nurse | Allowed resident to take medication that fell on the floor. |
Inspection Report
Follow-Up
Deficiencies: 0
May 6, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report indicates that all previously cited deficiencies were corrected as of the revisit date, with corrections completed and documented for the identified regulations.
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 7, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Lincoln Park Manor.
Findings
The plan addresses deficiencies related to abuse investigations, including notification of physicians, implementation of an abuse investigation checklist, staff suspension policies, and revised reporting guidelines for injuries in new admissions.
Complaint Details
The plan of correction is related to a complaint investigation at Lincoln Park Manor dated 04/07/2016, involving allegations of abuse that were unsubstantiated for Resident #1.
Severity Breakdown
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility-wide system to assure correction and continued compliance with regulations. | — |
| Resident #1's physician was notified late; abuse investigation checklist was incomplete. | D |
| Nurse Aide E suspended due to unsubstantiated abuse allegation; reporting guidelines for injuries in new admissions were inadequate. | D |
Report Facts
Complete Date for F0000 deficiency: Apr 13, 2016
Complete Date for F157-D deficiency: Apr 8, 2016
Complete Date for F225-D deficiency: May 6, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christen Robinson | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 7, 2016
Visit Reason
An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person for the survey and findings. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Apr 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#99054) related to allegations of abuse and failure to notify physicians and state agencies regarding incidents involving residents.
Findings
The facility failed to notify the physician of an allegation of abuse for one resident, failed to thoroughly investigate abuse allegations, failed to suspend a nurse aide pending investigation, and failed to report bruises of unknown origin and unwitnessed falls with injury to the state agency for multiple residents.
Complaint Details
The complaint investigation (#99054) was triggered by allegations of abuse involving Resident #1 and concerns about failure to notify physicians and state agencies about incidents involving residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician of an allegation of abuse for Resident #1. | SS=D |
| Failed to thoroughly investigate and follow facility policy for abuse, neglect, and exploitation for Resident #1 and failed to notify the state agency of bruises of unknown origin and an unwitnessed fall with injury for Residents #2 and #3. | SS=D |
Report Facts
Census: 32
Sample size: 4
Bruise size: 15
Bruise size: 7
Bruise size: 2
Bruise size: 0.5
Bruise size: 16
Hematoma size: 3.5
Fall risk score: 16
BIMS score: 15
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide E | Nurse Aide | Named in abuse allegation and investigation; was not suspended pending investigation. |
| Administrative Staff F | Administrative Staff | Verified abuse allegation investigation status and communicated with Resident #1. |
| Administrative Nurse B | Administrative Nurse | Verified failure to notify physician and state agency regarding abuse allegations and bruises. |
| Nurse D | Nurse | Documented Resident #3 fall and injury. |
| Restorative Aide A | Restorative Aide | Provided information on Resident #3's confusion and fall risk. |
Inspection Report
Life Safety
Deficiencies: 1
Mar 14, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm not constituting immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jun 14, 2016
Provider agreement termination date: Sep 14, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Follow-Up
Deficiencies: 16
Apr 23, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report documents that all previously identified deficiencies were corrected as of 03/20/2015, with no uncorrected deficiencies noted at the time of the revisit.
Deficiencies (16)
| Description |
|---|
| Deficiency identified under regulation 483.13(b), 483.13(c)(1)(i) |
| Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulation 483.15(h)(2) |
| Deficiency identified under regulation 483.20(g)-(j) |
| Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency identified under regulation 483.25 |
| Deficiency identified under regulation 483.25(d) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.25(m)(1) |
| Deficiency identified under regulation 483.60(a),(b) |
| Deficiency identified under regulation 483.60(c) |
| Deficiency identified under regulation 483.60(b), (d), (e) |
| Deficiency identified under regulation 483.65 |
| Deficiency identified under regulation 483.75(o)(1) |
Report Facts
Correction completion date: Mar 20, 2015
Follow-up survey date: Apr 23, 2015
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 12, 2015
Visit Reason
The visit was an Assisted Living/Residential Healthcare resurvey of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 4, 2015
Visit Reason
A Health resurvey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs, following a period of immediate jeopardy from January 25, 2015 through February 27, 2015.
