Inspection Reports for
Lincoln Park Manor Inc
922 N 5TH ST PO BOX 466, LINCOLN, KS, 67455-466
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
14.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
148% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
94% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 34
Deficiencies: 10
Date: Aug 20, 2025
Visit Reason
Routine inspection of Lincoln Park Manor Inc nursing home to assess compliance with healthcare regulations including medication management, care planning, infection control, and hospice services.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration orders, medication privacy, psychotropic medication management, care plan updates, respiratory care, medication regimen review by pharmacist, medication labeling and storage, dietary manager qualifications, hospice care coordination, and infection prevention practices.
Deficiencies (10)
F 0554: The facility failed to ensure Resident 1 had a physician's order and assessment for safe self-administration of medications left at bedside.
F 0583: The facility failed to ensure staff secured and protected the privacy and confidentiality of Resident 24's medical record.
F 0605: The facility failed to obtain stop dates, appropriate indications, and rationale for psychotropic medications for Residents 6, 10, and 17.
F 0657: The facility failed to update care plans for Residents 2 and 38 to reflect current care needs and enhanced barrier precautions.
F 0695: The facility failed to provide adequate respiratory care for Resident 10 by not storing oxygen tubing and nebulizer mask in a sanitary manner.
F 0756: The facility pharmacist consultant failed to provide timely monthly drug regimen reviews and follow-up on recommendations for Residents 6, 10, and 17.
F 0761: The facility failed to ensure medications were secure, insulin pens labeled and dated, and expired medications removed from use.
F 0801: The facility failed to ensure the director of food and nutrition services had required certified dietary manager qualifications.
F 0849: The facility failed to ensure collaboration and communication with hospice providers for Residents 2 and 38 including hospice services and care plan updates.
F 0880: The facility failed to ensure staff followed enhanced barrier precautions and hand hygiene during wound care for Residents 2 and 38 and failed to properly store respiratory equipment for Resident 10.
Report Facts
Resident census: 34
Sample size: 13
Medication Regimen Review delay: 1
Expired medications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse and Infection Preventionist | Provided statements on medication orders, care plan updates, infection control, and pharmacist communication |
| Licensed Nurse H | Licensed Nurse | Observed medication administration and respiratory care; provided statements on medication storage and resident care |
| Certified Medication Aide R | Certified Medication Aide | Administered medications and provided observations on resident behavior |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements on enhanced barrier precautions and resident care |
| Licensed Nurse G | Licensed Nurse | Observed wound care and medication cart issues; provided statements on infection control |
| Certified Medication Aide T | Certified Medication Aide | Verified expired medications in medication cart |
| Dietary BB | Director of Food and Nutrition Services | Stated lack of certified dietary manager qualification |
| Administrative Staff A | Administrative Staff | Confirmed dietary manager certification status and dietician availability |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 15
Date: Dec 19, 2023
Visit Reason
Annual inspection of Lincoln Park Manor Inc nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to include residents in care planning, medication management errors, inadequate notification for transfers, incomplete care plans, ineffective fall prevention interventions, inconsistent fluid intake monitoring, improper medication regimen reviews, lack of certified dietary manager, food safety violations, failure to coordinate hospice care, inaccurate staffing data submission, and poor infection control practices.
Deficiencies (15)
F 0553: The facility failed to include residents R1 and R14 in the development and planning of their person-centered care plans, risking impaired care and autonomy.
F 0554: The facility failed to ensure R1 had a physician's order and assessment for safe self-administration of medications left at bedside, risking improper medication use.
F 0623: The facility failed to provide timely written notice to resident R32 or representative before transfer to hospital, risking uninformed care choices.
F 0625: The facility failed to provide resident R32 or representative written information about the facility's bed hold policy during hospital transfer, risking loss of bed reservation.
F 0657: The facility failed to revise the care plan for resident R30 to include Black Box Warning for risperidone and monitoring instructions, risking uncommunicated care needs.
F 0689: The facility failed to evaluate and modify ineffective fall prevention interventions for resident R19, placing the resident at risk for further falls and injury.
F 0692: The facility failed to consistently monitor and document resident R32's physician-ordered 2000 cc fluid restriction, risking fluid overload.
