Inspection Report Summary
The most recent inspection on June 18, 2025, found the facility in compliance based on a paper review of complaint investigations. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, quality of care including activities of daily living, infection control, and life safety code compliance issues such as emergency lighting and fire system maintenance. Several complaint investigations were substantiated, including failures in blood sugar monitoring, timely incontinence care, resident safety during transport, and reporting of abuse, though many complaints were also found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in recent months with the most current inspections indicating compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
264% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00456433 and IN00460374 completed on June 5, 2025.
Complaint Details
The visit was related to complaint investigations IN00456433 and IN00460374, with the facility found in compliance based on paper review.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456433 and IN00460374 regarding quality of care issues related to blood sugar monitoring and medication administration.
Complaint Details
The investigation was triggered by complaints IN00456433 and IN00460374. Both complaints resulted in federal/state deficiencies cited at F684 related to quality of care and medication administration.
Findings
The facility failed to ensure that blood sugar monitoring, insulin, and hypoglycemic medications were administered as ordered by the physician for 3 of 3 residents reviewed. Documentation and administration of blood sugar levels and medications were incomplete or missing for multiple dates.
Deficiencies (1)
Failed to ensure residents received blood sugar monitoring, insulin, and hypoglycemic medications as ordered by the physician for 3 of 3 residents.
Report Facts
Census: 74
Total Capacity: 74
Medicare Residents: 9
Medicaid Residents: 49
Other Residents: 16
Residents Reviewed for Diabetes Management: 3
Audit Frequency: 2
Audit Duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tawana Lee-Daniel | Administrator | Signed the report and involved in the inspection process |
| Director of Nursing (DON) | Interviewed regarding blood sugar monitoring and medication administration issues | |
| Corporate RN Consultant | Interviewed and acknowledged missing blood sugar documentation and resident transfer |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00440944, IN00442521, IN00444646, and IN00446322 at Lincolnshire Health & Rehabilitation Center.
Complaint Details
Complaints IN00440944, IN00442521, IN00444646, and IN00446322 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the complaints.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 12
Inspection Report
Re-Inspection
Census: 69
Capacity: 100
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/09/24 by the Indiana Department of Health.
Findings
Lincolnshire Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for one detached storage shed.
Report Facts
Facility capacity: 100
Census: 69
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00436382 completed on July 12, 2024.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Life Safety
Census: 76
Capacity: 100
Deficiencies: 7
Date: Aug 9, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/09/2024 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included obstructed service corridor width, failure to test emergency lighting monthly, lack of self-closing device on a hazardous storage room door, fire alarm pull stations installed above the required height, unresolved fire alarm system defects, missing weekly inspections of dry pipe sprinkler system gauges and valves, and missing fire drills on one shift for one quarter.
Deficiencies (7)
Service corridor width was obstructed by wooden skids and boxes, reducing clear width to approximately 28.5 inches instead of the required minimum 44 inches.
Failed to ensure 3 of 3 battery backup emergency lights were tested monthly as required.
Corridor door to a hazardous storage room lacked a self-closing device.
Two manual fire alarm pull stations exceeded the maximum height of 48 inches from the floor.
Fire alarm system had unresolved defects including duct detectors and tamper switch not reporting to the fire panel.
Missing weekly inspections of dry pipe sprinkler system gauges and valves for several months.
Missing documentation of fire drills on the third shift for the fourth quarter of 2023.
Report Facts
Certified beds: 100
Census: 76
Deficiencies cited: 7
Fire alarm pull stations too high: 2
Battery backup lights: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Weaver | Administrator | Named in relation to exit conference and review of findings |
| Maintenance Director | Interviewed and involved in observations and findings related to corridor obstruction, emergency lighting, fire alarm system, sprinkler system, and fire drills |
Inspection Report
Annual Inspection
Census: 74
Capacity: 74
Deficiencies: 13
Date: Jul 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00436382, IN00437153, and IN00437146.
Complaint Details
Complaint IN00436382 resulted in Federal/State deficiencies related to the allegations cited at F580, F657, and F697. Complaints IN00437153 and IN00437146 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, notification of changes to residents and families, accuracy of assessments, care plan meetings, ADL care, quality of care including medication administration and skin care, hearing and vision services, range of motion treatments, nutrition and hydration, respiratory care, pain management, food preparation consistency, and infection prevention and control practices.
Deficiencies (13)
Failed to ensure residents had physician's orders for medication self-administration and assessments for 1 of 2 residents reviewed.
Failed to notify family/representative of new medication orders for 1 of 5 residents reviewed.
Failed to ensure Minimum Data Set assessments were accurately completed related to anticoagulant and diuretic medication use for 2 of 19 residents reviewed.
Failed to ensure quarterly care plan meetings were completed and/or family representatives invited for 3 of 4 residents reviewed.
Failed to ensure residents received necessary ADL care related to incontinence care documentation and nail care for 3 of 11 residents reviewed.
