Inspection Reports for
Lincoln Park Renaissance
521 Pine Brook Road, Lincoln Park, NJ, 07035
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
95% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Date: 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
Annual Inspection
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
Annual inspection survey of Lincoln Park Renaissance nursing home conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 0
Date: 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
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 176
Capacity: 189
Deficiencies: 7
Date: 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.
Complaint Details
Complaint investigations were conducted for complaint numbers NJ 173810, 174365, 174581, 175435, 176286, 177537, 177694. Deficiencies were cited related to these complaints.
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.
Deficiencies (7)
Facility failed to maintain the call bell within reach of residents.
Facility failed to start, complete and transmit the Minimum Data Set (MDS) assessments timely and accurately.
Facility failed to meet professional standards of care in medication administration.
Facility failed to ensure adequate staffing ratios as mandated by the state of New Jersey.
Facility failed to ensure doors with self-closing devices were functioning properly in accordance with NFPA 101 Life Safety Code.
Facility failed to ensure smoke barriers were free from unsealed gaps and penetrations.
Facility failed to ensure residents received appropriate care related to incontinence, respiratory care, dialysis, and mobility.
Report Facts
Census: 176
Total Capacity: 189
Deficiencies cited: 7
Staffing ratios: 21
Staffing ratios: 23
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to complaints NJ 177694 and NJ 176286 concerning failure to ensure an abnormal urine lab result was communicated to the physician and treated timely for Resident #319.
Complaint Details
Complaint NJ 177694 and NJ 176286 involved failure to communicate and treat an abnormal urine lab result for Resident #319. The complaint was substantiated with findings of delayed treatment and lack of documented communication.
Findings
The facility failed to communicate and treat an abnormal urine culture and sensitivity result for Resident #319 in a timely manner, resulting in delayed treatment of a urinary tract infection caused by Pseudomonas Aeruginosa. Documentation of communication with the physician was lacking, and treatment was delayed four days after lab results were available.
Deficiencies (1)
Failure to ensure abnormal urine lab results were communicated to the physician and treated timely for Resident #319.
Report Facts
Colony count: 100000
BIMS score: 3
Date of physician order: Oct 26, 2023
Date of urine sample collection: Nov 29, 2023
Date final lab report: Dec 2, 2023
Days delayed treatment: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Infection Preventionist (LPN/IP) | Interviewed regarding ordering and communication of UA/C&S results | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding lack of documented communication of lab results and follow-up | |
| Nurse Practitioner (NP) | Interviewed regarding treatment standards and involvement of infectious disease prescriber |
Inspection Report
Routine
Deficiencies: 11
Date: Oct 10, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain call bells within reach, incomplete and inaccurate Minimum Data Set (MDS) assessments, medication administration errors, inadequate incontinence care, failure to communicate abnormal lab results timely, failure to follow physician orders for oxygen therapy and orthopedic device use, inconsistent post-dialysis assessments, and insufficient nursing staff to meet resident needs.
Deficiencies (11)
Failure to maintain call bells within reach of residents #59 and #127.
Failure to complete and transmit Minimum Data Set (MDS) for death and discharge in a timely manner for residents #144 and #54.
Inaccurate MDS assessments for residents #88, #77, #129, and #25 including oral health, splint use, catheter use, and skin condition.
Failure to follow professional standards in medication administration including missed blood pressure check for Resident #131 and missed narcotic administration for Resident #367.
Failure to perform consistent pain assessments and monitoring for Resident #14.
Failure to provide timely incontinence care to dependent residents #59, #82, and #29.
Failure to communicate abnormal urine lab results timely and provide treatment for Resident #319.
Failure to follow physician's order for placement of orthopedic device for Resident #77.
Failure to administer oxygen therapy according to physician's order for Residents #29 and #136.
Failure to assess vital signs and dialysis access site for complications upon return from dialysis for Residents #90 and #134.
Failure to maintain required minimum direct care staff-to-resident ratios, resulting in deficient CNA staffing on multiple day shifts.
Report Facts
Residents reviewed: 38
Residents reviewed for pain management: 1
Residents reviewed for dialysis care: 2
CNA staffing deficiency days: 13
CNA staffing deficiency days: 5
Residents on day shifts: 170
Required CNAs: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Acknowledged call bells should be kept within reach but did not ensure it for residents #59 and #127 | |
| Licensed Nursing Home Administrator | Acknowledged all residents should have call bells within reach | |
| Regional Director of Nursing | Acknowledged call bell requirements and medication administration concerns | |
| Registered Nurse / MDS Director | Acknowledged inaccuracies in MDS assessments and incomplete submissions | |
| Director of Nursing | Discussed concerns regarding pain assessments and staffing | |
| Licensed Practical Nurse / Infection Preventionist | Discussed medication administration and lab communication practices | |
| Licensed Practical Nurse / Unit Manager | Discussed dialysis communication and oxygen therapy concerns |
Inspection Report
Census: 175
Capacity: 189
Deficiencies: 13
Date: 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.