F 0756: The facility failed to ensure consultant pharmacist identified and reported that resident R26's PRN Xanax lacked a 14-day stop date or physician rationale, risking inappropriate medication use.
F 0758: The facility failed to ensure appropriate indication, documentation, and stop dates for psychotropic medications for residents R26 and R30, risking unnecessary adverse effects.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 27% error rate in administration to resident R1, risking improper medication use and side effects.
F 0801: The facility failed to employ a full-time certified dietary manager for 32 residents receiving meals from the kitchen, risking inadequate nutrition.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, including uncovered hamburger in freezers and expired dishwasher sanitizing strips, risking foodborne illness.
F 0849: The facility failed to ensure a coordinated hospice care plan was developed and available for resident R26 receiving hospice services, risking unmet end of life care.
F 0851: The facility failed to submit complete and accurate Payroll Based Journal staffing data, incorrectly reporting licensed nurse coverage, risking unidentified inadequate staffing.
F 0880: The facility staff failed to change gloves and wash hands appropriately when providing incontinent and catheter care to resident R31, risking infection.
Report Facts
Medication error rate: 27
Census: 32
PRN Benadryl doses: 14
Fall risk assessments: 13
Inspection Report
Routine
Census: 32
Deficiencies: 12
Date: May 26, 2022
Visit Reason
Routine inspection of Lincoln Park Manor Inc nursing home to assess compliance with regulatory standards including resident care, medication management, infection control, and safety.
Findings
The facility had multiple deficiencies including failure to prevent neglect during resident transfers, failure to report and investigate injuries of unknown origin, failure to provide written discharge notices, failure to revise care plans with meaningful fall prevention interventions, failure to follow up on changes in resident condition, failure to complete root cause analyses for falls, failure to maintain oxygen equipment properly, failure to follow up on pharmacist recommendations for medication use, failure to provide bowel management interventions, and failure to follow infection control practices.
Deficiencies (12)
F0600: The facility failed to prevent neglect when staff did not provide necessary care during a resident transfer, resulting in falls and injuries.
F0609: The facility failed to timely report suspected abuse or injury of unknown origin to administration for a resident with a bruise, risking further injury.
F0610: The facility failed to investigate an injury of unknown origin for a resident with a bruise, risking further injury and unidentified abuse.
F0623: The facility failed to provide written notice of discharge to a resident's representative when discharged to an acute care facility.
F0657: The facility failed to revise and update care plans with meaningful fall prevention interventions for multiple residents at high risk for falls.
F0684: The facility failed to follow up timely with physician orders after a resident developed increased right arm weakness, risking delayed treatment.
F0689: The facility failed to complete root cause analyses and implement meaningful fall prevention interventions for multiple residents with frequent falls.
F0695: The facility failed to ensure oxygen tubing was dated and stored properly for two residents, risking respiratory complications and infection.
F0756: The facility failed to ensure the consultant pharmacist followed up on recommendations to change an inappropriate diagnosis for antipsychotic medication use.
F0757: The facility failed to provide interventions for lack of bowel movements for a resident with constipation history, risking complications.
F0758: The facility failed to ensure an appropriate diagnosis for antipsychotic medication use, placing the resident at risk for adverse side effects.
F0880: The facility failed to ensure staff practiced proper hand hygiene while serving food, sanitized glucometers between uses, placed barriers under glucometers, and stored ice scoops properly, risking infection transmission.
