Inspection Reports for
Lincoln Hills of New Albany

The facility failed to ensure timely removal of meal trays for residents, proper revision of care plans for dementia residents, and maintenance of a clean and sanitary kitchen environment. Several residents were observed with uneaten meals left unattended, and the kitchen had expired condiments and unsanitary conditions.

This citation relates to Complaint IN00452723.

The facility failed to ensure a timely care plan was in place for a resident who frequently removed hipsters intended to reduce fall injury risk, resulting in a fall and hip fracture. The facility lacked a formal policy on care plans but followed the Resident Assessment Instrument manual.

Complaint IN00452723 was substantiated with a Federal/State deficiency cited as F656. Complaint IN00452878 had no deficiencies related to the allegations.

The facility was found deficient related to Complaint IN00452723 involving failure to ensure a timely plan of care for a resident's non-compliance with fall interventions, specifically the use of hipsters. Complaint IN00452878 had no deficiencies cited.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including issues with emergency power system maintenance, fire door latching, sprinkler system obstructions and maintenance, corridor door latching, combustible decorations on resident room doors, and fire drill timing. Corrective actions and plans of correction were submitted with a completion date of October 31, 2024.

The facility failed to promptly resolve Resident Council grievances, ensure mail delivery on Saturdays, prevent worsening pressure ulcers in a resident, conduct hot liquid assessments for residents with feeding difficulties, and properly document narcotic administration on Controlled Drug Records.

Complaint IN00443610 and IN00443867 were investigated with no deficiencies related to the allegations cited.

The facility was found to have deficiencies related to resident council grievance resolution, mail delivery on Saturdays, pressure ulcer care resulting in a Stage 4 pressure ulcer for one resident, failure to complete hot liquid assessments for a resident with functional decline, and narcotic documentation discrepancies for six residents.

This citation relates to Complaint IN00422843. The complaint involved failure to provide adequate care and supervision for a resident with dementia exhibiting multiple behavioral issues.

The facility failed to ensure appropriate interventions, supervision, and care for a resident with dementia-related behaviors, including wandering into other residents' rooms, removing his colostomy bag, exhibiting sexually inappropriate behaviors, verbal and physical aggression, and inadequate care plan updates. Staff monitoring and redirection were inconsistent, and the resident's care plan lacked sufficient specific interventions for behavior management.

Complaint IN00422843 was substantiated with a federal/state deficiency cited at F0744 related to the allegations. Complaint IN00424143 had no deficiencies related to the allegations.

The facility failed to ensure appropriate interventions, supervision, and care for a resident with dementia-related behaviors. Resident B exhibited multiple behavioral issues including wandering into other residents' rooms, removing his colostomy bag, sexually inappropriate behaviors, verbal and physical aggression, and difficulty with redirection. The care plans lacked sufficient updates and specific interventions to manage these behaviors effectively. Staff monitoring and supervision were inconsistent, and the facility did not implement increased monitoring despite the resident's ongoing behaviors.

Complaint Number IN00420897 was investigated and a Federal/State deficiency related to the allegation was cited at K712.

The facility was found in substantial compliance with Medicare/Medicaid participation requirements and Life Safety Code. However, the facility failed to ensure that one fire drill report during the past month included complete documentation of the transmission of the fire alarm signal to the monitoring company/fire department.

The facility was found not in compliance with Life Safety Code requirements including issues with egress doors, smoke barrier doors, exit discharge surfaces, illumination of means of egress, fire alarm system installation and maintenance, sprinkler system installation and maintenance, portable fire extinguishers, and electrical safety. The facility submitted plans of correction for all deficiencies.

The facility was found deficient in multiple areas including failure to notify physicians of critical blood sugar and weight changes, inadequate fall prevention and supervision, improper infection control during perineal care, and insufficient pain management interventions.

The visit included a Complaint Survey conducted on August 29, 2023, related to allegations of noncompliance, with a Plan of Correction submitted alleging substantial compliance by September 13, 2023.

The facility was found deficient in multiple areas including failure to notify physicians of significant changes in residents' conditions such as out-of-range blood sugar readings and dialysis weight gains, failure to implement fall prevention interventions, improper perineal care infection control practices, and inadequate pain management interventions.

Complaint IN00412136 alleged failure to notify the physician of a resident's change in condition and failure to provide appropriate care. The complaint was substantiated with findings of delayed physician notification, failure to follow physician orders, and inadequate monitoring leading to resident death.

The facility failed to ensure prompt physician notification of a resident's change in condition and failed to provide appropriate care and monitoring for a resident with respiratory failure and hypercapnia. The resident experienced a significant decline, was left unattended while in respiratory distress, and was found deceased in her wheelchair. The facility also failed to ensure proper use of the resident's BIPAP device and timely assistance to bed.

Complaint IN00412136 triggered the investigation. The complaint involved allegations of substandard quality of care and immediate jeopardy related to failure in physician notification, professional standards of care, and quality of care resulting in a resident's death.

The facility failed to ensure prompt physician notification of a resident's change in condition, failed to meet professional standards of care related to implementation of physician orders and provision of medically necessary emergent care, and failed to provide appropriate care and monitoring for a resident with respiratory failure and hypercapnia, resulting in the resident's death. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

The complaint investigation was triggered by an incident on 5/23/23 where Resident G spilled hot coffee on himself, resulting in blistered areas on his thighs. The investigation found the resident was not formally assessed for hot liquid safety and the facility lacked a specific hot liquids assessment policy.

The facility failed to ensure a hot liquid assessment was completed for a resident with a decline in function who spilled hot coffee and sustained burn wounds. Interviews and record reviews revealed lack of a formal hot liquid assessment policy and inconsistent monitoring of the resident's ability to safely handle hot liquids.

Complaint IN00404123 and IN00407228 were investigated with no deficiencies related to the allegations cited. The deficiency found was unrelated to the complaints.

The facility failed to ensure a hot liquid assessment was completed for a resident with a decline in function, resulting in a burn injury from spilled coffee. The resident required a no-spill cup and increased supervision. The facility implemented corrective actions including observation during meal service and referrals to occupational therapy.

Complaint IN00391638 was substantiated with a related federal/state deficiency cited at F689. Complaints IN00389798 and IN00387110 were substantiated but no deficiencies related to those allegations were cited.

The facility was found to have failed to obtain a physician's order and ensure safe usage of warm compresses, resulting in second-degree burns to one resident's back. The resident developed blisters and subsequent complications including sepsis. The facility took immediate corrective actions including re-education of staff and disciplinary action for the nurse involved.

The facility was found not in compliance with several Life Safety Code requirements including maintenance of kitchen range hood extinguishing system, sprinkler system maintenance, sprinkler head cleanliness and ceiling integrity, corridor door functionality, smoke barrier wall protection, and ground fault circuit interrupter (GFCI) protection in wet locations.

Complaint IN00378436 was substantiated with no deficiencies cited. Complaint IN00383068 was substantiated with a Federal/State deficiency cited at F689 related to the allegations.

The facility was found to have deficiencies related to fall interventions, catheter care, nutrition/hydration monitoring, respiratory care, and behavioral health services. Specific issues included failure to implement safe transfer procedures resulting in resident injuries, improper catheter care, failure to follow physician orders for daily weights, inadequate oxygen concentrator maintenance, and incomplete behavioral care planning for resident aggression.