Complaint Details
Complaint #NJ165572, NJ155763 involved failure to timely report witnessed abuse and neglect incidents for residents R21 and R122.
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.
Deficiencies (13)
Failure to provide a safe, clean, and homelike environment including dirty and broken windows, leaking ceiling pipes, and failure to protect resident property.
Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment timely to the state survey agency.
Failure to provide required written notice before transfer or discharge including reason, location, appeal rights, and ombudsman contact information.
Failure to encode and transmit Minimum Data Set (MDS) discharge assessment timely.
Failure to accurately assess and encode MDS related to presence of indwelling catheter.
Failure to provide assistance with facial grooming for dependent residents.
Failure to maintain a quality assessment and assurance committee with required members and documentation of attendance.
Failure to follow infection prevention and control practices including hand hygiene and glove use.
Failure to ensure residents received influenza and pneumococcal immunizations per CDC guidelines.
Failure to provide behavioral health training to direct care staff consistent with facility assessment.
Failure to ensure fire rated door assemblies for stairway exit doors were equipped with approved fire exit hardware instead of panic hardware.
Failure to ensure sprinklers were located to provide protection of an area in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems.
Failure to ensure sprinklers were free of paint and any painted sprinkler heads were replaced in accordance with NFPA 25.
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
Routine
Census: 175
Deficiencies: 10
Date: Jul 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident safety, care, and facility environment, including investigation of complaints and review of facility policies and practices.
Complaint Details
Complaint #NJ165572, NJ155763 involved failure to timely report a witnessed resident-to-resident altercation and an injury of unknown origin. The injury was reported to the State Agency with delay, and the altercation was reported but verification of receipt by the State Agency was lacking.
Findings
The facility failed to maintain a safe, clean, and homelike environment, including issues with dirty and broken windows, leaking ceiling pipes, and missing resident property. Additional deficiencies included failure to timely report incidents, inadequate transfer/discharge notifications, delayed MDS transmissions, inaccurate resident assessments, inadequate assistance with activities of daily living, incomplete quality assurance committee documentation, improper infection control practices, incomplete pneumococcal vaccination coverage, and lack of behavioral health training for staff.
Deficiencies (10)
Failed to provide a safe, clean, and homelike environment including dirty and broken windows, leaking ceiling pipes, and missing resident property.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to provide timely notification to residents and representatives before transfer or discharge including appeal rights.
Failed to encode and transmit Minimum Data Set (MDS) discharge assessment within required timeframe.
Failed to accurately assess and encode presence of indwelling catheter in MDS.
Failed to provide assistance with facial grooming and preserve dignity for residents.
Quality Assurance committee failed to ensure required members attended quarterly meetings.
Failed to follow appropriate infection control practices for hand hygiene and glove use.
Failed to ensure residents were up to date with pneumococcal vaccinations per CDC guidelines.
Failed to provide behavior health training consistent with requirements for staff caring for residents with mental health illnesses.
Report Facts
Residents affected: 175
Residents affected: 3
Grievance date: 2023
Bruise size: 18
MDS delay: 120
QAPI meeting date: 2022
Hand hygiene duration: 20
Pneumococcal vaccine dates: 5
Behavioral health training hours: 17.5
Residents with depression: 86
Residents with psychiatric diagnoses: 36
Residents with behavioral healthcare needs: 9
Residents prescribed psychoactive medications: 118
Residents prescribed antipsychotic medications: 20
Residents prescribed anxiolytic medications: 33
Residents prescribed antidepressant medications: 77
Residents prescribed hypnotic medications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA4 | Certified Nurse Aide | Instructed to shave resident R84 and did so |
| LPN1 | Licensed Practical Nurse | Expected CNAs to shave residents' facial hair every other day and instructed CNA4 to shave R84 |
| Administrator | Provided information on grievance and missing items process, transfer notifications, and QAPI meetings | |
| Director of Nursing | DON | Reviewed MDS assessments, acknowledged vaccination and training deficiencies, and stated expectations for resident care |
| Director of Plant Operations | DPO | Provided information on window cleaning and maintenance |
| Social Worker 2 | SW2 | Investigated missing items and grievances |
| Regional Director of Nursing | RDON | Discussed reporting requirements and behavioral health training |
| Certified Nurse Aide 5 | CNA5 | Observed failing to perform hand hygiene properly |
| Licensed Practical Nurse 3 | LPN3 | Stated no behavioral health training received |
| Licensed Practical Nurse 4 | LPN4 | Stated no behavioral health training received |
| Licensed Practical Nurse 5 | LPN5 | Stated no behavioral health training received |
| Chief Operating Officer | COO | Acknowledged lack of behavioral health training evidence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report a witnessed resident-to-resident altercation and an injury of unknown origin as required by state regulations.