Report Facts
Residents affected: 32
Sample residents reviewed: 13
Falls documented: 6
Falls documented: 3
Falls documented: 12
Bruise size: 1.5
Bruise size: 1
Medication dose: 12.5
MiraLAX dose: 17
Bisacodyl dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in medication administration and infection control findings |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including care plan revisions, medication follow-up, and infection control |
| Certified Nurse Aide M | Certified Nurse Aide | Named in fall and transfer related findings |
| Certified Nurse Aide N | Certified Nurse Aide | Named in fall and transfer related findings |
| Certified Nurse Aide O | Certified Nurse Aide | Named in infection control and fall findings |
| Licensed Nurse H | Licensed Nurse | Named in fall and infection control findings |
| Certified Medication Aide R | Certified Medication Aide | Named in infection control and blood sugar monitoring findings |
| Dietary Staff CC | Dietary Staff | Named in infection control findings |
| Dietary Staff DD | Dietary Staff | Named in infection control findings |
| Dietary Staff BB | Dietary Staff | Named in infection control findings |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 29, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported 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
Date: Jun 29, 2016
Visit Reason
This document is a Plan of Correction submitted by Lincoln Park Manor to address deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies including fluid restriction monitoring, dining assistance practices, footwear safety, unlocked hazardous cabinets, kitchen flooring conditions, and updated infection control policies. Corrective actions and monitoring plans were implemented for each deficiency.
Deficiencies (6)
F157-D Resident #3's physician was notified about fluid restriction and monitoring was implemented to ensure compliance with the 2000cc daily fluid limit.
F241-D Nurse Aide E was re-educated on Dining with Dignity and additional seating was provided to ensure staff sit at eye level with residents during meals.
F314-D Resident #8 had tight shoes removed and is wearing gripper socks while root cause analysis is conducted for foot sores.
F323-D The unlocked cabinet below the sink was locked immediately and staff were re-educated on safety policies to protect residents.
F371-F Bids are in process for kitchen flooring replacement with completion expected by December 2016; cleaning and maintenance protocols are in place.
F441-E Infection control policies were updated and staff were re-educated on chemical use and medication pass guidelines.
Report Facts
Complete Date: Jun 29, 2016
Fluid restriction amount: 2000
Flooring project completion estimate: 201612
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 14, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation 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, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Date: 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.
Complaint Details
The visit was complaint-related as it included Complaint Investigations #99688 and #99839. Specific substantiation status is not stated.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician about 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.
Deficiencies (6)
F 157: The facility failed to notify Resident #3's physician regarding fluid intake exceeding the physician ordered 2000 cc daily during March, April, and May 2016.
F 241: The facility failed to promote dignity and respect by having staff stand while assisting Resident #7 with meals in the dining room.
F 314: The facility failed to implement interventions to ensure appropriate footwear to prevent pressure ulcers for Resident #8.
F 323: The facility failed to adequately assess an air mattress for Resident #1, who had a fall with minor injury from bed, and failed to secure hazardous chemicals.
F 371: The facility failed to prepare, store, distribute, and serve food under sanitary conditions, including missing floor tiles and greasy buildup in the kitchen.
F 441: The facility failed to maintain infection control by improper cleaning of shower areas and administering a contaminated medication to Resident #35.
Report Facts
Resident census: 29
Sample size: 15
Fluid intake: 3500
Fluid intake: 4650
Fall risk assessment date: Apr 1, 2016
Fall investigation date: Apr 21, 2016
Medication administration date: Jun 7, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Verified failure to notify physician about fluid intake, improper meal assistance, inadequate air mattress assessment, and medication administration practices. | |
| Nurse Aide E | Observed standing while assisting Resident #7 with meals. | |
| Dietary Manager F | Verified kitchen floor issues and sanitation concerns. | |
| Maintenance Staff B | Verified missing floor tiles and greasy buildup in kitchen. | |
| Nurse Aide A | Observed improper cleaning of shower area. | |
| Nurse H | Administered medication that fell on floor to Resident #35. | |
| Medication Aide G | Poured pills into Resident #35's hand including one that fell on the floor. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: 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 have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 483.10(b)(11) and 483.13(c)(1)(i)-(iii), (c)(2)-(4) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.10(b)(11) deficiency was corrected by the revisit date. The facility addressed the previously cited issue.
Regulation 483.13(c)(1)(i)-(iii), (c)(2)-(4) deficiency was corrected by the revisit date. The facility implemented required corrective actions.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
The facility had 'D' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person for the survey and plan of correction. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Apr 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#99054) regarding allegations of abuse and failure to notify and investigate incidents involving 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, failure to investigate abuse allegations, and failure to suspend staff pending investigation.
