A list of the most recent deficiencies for Lincoln Park Manor Inc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-12-19 | 2024-01-31 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-19 | 2024-01-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-19 | 2024-01-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-19 | 2024-01-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-19 | 2024-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-19 | 2024-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-19 | 2024-01-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-19 | 2024-01-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-19 | 2024-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-19 | 2024-01-31 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-19 | 2024-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-19 | 2024-01-31 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-19 | 2024-01-31 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-19 | 2024-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-19 | 2024-01-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-12 | 2022-08-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-26 | 2022-06-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-26 | 2022-06-30 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-26 | 2022-06-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-26 | 2022-06-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-06-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-26 | 2022-06-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-08 | 2020-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-09-08 | 2020-10-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-09-08 | 2020-10-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-09-08 | 2020-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-08 | 2020-10-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Develop a communication plan. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-11 | 2020-03-12 | N |
