A list of the most recent deficiencies for Lincoln Square Post Acute Care. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-12-06 | 2024-02-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-06 | 2024-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-06 | 2024-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-06 | 2024-02-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-01 | 2023-12-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-01 | 2023-12-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-01 | 2023-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-01 | 2023-12-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-01 | 2023-12-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2023-12-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-01 | 2023-12-22 | 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 | 2023-12-01 | 2023-12-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-01 | 2023-12-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2023-12-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-01 | 2023-12-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-01 | 2023-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-22 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-06 | 2023-03-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-06 | 2023-03-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-15 | 2023-01-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-15 | 2023-01-16 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-22 | 2023-01-15 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-22 | 2023-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-22 | 2023-01-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-06 | 2022-09-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-17 | 2022-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-28 | 2022-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-28 | 2022-06-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-14 | 2022-02-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-14 | 2022-02-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-14 | 2022-02-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-14 | 2022-02-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-14 | 2022-02-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-14 | 2022-02-13 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-01-14 | 2022-02-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-14 | 2022-02-13 | 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 | 2022-01-14 | 2022-02-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-01-14 | 2022-02-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-14 | 2022-02-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-14 | 2022-02-13 | 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 | 2022-01-14 | 2022-02-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-14 | 2022-02-13 | 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 | 2022-01-14 | 2022-02-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-14 | 2022-02-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-14 | 2022-02-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-14 | 2022-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-18 | 2022-01-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-18 | 2022-01-31 | 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 | 2022-01-18 | 2022-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-18 | 2022-01-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-01-18 | 2022-01-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-22 | 2021-11-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-22 | 2021-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-14 | 2020-09-04 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-05 | 2019-09-03 | 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 | 2019-08-05 | 2019-09-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-05 | 2019-09-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-12 | 2019-08-06 | N |