Findings
The facility failed to notify the physician of an allegation of abuse for one resident, failed to thoroughly investigate abuse allegations, and failed to notify the state agency of bruises of unknown origin and unwitnessed falls with injury for multiple residents. The facility also failed to suspend a nurse aide pending investigation of abuse allegations.
Deficiencies (2)
F 157: The facility failed to notify the physician of an allegation of abuse for Resident #1.
F 225: The facility 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 Residents #1, #2, and #3.
Report Facts
Resident census: 32
Sample size: 4
Bruise size: 15
Bruise size: 10
Bruise size: 7
Bruise size: 9
Bruise size: 2
Bruise size: 0.5
Bruise size: 0.5
Bruise size: 16
Bruise size: 13.5
Hematoma size: 3.5
Hematoma size: 0.5
Hematoma size: 3
Fall risk score: 16
Laceration size: 0.5
Laceration size: 0.3
Swollen area size: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Lincoln Park Manor on 04/07/2016.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific corrective actions include notifying physicians, revising abuse investigation checklists, suspending staff involved in alleged abuse, and improving reporting and investigation procedures for injuries of unknown origin.
Deficiencies (3)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. The Quality Assurance Committee will review the complete survey and corrective action plans.
F157-D: Resident #1's physician was notified on 4/8/2016. The abuse investigation checklist was updated to ensure all investigation items are completed and reviewed by the QAPI Committee.
F225-D: Nurse Aide E was removed due to an unsubstantiated abuse allegation. Reporting guidelines were revised to include injuries for new admissions regardless of cognition, and a root cause analysis pathway will be used for injury investigations.
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 14, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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 the 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at the 'F' level indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 14, 2016
Provider agreement termination date: Sep 14, 2016
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 16
Date: Apr 23, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected as of 03/20/2015.
Deficiencies (16)
Regulation 483.13(b), 483.13(c)(1)(i) deficiency corrected on 03/20/2015.
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency corrected on 03/20/2015.
Regulation 483.15(a) deficiency corrected on 03/20/2015.
Regulation 483.15(h)(2) deficiency corrected on 03/20/2015.
Regulation 483.20(g)-(j) deficiency corrected on 03/20/2015.
Regulation 483.20(d)(3), 483.10(k)(2) deficiency corrected on 03/20/2015.
Regulation 483.25 deficiency corrected on 03/20/2015.
Regulation 483.25(d) deficiency corrected on 03/20/2015.
Regulation 483.25(h) deficiency corrected on 03/20/2015.
Regulation 483.25(l) deficiency corrected on 03/20/2015.
Regulation 483.25(m)(1) deficiency corrected on 03/20/2015.
Regulation 483.60(a),(b) deficiency corrected on 03/20/2015.
Regulation 483.60(c) deficiency corrected on 03/20/2015.
Regulation 483.60(b),(d),(e) deficiency corrected on 03/20/2015.
Regulation 483.65 deficiency corrected on 03/20/2015.
Regulation 483.75(o)(1) deficiency corrected on 03/20/2015.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 12, 2015
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance after a prior inspection.
Findings
The resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: 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.
Findings
The facility was found not in substantial compliance and had conditions constituting immediate jeopardy to resident health or safety from January 25, 2015 through February 27, 2015. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.
Deficiencies (1)
F225 CFR 01-483.13(c) was cited for substandard quality of care constituting immediate jeopardy to resident health or safety.
Report Facts
Civil Money Penalty: 5000
Effective date of denial of payment: March 27, 2015
Recommended termination date: September 4, 2015 if substantial compliance not achieved
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 and communicated enforcement actions. |
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 16
Date: Mar 4, 2015
Visit Reason
Health Resurvey and Extended Health Resurvey to assess compliance with federal regulations.
Findings
The facility had multiple deficiencies including failure to protect residents from abuse, failure to investigate and report abuse allegations, inadequate care plan updates, failure to provide ongoing reassessments, inadequate catheter care, unsafe environment and supervision, medication monitoring and administration errors, infection control lapses, and ineffective quality assurance processes.
Deficiencies (16)
F 223: The facility failed to provide Resident #26 a safe environment free from potential abuse and did not immediately investigate an allegation of abuse by a staff member, leaving the resident fearful.