Findings
The facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.
Severity Breakdown
Substandard Quality of Care: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F225 CFR 01-483.13(c) constituting immediate jeopardy and substandard quality of care | Substandard Quality of Care |
Report Facts
Denial of payment effective date: Mar 27, 2015
Provider agreement termination date: Sep 4, 2015
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christen Robinson | Administrator | Named as facility administrator in relation to the survey and findings |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 13
Mar 4, 2015
Visit Reason
The inspection was a Health Resurvey and Extended Health Resurvey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to protect residents from abuse, failure to investigate and report abuse allegations, failure to maintain dignity and respect, inadequate housekeeping and maintenance, inaccurate resident assessments, failure to revise care plans, inadequate care and monitoring of urinary catheters, failure to provide highest practicable well-being, medication management deficiencies including monitoring effectiveness and medication errors, infection control lapses, and failure of the Quality Assessment and Assurance Committee to identify and correct quality deficiencies.
Severity Breakdown
SS=G: 1
SS=L: 1
SS=E: 4
SS=D: 6
SS=F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to protect Resident #26 from abuse and failure to investigate and report abuse allegations. | SS=G |
| Failure to investigate and report allegations of abuse and protect residents during investigations. | SS=L |
| Failure to maintain dignity and respect for residents during weighing procedures. | SS=E |
| Failure to provide and maintain a sanitary, orderly, and comfortable interior environment. | SS=E |
| Failure to accurately complete resident assessments (MDS). | SS=D |
| Failure to revise care plan for urinary catheter use and failure to properly care for urinary catheter. | SS=D |
| Failure to provide ongoing reassessment and neurological assessments after falls. | SS=D |
| Failure to monitor medication effectiveness and adverse consequences. | SS=D |
| Failure to maintain medication error rates below 5%, including incorrect medication timing and unlabeled medication cups. | SS=D |
| Failure to provide accurate and safe pharmaceutical services including correct medication labeling and pharmacist consultation follow-up. | SS=D |
| Failure to maintain an effective infection control program including proper linen transport and adequate cleaning of resident rooms. | SS=E |
| Failure of the Quality Assessment and Assurance Committee to identify, address, and implement corrective plans for quality deficiencies. | SS=F |
| Failure to provide a safe environment free from accident hazards and adequate supervision to prevent accidents. | SS=D |
Report Facts
Deficiencies cited: 12
Residents reviewed: 17
Medication administration errors: 1
Medication error rate: 5
Fall risk score: 12
INR lab result: 2.17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administered medication incorrectly and failed to label medication cups | |
| Administrative Nurse B | Verified multiple deficiencies including medication errors, catheter care, and failure to notify physician of pharmacist recommendations | |
| Nurse J | Provided statements regarding medication monitoring and neurological assessments | |
| Nurse L | Provided statements regarding medication monitoring and resident supervision | |
| Housekeeping Staff P | Observed performing inadequate cleaning and infection control practices | |
| Housekeeping Supervisor Q | Provided statements regarding cleaning protocols for infection control | |
| Administrative Staff G | Verified unsafe environment with resident's drills and paint thinner | |
| Nurse Aide I | Provided statements regarding resident supervision and assistance | |
| Nurse Aide H | Verified urinary catheter bag should not drag on floor | |
| Nurse F | Failed to relay information about resident abuse incident | |
| Direct care staff D | Alleged perpetrator in resident abuse incident |
Inspection Report
Plan of Correction
Deficiencies: 6
Feb 25, 2015
Visit Reason
This document is a Plan of Correction submitted by Lincoln Park Manor in response to deficiencies cited during a prior survey, detailing corrective actions to address abuse/neglect allegations and other compliance issues.
Findings
The plan outlines suspension and investigation of Staff D for alleged abuse, interviews with residents and staff finding no substantiating evidence of abuse or neglect, notification and involvement of the State Ombudsman, staff inservices on updated Abuse Reporting Policy, and multiple corrective actions to ensure resident safety and regulatory compliance.
