Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincoln Park Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
During a COVID-19 outbreak, five staff members, including a laundry employee, LNHA, IT staff, a psychiatrist, and a student intern, failed to wear required surgical masks or wore them incorrectly in areas where PPE was mandated. Two residents were COVID positive, and several rooms were under droplet precautions, yet staff non-compliance with infection control protocols was observed and acknowledged by facility leadership.
The facility failed to follow proper infection control practices and hand hygiene during meal service and tracheostomy care. CNAs did not perform hand hygiene between residents, and an LPN did not adhere to hand hygiene protocols during tracheostomy care for a resident on Enhanced Barrier Precautions. These actions were contrary to the facility's policies, as confirmed by staff interviews.
A facility failed to administer a full dose of Risperidone to a resident with schizophrenia. During a medication pass, an RN diluted the medication in water, but the resident did not consume the entire dose. The RN acknowledged the error after observing leftover medication in the cup, indicating the resident did not receive the full prescribed amount.
A facility failed to provide proper pharmaceutical services, including an unlockable medication refrigerator, improper handling of controlled substances, and borrowing medications between residents. A medication refrigerator was found unlocked, and a discharged resident's medication was not removed from inventory. Additionally, a nurse borrowed medications from other residents for a newly admitted resident, and a discontinued medication was not removed from active inventory.
A resident with chronic health conditions was not offered the pneumococcal vaccination according to CDC guidelines. The facility's policy did not reflect current recommendations, and the resident's immunization record lacked necessary details. The RN/IP and DON could not justify the administration of Prevnar 13, and there was no documentation of communication with the physician regarding CDC recommendations.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Enforce PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow infection control procedures on all three nursing units during a COVID-19 outbreak. Specifically, five out of thirteen staff members were observed not wearing required personal protective equipment (PPE), such as surgical masks, in designated areas where mask use was mandated. During the initial tour, a laundry employee was seen without a surgical mask and stated they were unaware of the requirement. The Licensed Nursing Home Administrator (LNHA) and an Information Technology (IT) employee also entered a unit without masks, later stating they forgot to put them on. Additionally, a psychiatrist and a student intern were observed at the nursing station with their surgical masks worn improperly under their chins and acknowledged this during an interview. The facility's outbreak response plan required all personnel to wear PPE, including respiratory protection, in common areas and when entering rooms under droplet precautions. At the time of the survey, two residents were COVID positive, and several rooms were under droplet precautions with appropriate signage and PPE supplies available. Despite these protocols, multiple staff members failed to comply with mask requirements in common areas, as confirmed by both observation and staff interviews. The Director of Nursing (DON) acknowledged that the observed staff should have been wearing surgical masks in the affected building.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices and hand hygiene during meal service and tracheostomy care, as observed by surveyors. On the first-floor JDT unit, a Certified Nursing Assistant (CNA) did not perform hand hygiene between residents while serving meals, despite acknowledging the facility's policy requiring such practices. Similarly, on the 2 East unit, another CNA failed to perform hand hygiene between residents and did not follow Enhanced Barrier Precautions (EBP) protocols, which require hand hygiene before entering and after leaving rooms of residents on EBP. Additionally, a Licensed Practical Nurse (LPN) on the 2 East unit did not perform proper hand hygiene during tracheostomy care for a resident on EBP. The LPN washed her hands without lathering outside the stream of water and used the same paper towel to turn off the faucet, contrary to the facility's hand hygiene policy. The LPN acknowledged the mistake, attributing it to nervousness. The facility's policies, including the Hand Hygiene policy and Enhanced Barrier Precaution Policy, emphasize the importance of hand hygiene in preventing the spread of infections. However, staff members failed to comply with these guidelines, as confirmed by interviews with the Infection Preventionist and the Director of Nursing. These deficiencies were observed and documented by the surveyor, highlighting lapses in infection control practices within the facility.