F 225: The facility failed to investigate and report an allegation of abuse by Resident #26 to the state agency and allowed the alleged perpetrator to continue working, placing residents in immediate jeopardy.
F 241: The facility failed to maintain dignity and respect for 12 residents by weighing them publicly and loudly announcing their weights in the dining room.
F 253: The facility failed to maintain a sanitary, orderly, and comfortable environment, with multiple stains, cracks, and unclean areas observed in resident rooms, hallways, and dining areas.
F 278: The facility failed to accurately code Resident #30's MDS assessment regarding falls and injury status.
F 280: The facility failed to update or revise the care plan for Resident #13 to direct staff on proper urinary catheter care and observed catheter bags and tubing dragging on the floor.
F 309: The facility failed to provide ongoing reassessment for Residents #15, #30, and #40, including incomplete neurological assessments after falls and failure to monitor lethargy and fall risks.
F 315: The facility failed to provide appropriate catheter care for Residents #13 and #17, allowing catheter bags and tubing to drag on the floor and lacking care plan interventions.
F 323: The facility failed to provide a safe environment free from accident hazards for cognitively impaired residents, including unsecured basement stairwell doors and unsafe tools in Resident #6's room, and failed to provide adequate supervision to prevent falls for Residents #30 and #40.
F 329: The facility failed to monitor medication effectiveness for Residents #21 and #31 after PRN medication administration and failed to monitor Resident #40 for adverse effects after starting a new medication.
F 332: The facility failed to maintain medication error rates below 5%, including administering Carafate at incorrect times, leaving medications unattended on dining tables, and improper mixing of Miralax.
F 425: The facility failed to ensure accurate medication labeling for Resident #36, administering Lexapro with incorrect timing instructions on the blister pack.
F 428: The facility failed to notify physicians of pharmacist consultant recommendations for Residents #31 and #3 regarding medication dosage adjustments and monitoring.
F 431: The facility failed to ensure safe and accurate medication administration by leaving unlabeled medication cups in the medication cart for Residents #17 and #9.
F 441: The facility failed to maintain infection control by transporting clean linens uncovered in hallways and inadequate cleaning of resident rooms, including failure to change gloves and wash hands between rooms.
F 520: The facility's Quality Assessment and Assurance Committee failed to identify, address, and implement effective corrective plans for multiple quality deficiencies including abuse, care planning, catheter care, accident prevention, medication monitoring, and medication error rates.
Report Facts
Resident census: 34
Medication administrations: 11
Medication administrations: 12
Medication administrations: 5
Medication administrations: 3
Medication administrations: 9
Medication administrations: 2
Medication administrations: 5
Medication administrations: 7
INR lab result: 2.17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administered medications incorrectly and left unlabeled medication cups | |
| Administrative Nurse B | Verified medication errors and failure to notify physicians | |
| Housekeeping Staff P | Inadequate cleaning practices and infection control lapses | |
| Housekeeping Supervisor Q | Provided cleaning protocol information | |
| Nurse J | Discussed medication monitoring and neurological assessments | |
| Nurse L | Verified catheter care and medication monitoring issues | |
| Administrative Staff G | Verified unsafe environment concerns | |
| Nurse Aide I | Provided resident care and supervision information | |
| Nurse Aide H | Verified catheter care standards |
Inspection Report
Plan of Correction
Deficiencies: 16
Date: 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. It outlines corrective actions to address abuse/neglect allegations and other regulatory concerns.
Findings
The plan details suspension of a staff member pending investigation, interviews with residents and staff finding no substantiated abuse beyond the alleged victim, and multiple corrective actions including staff training, policy updates, and enhanced monitoring to prevent future incidents.
Deficiencies (16)
F223-G: The facility suspended Staff D pending investigation to ensure no other residents were put in immediate jeopardy. Interviews and notarized statements found no substantiating evidence of abuse or neglect with other residents.
F225-L: Staff D was suspended from work until investigation completion. No substantiating evidence of abuse or neglect was found with other residents after interviews and statements.
F241-E: Staff were in-serviced on expectations for gathering resident weekly weights with measures to respect resident dignity and proper monitoring by Dietary and Medical Records staff.