Failed to ensure residents received necessary care related to medication administration out of prescribed parameters, lack of assessment and treatment orders for bandages, and failure to apply heel protectors as ordered for 3 residents.
Failed to ensure residents with impaired hearing received necessary services for 1 of 1 resident reviewed.
Failed to ensure a resident received necessary treatment to prevent decreased range of motion related to a splint not in place as recommended for 1 of 3 residents reviewed.
Failed to ensure a resident with dysphagia received adaptive equipment as ordered during meals for 1 of 2 residents reviewed.
Failed to ensure infection control measures were in place related to lack of clothing protector when sorting soiled laundry, incorrect signage for contact isolation, and failure to clean shared blood pressure cuff between uses.
Failed to ensure residents received proper respiratory care related to oxygen administration for 1 of 1 resident reviewed.
Failed to ensure pain medications were available and administered per physician orders for 1 of 2 residents reviewed.
Failed to ensure food was prepared in form to meet individual needs related to not following recipe for pureed food and incorrect consistency.
Report Facts
Census: 74
Total Capacity: 74
Survey Dates: 2024-07-08 to 2024-07-12
Deficiency Severity Counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Weaver | Administrator | Signed the report |
| LPN 1 | Mentioned in relation to Resident 23's blood pressure cuff use and Resident C's hearing | |
| QMA 1 | Mentioned in relation to blood pressure cuff cleaning and medication administration | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including oxygen orders, medication administration, care planning, and infection control |
| Unit B Manager | Interviewed regarding care plan meetings and signage for isolation | |
| Therapy Director | Interviewed regarding splint recommendations | |
| Dietary Manager | Interviewed regarding pureed food preparation | |
| Laundry Aide 1 | Observed and interviewed regarding laundry sorting and clothing protection | |
| CNA 1 | Observed removing breakfast tray | |
| CNA 2 | Interviewed regarding incontinence care | |
| CNA 3 | Interviewed regarding Resident C's hearing | |
| Social Service Director | Interviewed regarding care plan meetings and audiology referrals |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
The visit was a paper compliance review related to the investigation of complaints IN00432040 and IN00432672 completed on May 31, 2024.
Complaint Details
The visit was related to complaint investigations IN00432040 and IN00432672, with findings indicating compliance.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: May 31, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432040 and IN00432672 at Lincolnshire Health & Rehabilitation Center.
Complaint Details
Complaint IN00432040 and Complaint IN00432672 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in the complaints were cited. However, an unrelated deficiency was cited regarding failure to ensure correct Personal Protective Equipment (PPE) use by a staff member when providing care to a resident on Enhanced Barrier Precautions (EBP).
Deficiencies (1)
Failure to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 1) when providing care to a resident on Enhanced Barrier Precautions (Resident D).
Report Facts
Census: 67
Residents on Enhanced Barrier Precautions affected: 1
Residents potentially affected: 34
Survey dates: May 30 & 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Weaver | Administrator | Signed the report and provided information about PPE availability and staff training |
| CNA 1 | Staff member observed not using correct PPE during care of resident on Enhanced Barrier Precautions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00429439 completed on April 8, 2024.
Complaint Details
Investigation of Complaints IN00429439 completed on April 8, 2024; paper compliance review found facility in compliance.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429439 regarding allegations of deficient care related to activities of daily living (ADLs), specifically timeliness of incontinence care.
Complaint Details
Complaint IN00429439 was substantiated with federal/state deficiencies cited at F677 related to inadequate ADL care and incontinence management.
Findings
The facility failed to ensure dependent residents received timely assistance with incontinence care for 2 of 3 residents reviewed (Residents B and C). Observations and record reviews showed residents were not checked or changed at least every 2 hours as required, resulting in residents lying in soiled briefs and bedding.
Deficiencies (1)
Failure to ensure dependent residents received assistance with activities of daily living related to timeliness of incontinence care for 2 of 3 residents reviewed.
Report Facts
Census: 66
Total Capacity: 66
Medicare Residents: 13
Medicaid Residents: 47
Other Residents: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
Paper compliance review to the investigation of multiple complaints (IN00415074, IN00415577, IN00419693, IN00422944, and IN00423001) completed on December 7, 2023.
Complaint Details
The visit was related to complaint investigations and the facility was found to be in compliance based on paper review.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 5
Date: Dec 7, 2023
Visit Reason
This visit was for the investigation of multiple complaints regarding resident safety, staffing, and environmental conditions at Lincolnshire Health & Rehabilitation Center.
Complaint Details
The investigation was triggered by multiple complaints (IN00415074, IN00415577, IN00415694, IN00419693, IN00422944, IN00423001) alleging resident safety issues, staffing deficiencies, and environmental concerns. Some complaints were substantiated with cited deficiencies, while others were not.
