Inspection Reports for Lincoln Park Renaissance
521 Pine Brook Road, NJ, 07035
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
High
Moderate
Low
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Census: 180
Deficiencies: 0
Mar 3, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 0
Dec 23, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by CertiSurv, LLC on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 176
Capacity: 189
Deficiencies: 7
Oct 10, 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
The facility was found to have multiple deficiencies including failure to maintain call bells within reach of residents, failure to accurately complete and transmit Minimum Data Set (MDS) assessments, failure to meet professional standards of care in medication administration, failure to maintain required staffing ratios, and life safety code violations such as doors with self-closing devices not functioning properly. Corrective actions and plans of correction were initiated for all cited deficiencies.
Complaint Details
Complaint investigations were conducted for complaint numbers NJ 173810, 174365, 174581, 175435, 176286, 177537, 177694. Deficiencies were cited related to these complaints.
Severity Breakdown
Level D: 2
Level E: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to maintain the call bell within reach of residents. | Level D |
| Facility failed to start, complete and transmit the Minimum Data Set (MDS) assessments timely and accurately. | Level D |
| Facility failed to meet professional standards of care in medication administration. | Level E |
| Facility failed to ensure adequate staffing ratios as mandated by the state of New Jersey. | Level E |
| Facility failed to ensure doors with self-closing devices were functioning properly in accordance with NFPA 101 Life Safety Code. | Level E |
| Facility failed to ensure smoke barriers were free from unsealed gaps and penetrations. | Level E |
| Facility failed to ensure residents received appropriate care related to incontinence, respiratory care, dialysis, and mobility. | Level E |
Report Facts
Census: 176
Total Capacity: 189
Deficiencies cited: 7
Staffing ratios: 21
Staffing ratios: 23
Inspection Report
Census: 175
Capacity: 189
Deficiencies: 13
Jul 25, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of New Jersey Department of Health (NJDOH). The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Findings
The facility had multiple deficiencies including failure to provide a safe, clean, and homelike environment, failure to report alleged violations timely, failure to provide proper notice before transfer/discharge, failure to encode/transmit resident assessments timely, inaccurate resident assessments, failure to provide ADL care for dependent residents, failure to maintain a quality assessment and assurance committee, failure to follow infection prevention and control practices, failure to ensure influenza and pneumococcal immunizations per guidelines, and failure to provide behavioral health training to staff.
Complaint Details
Complaint #NJ165572, NJ155763 involved failure to timely report witnessed abuse and neglect incidents for residents R21 and R122.
Severity Breakdown
SS=D: 9
SS=F: 3
SS=C: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide a safe, clean, and homelike environment including dirty and broken windows, leaking ceiling pipes, and failure to protect resident property. | SS=D |
| Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment timely to the state survey agency. | SS=D |
| Failure to provide required written notice before transfer or discharge including reason, location, appeal rights, and ombudsman contact information. | SS=D |
| Failure to encode and transmit Minimum Data Set (MDS) discharge assessment timely. | SS=D |
| Failure to accurately assess and encode MDS related to presence of indwelling catheter. | SS=D |
| Failure to provide assistance with facial grooming for dependent residents. | SS=D |
| Failure to maintain a quality assessment and assurance committee with required members and documentation of attendance. | SS=F |
| Failure to follow infection prevention and control practices including hand hygiene and glove use. | SS=D |
| Failure to ensure residents received influenza and pneumococcal immunizations per CDC guidelines. | SS=D |
| Failure to provide behavioral health training to direct care staff consistent with facility assessment. | SS=C |
| Failure to ensure fire rated door assemblies for stairway exit doors were equipped with approved fire exit hardware instead of panic hardware. | SS=F |
| Failure to ensure sprinklers were located to provide protection of an area in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems. | SS=F |
| Failure to ensure sprinklers were free of paint and any painted sprinkler heads were replaced in accordance with NFPA 25. | SS=F |
Report Facts
Survey Census: 175
Total Capacity: 189
Sample Size: 39
Deficiency counts: 13
CNA staffing deficiency days: 23
Required CNA staffing: 21
Actual CNA staffing: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA5 | Certified Nurse Aide | Named in infection control hand hygiene and glove use deficiency |
| Director of Nursing | Director of Nursing | Named in multiple findings including reporting, immunization, behavioral health training, and infection control |
| Administrator | Facility Administrator | Named in reporting and staffing deficiencies |
| Maintenance Director | Maintenance Director | Named in fire safety and sprinkler system deficiencies |
| Regional Director of Nursing | Regional Director of Nursing | Named in reporting and behavioral health training deficiencies |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Named in infection control and behavioral health training deficiencies |
| Certified Nurse Aide 4 | Certified Nurse Aide | Named in ADL care deficiency |
Inspection Report
Abbreviated Survey
Census: 177
Deficiencies: 1
Dec 2, 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.