F253-E: Facility is addressing maintenance issues including tile cracks, linoleum discoloration, and sidewalk repairs with projected completion dates in 2015 and 2016.
F278-D: Resident #30's MDS was corrected to reflect a non-injury fall. QA/QI and Casper reports are reviewed quarterly to ensure accurate coding and care planning.
F280-D: Care plan for Resident #13 updated to reflect urinary catheter care with audits to ensure checkpoints are met upon admission or condition changes.
F309-D: Neuro checks policy updated for unwitnessed falls or head injuries. Nurses trained and Medical Records monitor compliance with guidelines.
F315-D: Residents #13 and #17 have catheter bags with shorter straps to prevent dragging. Care plans updated and monitored by charge nurse.
F323-D: Safety measures implemented for Resident #6 including locking hazards and monitoring woodworking equipment use. Monthly safety audits include risk factors for cognitively impaired residents.
F329-D: Nurses follow guidelines for PRN and new medications. Medication pass competency completed and monitored quarterly by DON.
F332-E: Residents protected from medication pass errors by adherence to five rights. Competency training completed and ongoing.
F425-D: Guidelines established for medication change-out processes to avoid errors. Nursing staff responsible for addressing labeling discrepancies with pharmacy.
F428-D: Pharmacy recommendations completed for January and February. Medication regimens reviewed by mental health clinician and primary care physician.
F431-D: Residents receive correct medications administered by nursing staff. Medication pass competency includes training on interruptions and resident identification.
F441-E: Environmental Services staff in-serviced on cleaning, infection control, and hand hygiene. Random audits conducted to ensure compliance and prevent disease transmission.
F520-F: QA team to implement more hands-on approach to identify and address deficiencies. Monthly meetings with Medical Director to monitor effectiveness of corrective actions.
Report Facts
Completion Date: Feb 25, 2015
Completion Date: Feb 26, 2015
Completion Date: Mar 9, 2015
Completion Date: Feb 27, 2015
Projected Completion Date: Dec 31, 2015
Projected Completion Date: May 31, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betty Behrens | CMA | Subject of investigation and suspension pending determination of return to work or termination |
| Christen Robinson | Administrator | Named as part of investigation and communication with Ombudsman |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 11, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied 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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that is widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Dec 11, 2014
Provider agreement termination date: Mar 11, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process and Director of Fire Prevention Division, SFMO. |
| Joe Ewert | Commissioner | Commissioner at KDADS copied on the report. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 8, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-12-23.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0225, F0441, and F0464 were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 2014-01-08.
Regulation 483.65 deficiency was corrected by 2014-01-08.
Regulation 483.70(g) deficiency was corrected by 2014-01-08.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 6, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions to address deficiencies related to reporting unwitnessed falls, sanitizing nebulizer equipment, and resident positioning during dining.
Deficiencies (4)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations, reviewed by the Quality Assurance Committee.
F225: A report will be filed for Resident #21 regarding unwitnessed falls with injury, and the facility will follow policies for reporting alleged abuse and neglect within 24 hours.
F441: Residents had their nebulizer masks and tubing bagged; staff were retrained on glucometer cleaning, and monitoring systems were implemented to ensure sanitation and supply management.
F464: Resident #21 was repositioned in a regular dining chair to improve positioning; the Nutrition/Weight committee added reminders to prevent positioning issues for other residents.
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 24, 2013
Visit Reason
The visit was a licensure resurvey to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 3
Date: Dec 23, 2013
Visit Reason
The visit was a health resurvey to assess compliance with regulatory requirements following a prior inspection.
Findings
The facility failed to notify the state agency of unwitnessed falls with injuries for one resident, did not maintain proper infection control practices regarding nebulizer equipment and glucometer cleaning, and failed to provide adequate dining furnishings for a resident.
Deficiencies (3)
F225: The facility failed to notify the state agency for Resident #21's unwitnessed falls with injuries on 11/5 and 11/27/13 as required by policy.
F441: The facility failed to maintain infection control by not covering nebulizer equipment for 8 residents and improperly cleaning glucometers used for 14 residents.