Complaint Details
The investigation was triggered by an allegation of abuse by Staff D. Interviews and notarized statements found no substantiating evidence of abuse or neglect with other residents. The alleged victim and his DPOA were interviewed. The State Ombudsman was involved as an outside advocate. The investigation is ongoing to determine further action regarding Staff D.
Deficiencies (6)
| Description |
|---|
| Suspension of Staff D pending investigation of alleged abuse to ensure no immediate jeopardy to residents. |
| Interviews and notarized statements found no substantiating evidence of abuse or neglect with other residents. |
| Implementation of facility-wide system to assure correction and continued compliance with regulations. |
| Mandatory staff inservice on updated Abuse Reporting Policy and Guidelines. |
| Designation of Medical Records Office to review Resident Concern Reports and Incident Reports for potential reportable incidents. |
| Multiple care plan updates and staff training related to resident safety, medication pass competency, infection control, and environmental safety. |
Report Facts
Completion Date: Mar 16, 2015
Completion Date: Feb 25, 2015
Completion Date: Feb 26, 2015
Completion Date: Mar 9, 2015
Completion Date: Feb 27, 2015
Completion Date: Mar 5, 2016
Date: 201605
Date: 201612
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Behrens | CMA | Subject of investigation to determine if she can return to work or face termination |
| Christen Robinson | Administrator | Administrator involved in investigation and report submission |
Inspection Report
Life Safety
Deficiencies: 1
Sep 11, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Dec 11, 2014
Provider agreement termination date: Mar 11, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christen Robinson | Administrator | Facility administrator named in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:) |
Inspection Report
Follow-Up
Deficiencies: 3
Jan 8, 2014
Visit Reason
This is a post-certification revisit to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.65, and 483.70(g) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(g) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Jan 6, 2014
Visit Reason
This document is a Plan of Correction submitted by Lincoln Park Manor addressing deficiencies cited during a prior survey.
Findings
The plan outlines corrective actions for deficiencies related to unwitnessed falls with injury, proper sanitization of nebulizer masks and glucometers, and resident positioning during dining to prevent weight and safety issues.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report and investigate unwitnessed falls with injury or hospitalization for Resident #21. | D |
| Improper sanitization and storage of nebulizer masks and glucometers for multiple residents. | E |
| Inadequate resident positioning during dining affecting Resident #21. | D |
Report Facts
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christen Robinson | Administrator | Administrator named in submission of Plan of Correction |
Inspection Report
Renewal
Deficiencies: 0
Dec 24, 2013
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance and determine if any deficiencies were present.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 3
Dec 23, 2013
Visit Reason
The inspection was a health resurvey to investigate compliance with regulatory requirements, including investigation and reporting of abuse, infection control, and adequacy of dining furnishings.
Findings
The facility failed to notify the state agency of unwitnessed falls with injury for Resident #21, failed to maintain a safe and sanitary environment regarding uncovered nebulizer equipment and improper cleaning of glucometers, and failed to provide adequate dining furnishings for Resident #21.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the state agency for unwitnessed falls with injuries for Resident #21. | Level D |
| Failure to provide a safe, sanitary, and comfortable environment regarding uncovered nebulizer equipment and improper cleaning of glucometers. | Level E |
| Failure to provide adequate dining furnishings for Resident #21. | Level D |
Report Facts
Census: 35
Residents in sample: 10
Residents reviewed for accidents: 3
Residents receiving nebulizer treatments: 8
Residents receiving blood glucose monitoring: 14
Skin tear size: 5
Skin tear width: 2.5
Dining table height: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Revealed the facility did not notify the state agency for unwitnessed falls and provided statements about nebulizer and glucometer cleaning practices. | |
| Nurse B | Observed placing glucometer on medication cart without cleaning it between uses. | |
| Medication Aide C | Observed wiping glucometer with alcohol prep pad and stated glucometers should be cleaned between resident use. | |
| Dietary Staff D | Measured dining table height and verified it was too high for Resident #21. | |
| Therapy Assistant E | Verified dining table height was too high for Resident #21. |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 7, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that all previously identified deficiencies under regulations 483.25(h), 483.25(l), 483.60(c), and 483.65 were corrected as of the revisit date.