Findings
The facility failed to ensure proper signage on the doors of residents' rooms on isolation, indicating the type of isolation and required PPE, affecting 5 of 5 rooms observed. The facility had eight residents on isolation and did not comply with infection prevention and control program requirements.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure signage on the door of residents' rooms indicated the type of isolation and PPE required before entry. | SS=E |
Report Facts
Census: 177
Sample Size: 12
Residents on isolation: 8
Rooms with deficient signage: 5
Plan of Correction Completion Date: February 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Interviewed regarding isolation signage and resident isolation status |
| CNA #5 | Certified Nursing Assistant | Interviewed about PPE use and knowledge of isolation precautions |
| CNA #9 | Certified Nursing Assistant | Interviewed about isolation cart and signage knowledge |
| LPN #10 | Licensed Practical Nurse | Interviewed about resident isolation and signage expectations |
| LPN #1 | Licensed Practical Nurse | Interviewed confirming lack of proper signage on isolation rooms |
| Corporate Director of Nursing | Corporate Director of Nursing | Interviewed about expectations for transmission-based precaution signage |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control program and signage deficiencies |
Inspection Report
Annual Inspection
Census: 161
Deficiencies: 10
Jun 15, 2021
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 and implement comprehensive care plans, maintain professional standards in medication administration, treatment and prevention of pressure ulcers, nutrition and hydration status maintenance, proper labeling and storage of drugs, and infection prevention and control practices.
Severity Breakdown
SS=E: 6
SS=D: 3
SS=G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to develop a person-centered comprehensive care plan for Resident #55. | SS=E |
| Failed to maintain professional standards of clinical practice including following physician orders and accurate medication administration for multiple residents. | SS=E |
| Failed to ensure care and treatment to prevent and heal a facility acquired pressure ulcer for Resident #52. | SS=D |
| Failed to maintain acceptable nutritional status, hydration, and therapeutic diet for Resident #30, including failure to monitor significant weight loss and provide prescribed fortified foods. | SS=G |
| Failed to properly label, store, and secure medications and medication rooms. | SS=E |
| Failed to follow infection prevention and control practices including proper disposal of PPE, hand hygiene, and use of PPE for staff. | SS=E |
| Failed to provide instructional signage on exit doors with delayed egress devices. | SS=E |
| Failed to provide continuous lighting for means of egress. | SS=D |
| Failed to ensure vertical openings were properly enclosed with 1-hour fire rated material. | SS=E |
| Failed to ensure combustible storage rooms exceeding 50 square feet were equipped with self-closing doors. | SS=D |
Report Facts
Census: 161
Sample Size: 32
Weight loss: 15
Weight loss: 7.7
Weight loss: 1
Medication carts inspected: 9
Medication rooms inspected: 7
Exit doors without signage: 6
Electrical closets with ceiling breaches: 4
Combustible storage room size: 136.89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Named in medication administration and infection control findings | |
| Licensed Practical Nurse (LPN #2) | Named in medication administration and infection control findings | |
| Licensed Practical Nurse (LPN #3) | Named in medication administration and infection control findings | |
| Licensed Practical Nurse (LPN #4) | Named in medication administration findings | |
| Licensed Practical Nurse (LPN #5) | Named in medication administration findings | |
| Registered Nurse (RN #1) | Named in medication administration findings | |
| Certified Nursing Assistant (CNA #1) | Named in infection control findings | |
| Certified Nursing Assistant (CNA #2) | Named in infection control findings | |
| Certified Nursing Assistant (CNA #3) | Named in infection control findings | |
| Infection Control Preventionist (ICP)/LPN #3 | Named in infection control findings | |
| Registered Dietitian (RD) | Named in nutrition and hydration findings | |
| Assistant Director of Nursing (ADON) | Named in pressure ulcer and nutrition findings | |
| Director of Nursing (DON) | Named in multiple findings | |
| Licensed Nursing Home Administrator (LNHA) | Named in multiple findings | |
| Administrator in Training (AIT) | Named in multiple findings | |
| Physician Assistant (PA) | Named in pressure ulcer and nutrition findings | |
| Physiatrist Physician Assistant | Named in pressure ulcer findings | |
| Maintenance Director | Named in Life Safety Code findings |
Inspection Report
Routine
Census: 145
Deficiencies: 0
Feb 9, 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 and recommended practices for 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: 5
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Dec 17, 2020
Visit Reason
The inspection was conducted based on complaints NJ00139485, NJ00134090, and NJ00133335.
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 NJ00139485, NJ00134090, and NJ00133335 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Nov 17, 2020
Visit Reason
The inspection was conducted in response to complaint NJ 141060 regarding the facility's failure to cancel indoor visitation during a COVID-19 outbreak as required by Executive Directive No. 20-026.
Findings
The facility administration failed to ensure indoor visitation was canceled during a COVID-19 outbreak despite two employees testing positive within a 14-day period. Indoor visitation continued except for one unit, contrary to directives, potentially risking resident safety.
Complaint Details
Complaint NJ 141060 was substantiated based on observations, interviews, and record review showing the facility did not comply with COVID-19 visitation restrictions during an outbreak.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility administration failed to cancel indoor visitation during a COVID-19 outbreak as required by Executive Directive No. 20-026. | SS=D |
Report Facts
Census: 121
Sample Size: 3
Positive COVID-19 cases among employees: 2
Indoor visitation dates: 5
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