F464: The facility failed to provide adequate dining furnishings for Resident #21, whose wheelchair was too low for the dining table, impairing ability to eat and drink.
Report Facts
Resident census: 35
Residents reviewed: 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
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 7, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.25(h), 483.25(l), 483.60(c), and 483.65 were corrected as of the revisit date.
Deficiencies (4)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(l): Previously cited deficiency was corrected by the revisit date.
Regulation 483.60(c): Previously cited deficiency was corrected by the revisit date.
Regulation 483.65: Previously cited deficiency was corrected by the revisit date.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 4
Date: Oct 16, 2012
Visit Reason
The visit was a health resurvey to assess compliance with previously identified deficiencies and regulatory requirements at Lincoln Park Manor Inc.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe environment free of accident hazards, failure to ensure drug regimens were free from unnecessary drugs, failure to report medication irregularities, and inadequate infection control practices related to glucometer sanitation.
Deficiencies (4)
F323: The facility failed to provide an environment free from accident hazards for 3 cognitively impaired, independently mobile residents due to an unlocked closet containing harmful chemicals.
F329: The facility failed to ensure residents' drug regimens were free from unnecessary drugs, including prolonged use of hypnotics without adequate rationale or monitoring for 3 sampled residents.
F428: The facility's pharmacist failed to report drug regimen irregularities to the physician or Director of Nursing for 3 residents, including failure to address prolonged hypnotic use and lack of required lab monitoring.
F441: The facility failed to maintain infection control practices by not properly disinfecting glucometers between resident uses, risking transmission of infection for 10 residents.
Report Facts
Resident census: 28
Sampled residents: 18
Residents reviewed for unnecessary drugs: 10
Residents requiring blood glucose checks: 10
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 15, 2012
Visit Reason
This document is a Plan of Correction submitted by Lincoln Park Manor addressing deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to door lock security for hazardous areas, medication management including gradual dose reductions of antipsychotics, pharmacy consultant review processes, and infection control practices involving glucose monitoring equipment cleaning.
Deficiencies (5)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations, discussed with the Quality Assurance Committee on 10/23/12.
F323-D: Key-in lock levers will be installed on all doors leading to chemical and biohazard storage to prevent access by cognitively impaired residents, with monthly door checks ongoing.
F329-D: Residents had medication adjustments and monitoring for side effects; pharmacy consultant reviews and gradual dose reductions of antipsychotics are implemented with bi-monthly QA audits.
F428-D: Pharmacy consultant drug review completed with changes to include face-to-face exit conferences with DON and follow-up on recommendations to ensure accuracy and compliance.
F441-E: Super Sani Wipes were replaced by Clorox Germicidal Wipes for glucose monitor disinfection; nurse competency audits and continuous education on infection control are ongoing.
Report Facts
Complete Date: Nov 7, 2012
Complete Date: Oct 15, 2012
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 23, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected as of 08/23/2011.
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Date: Aug 17, 2011
Visit Reason
The inspection was conducted as a health facility resurvey and complaint investigation related to complaint #50971 concerning failure to report a resident fall with injury.
Complaint Details
The complaint investigation was related to failure to report a fall with injury of Resident #21. The complaint was substantiated as the facility did not report the incident to the state agency as required.
Findings
The facility failed to report a fall with injury of Resident #21 to the state agency. The resident had multiple diagnoses and was found on the floor with injuries including a large laceration and bruising. The facility's policies required reporting such incidents, but the fall was not reported within the required timeframe.
Deficiencies (1)
483.13(c)(1)(ii)-(iii), (c)(2)-(4) - The facility failed to report a fall with injury of Resident #21 to the state agency within 5 working days as required by state law and facility policy.
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. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N053001 POC PO2J11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N053001.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a Plan of Correction submission with no records found or described.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N053001 POC RIBL11
Visit Reason
This document is a plan of correction related to a previous inspection or deficiency report for Lincoln Park Manor.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N053001 POC 20J411
Visit Reason
This document is a plan of correction related to a prior inspection event at Lincoln Park Manor.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N053001 POC BMY511
Visit Reason
This document is a Plan of Correction related to deficiencies cited in a prior inspection of Lincoln Park Manor ALF.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
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