Report Facts
Deficiency corrections completed: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Oct 23, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility has outlined corrective actions for deficiencies related to door lock systems for hazardous areas, medication management including gradual dose reductions of antipsychotic medications, pharmacy consultant drug reviews, and infection control practices involving glucose monitoring equipment cleaning.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Key-in lock levers ordered and to be installed on doors leading to chemical and biohazard storage to prevent access by cognitively impaired residents. | D |
| Medication adjustments including discontinuation and dose reduction of certain medications with monitoring for side effects and pharmacy consultant reviews. | D |
| Pharmacy consultant drug review process enhanced to include face-to-face exit conferences and bi-monthly QA meetings to ensure follow-up on recommendations. | D |
| Super Sani Wipes removed and replaced with Clorox Germicidal Wipes for proper disinfection of glucose monitoring equipment; ongoing nurse competency audits implemented. | E |
Report Facts
Complete date for corrective actions: Nov 7, 2012
Date of Quality Assurance Committee discussion: Oct 23, 2012
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 4
Oct 9, 2012
Visit Reason
The inspection was a health resurvey (re-inspection) to evaluate compliance with previously cited deficiencies at Lincoln Park Manor Inc.
Findings
The facility failed to maintain a safe environment free of accident hazards, failed to ensure drug regimens were free from unnecessary drugs without adequate rationale, failed to ensure pharmacist reports of drug irregularities were communicated and acted upon, and failed to maintain proper infection control practices related to glucometer sanitation.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide an environment free from accident hazards for 3 cognitively impaired, independently mobile residents due to unlocked closet with harmful chemicals accessible. | SS=D |
| Failed to ensure residents' drug regimens were free from unnecessary drugs without adequate rationale for 3 of 10 sampled residents. | SS=D |
| Pharmacist consultant failed to report drug irregularities to physician or Director of Nursing for 3 of 10 sampled residents. | SS=D |
| Failed to establish and maintain infection control program to prevent transmission of infection related to improper cleaning of glucometers used for blood glucose testing. | SS=E |
Report Facts
Census: 28
Sampled residents: 18
Residents reviewed for unnecessary drugs: 10
Residents requiring blood glucose checks: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified unlocked closet with harmful chemicals | |
| Nurse B | Verified lack of sleep hygiene interventions and pharmacist communication | |
| Nurse C | Verified absence of T4 and TSH lab results and observed glucometer cleaning | |
| Nurse D | Observed performing blood glucose testing without cleaning glucometer between residents | |
| Nurse E | Observed performing blood glucose testing and wiping glucometer with Super Sani Wipes | |
| Nurse F | Verified number of residents requiring blood glucose monitoring |
Inspection Report
Follow-Up
Deficiencies: 1
Aug 23, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2011-08-17.
Findings
The report shows that the previously cited deficiency with regulation number 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 08/23/2011.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Aug 17, 2011
Visit Reason
The inspection was conducted as a health facility resurvey and complaint investigation (#50971) related to failure to report a resident fall with injury.
Findings
The facility failed to report to the state agency a fall with injury involving Resident #21, who had severe cognitive impairment and sustained a large laceration and bruising after a fall on 7/23/2011. The facility's policy required reporting such incidents within 24 hours, but the fall was not reported.
Complaint Details
Complaint #50971 triggered the investigation. The facility failed to report possible incidents of abuse or neglect to the State Agency for Resident #21, as verified by Nurse H on 8/16/2011.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report to the state agency a fall with injury involving Resident #21. | SS=D |
Report Facts
Resident census: 23
Sample size: 12
Wound measurement: 17
Wound measurement: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Verified the facility failed to report the resident's fall to the state agency. |
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