Failure to Administer Full Dose of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that an antipsychotic medication was administered in accordance with professional standards of clinical practice to a resident experiencing episodes of auditory hallucinations. During a medication pass observation, a Registered Nurse (RN) was responsible for administering Risperidone Solution to the resident. The RN diluted the medication in water, as the resident preferred it this way, but did not ensure the full dose was consumed. After administering the medication, the RN noticed that some of the diluted solution remained in the cup, indicating that the resident did not receive the full prescribed dose. The resident involved had a history of paranoid schizophrenia and anxiety disorder, with documented episodes of auditory hallucinations. The RN's medication pass observation competencies showed a history of errors, although none were recorded in the most recent assessment. The incident was observed by a surveyor, who confirmed with the RN that the full dose was not administered. The RN acknowledged the mistake and stated that the resident likely did not receive the entire 4 mg dose as ordered by the physician.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to consistently provide pharmaceutical services in accordance with professional standards, as observed during a survey. One of the deficiencies involved a medication refrigerator on the 3-West unit that was not lockable, containing prescription medications such as insulin. The Licensed Practical Nurse (LPN) on duty was unaware of the lock's functionality, and attempts by multiple staff members, including the Assistant Director of Nursing (ADON), to lock the refrigerator were unsuccessful. This issue was acknowledged by the Director of Nursing (DON) during a discussion with the surveyor. Another deficiency was identified in the handling of controlled substances. A discrepancy was found in the narcotic count for a resident who had been discharged from the facility. The resident's Lorazepam medication was not removed from the active inventory, and a tablet was unaccounted for. The LPN involved admitted to an error in the shift-to-shift count and acknowledged that the medication should have been removed or returned to the pharmacy upon the resident's discharge. The ADON confirmed that the medication should have been pulled to prevent errors and misplacement. Additionally, the facility was found to have borrowed medications from one resident to administer to another, which is against policy. A newly admitted resident experienced a seizure, and due to the unavailability of their medications, the LPN borrowed Lorazepam and Keppra from other residents. This action was confirmed by the DON after reviewing camera footage. Furthermore, a discontinued medication for another resident was not removed from the active inventory, and an undated bottle of blood glucose test strips was found in a narcotic box, which should have been dated according to the manufacturer's specifications.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #114, was offered the pneumococcal vaccination according to the current CDC and ACIP recommendations. The resident, who had a history of chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, was observed by a surveyor and had a BIMS score indicating intact cognition. Despite the resident's medical record indicating that their pneumococcal vaccine was up to date, documentation showed that they had received Prevnar 13, and there was no record of prior pneumococcal immunization or an offer of PCV15 or PCV20 as recommended by the CDC. The facility's policy on pneumococcal vaccination, dated September 10, 2023, stated that vaccinations should be administered in accordance with CDC recommendations. However, the policy did not reflect the current recommendations, and the resident's immunization record lacked essential details such as the type of vaccine administered, site, date, lot number, expiration date, and the name of the person administering the vaccine. The RN/IP and DON were unable to provide a rationale for the administration of Prevnar 13 instead of the recommended vaccines, and there was no documentation of communication with the physician regarding the CDC's current recommendations. During interviews, the RN/IP and DON acknowledged the oversight, and the DON stated that the policy was updated following the surveyor's inquiry. The physician involved indicated that Prevnar 13 was still relevant and that PCV20 could be administered as a subsequent dose. However, the facility's documentation practices did not align with their policy, as there was no record of the physician's rationale for choosing Prevnar 13 or any communication about the CDC's recommendations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincoln Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Park Renaissance | 0.1 mi | — | 16 | 0 |
| Atrium Post Acute Care Of Wayneview | 2.8 mi | — | 1 | 0 |
| Careone At Wayne | 3.4 mi | — | 8 | 0 |
| Atrium Post Acute Care Of Wayne | 3.8 mi | — | 0 | 0 |
| Complete Care At West Caldwell Llc | 4.1 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.