Complaint Details
Complaint #NJ165572, NJ155763 involved failure to timely report a witnessed resident-to-resident altercation and an injury of unknown origin. The complaint was substantiated based on interviews, record review, and policy review.
Findings
The facility failed to report within the required timeframe a resident-to-resident altercation and an injury of unknown origin. The injury was reported late, and the facility did not recognize the significance of the injury until the following day. The facility policy requires immediate reporting of such incidents to the state survey agency.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Bruise size: 18
Bruise size: 20
Report time delay: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Provided statement about bruise discovery on 07/06/23 |
| Regional Director of Nursing | RDON | Interviewed regarding reporting procedures and verification of report to State Survey Agency |
| Administrator | Confirmed reportable form and explained delay in recognizing injury significance |
Inspection Report
Abbreviated Survey
Census: 177
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to ensure signage on the door of residents' rooms indicated the type of isolation and PPE required before entry.
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
Date: 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.
Deficiencies (10)
Failed to develop a person-centered comprehensive care plan for Resident #55.
Failed to maintain professional standards of clinical practice including following physician orders and accurate medication administration for multiple residents.
Failed to ensure care and treatment to prevent and heal a facility acquired pressure ulcer for Resident #52.
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.
Failed to properly label, store, and secure medications and medication rooms.
Failed to follow infection prevention and control practices including proper disposal of PPE, hand hygiene, and use of PPE for staff.
Failed to provide instructional signage on exit doors with delayed egress devices.
Failed to provide continuous lighting for means of egress.
Failed to ensure vertical openings were properly enclosed with 1-hour fire rated material.
Failed to ensure combustible storage rooms exceeding 50 square feet were equipped with self-closing doors.
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
Deficiencies: 6
Date: Jun 15, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including care planning, medication management, wound care, nutrition, medication storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, medication errors and improper medication storage, inadequate wound care and documentation, failure to prevent significant weight loss and properly monitor nutrition, and lapses in infection control practices including improper PPE use and hand hygiene.
Deficiencies (6)
Failure to develop a person-centered comprehensive care plan for a resident's indwelling catheter.
Failure to maintain professional standards in medication administration, including not following physician orders, inaccurate transcription, and improper signing of medication records.
Failure to provide appropriate pressure ulcer care, including lack of RN assessment, missing physician orders, improper offloading, and no comprehensive care plan for a facility-acquired pressure ulcer.
Failure to prevent severe weight loss, including lack of timely identification, monitoring, nutritional intervention, and care plan revision.
Failure to secure medication rooms and properly label, store, and dispose of medications, including expired and improperly stored medications.
Failure to implement infection prevention and control program, including improper disposal of PPE, inadequate hand hygiene, and improper use of PPE by staff.
Report Facts
Weight loss: 8.6
Weight loss: 7.7
Weight loss: 2.1
Weight: 89.2
Weight: 80.6
Weight: 72.9
Weight: 72.6
Weight: 70.8
Weight loss: 18.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error finding and medication storage deficiency; also involved in infection control deficiency |
| LPN #2 | Licensed Practical Nurse | Named in medication error finding and infection control deficiency |
| LPN #3 | Licensed Practical Nurse / Infection Control Preventionist | Named in medication storage deficiency and infection control deficiency |
| LPN #4 | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN #5 | Licensed Practical Nurse | Named in medication storage deficiency |
| RN #1 | Registered Nurse | Named in medication storage deficiency and wound care deficiency |
| CNA #1 | Certified Nursing Assistant | Named in infection control deficiency |
| CNA #2 | Certified Nursing Assistant | Named in infection control deficiency |
| CNA #3 | Certified Nursing Assistant | Named in infection control deficiency |
| RD | Registered Dietitian | Named in nutrition deficiency |
| DON | Director of Nursing | Named in multiple findings including wound care, nutrition, medication storage, and infection control |
| LNHA | Licensed Nursing Home Administrator | Named in infection control deficiency |
| AIT | Administrator in Training | Named in infection control deficiency |
| Physiatrist Physician Assistant | Physician Assistant | Named in wound care deficiency and nutrition deficiency |
Inspection Report
Routine
Census: 145
Deficiencies: 0
Date: 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
Date: Dec 17, 2020
Visit Reason
The inspection was conducted based on complaints NJ00139485, NJ00134090, and NJ00133335.
Complaint Details
Complaint numbers NJ00139485, NJ00134090, and NJ00133335 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Facility administration failed to cancel indoor visitation during a COVID-19 outbreak as required by Executive Directive No. 20-026.
Report Facts
Census: 121
Sample Size: 3
Positive COVID-19 cases among employees: 2
Indoor visitation dates: 5
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