Findings
The facility was found deficient in ensuring resident safety during transport, maintaining adequate RN staffing, posting accurate nurse staffing information, providing a sanitary and comfortable environment, and timely reporting major accidents to the Indiana Department of Health. Specific incidents included a resident falling in a bus due to improper wheelchair securing, failure to schedule an RN for 8 consecutive hours daily, inaccurate nurse staffing postings, unsanitary resident rooms, and failure to report a major accident involving a resident injury.
Deficiencies (5)
Failed to ensure a resident being transported in a bus was secured properly to prevent wheelchair tipping and lacked physician orders and care plan interventions for fall prevention related to anti-roll back devices on wheelchairs.
Failed to ensure a Registered Nurse was scheduled for at least 8 consecutive hours a day, 7 days a week.
Failed to ensure posted Nurse Staffing Information was up-to-date and accurate related to call-offs, no shows, and replacements.
Failed to ensure residents' environment was sanitary and comfortable, with issues such as cobwebs, dirt, dried feeding residue on equipment and floors, loose outlet covers, soiled furniture, and dust accumulation.
Failed to notify the Indiana Department of Health of a major accident and injury of unknown cause involving residents, including a wheelchair tipping incident and a resident with a bruised eye/forehead.
Report Facts
Residents present: 62
Medicare residents: 8
Medicaid residents: 44
Other residents: 10
Days of nurse staffing posting inaccurate: 19
Date of compliance: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Gatson | Administrator | Signed the report and involved in administrative oversight |
| Employee 1 | Provided care to resident with injury and acknowledged environmental deficiencies | |
| Employee 3 | Provided care and observations related to resident injury | |
| Regional Vice President of Operations | Interviewed regarding incident reporting and bus driver training | |
| Bus Driver | Involved in wheelchair securing incident and retraining | |
| Director of Nursing | Acknowledged staffing schedule issues and environmental concerns | |
| Maintenance Director | Provided re-education to bus driver on wheelchair securing |
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
The visit was a Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/16/2023.
Findings
Lincolnshire Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 68
Capacity: 100
Deficiencies: 1
Date: Oct 13, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/16/23 was performed to assess compliance with life safety and fire protection regulations.
Findings
The facility was found not in compliance with the Life Safety Code requirements, specifically failing to properly document monthly load testing of the emergency generator for 12 of 12 months as required by NFPA 110 standards. The deficiency could affect all occupants.
Deficiencies (1)
Failure to exercise the emergency generator for 12 of 12 months and failure to document the load percentage during monthly testing as required by NFPA 110.
Report Facts
Facility capacity: 100
Census: 68
Deficiency count: 1
Generator exercise frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Gatson | Administrator | Named in relation to exit conference and interview regarding deficiency |
Inspection Report
Life Safety
Census: 68
Capacity: 100
Deficiencies: 6
Date: Aug 16, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to ensure continuous illumination of exit signs, failure to complete annual inspection and testing of fire door assemblies, failure to document generator transfer times and load testing, and improper use of extension cords as substitutes for fixed wiring.
Deficiencies (6)
Failed to ensure 2 of 10 exit signs were continuously illuminated, affecting approximately 20 residents and staff.
Failed to ensure annual inspection and testing of 11 fire door assemblies were completed as required by NFPA 80.
Failed to document the transfer time to the alternate power source on monthly load tests for 11 of the past 12 months.
Failed to exercise the generator for 11 of 12 months to meet NFPA 110 requirements.
Failed to document the actual load percentage for the diesel powered generator during load testing.
Failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring, including extension cords used in the B-wing med room.
Report Facts
Certified beds: 100
Census: 68
Exit signs not illuminated: 2
Fire door assemblies: 11
Generator load tests missing transfer time documentation: 11
Generator monthly exercises missed: 1
Flexible cords improperly used: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Gatson | Administrator | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed regarding deficiencies including exit signs, fire door inspections, generator testing, and extension cord use | |
| VP of Operations | Interviewed and participated in exit conference regarding deficiencies |
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 10
Date: Jul 28, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 24 to July 28, 2023.
Findings
The facility was found deficient in multiple areas including management of personal funds, comprehensive care planning, activity programming, quality of care, pressure ulcer treatment, bowel/bladder care, medication regimen review, nurse staffing postings, dietary staffing, and environmental cleanliness and maintenance.
Deficiencies (10)
Failed to ensure residents had access to their personal funds at all times.
Failed to develop and implement comprehensive, resident-centered care plans related to activities and medications.
Failed to ensure an ongoing activity program was implemented for dependent residents.
Failed to ensure residents received necessary treatment and services related to monitoring and assessment of change in condition, skin discolorations, and positioning.
Failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing in a timely manner.
Failed to ensure residents with abnormal urine in indwelling catheters were assessed timely and residents with colostomies received daily care.
Failed to have accurate and complete daily nurse staffing postings.
Failed to employ sufficient dietary staff to effectively serve meals in a timely manner.
Failed to maintain a safe, functional, sanitary, and comfortable environment related to dirty floors, damaged walls, peeling non-skid strips, running toilet, and broken furniture on two units.
Failed to identify or act on an irregularity in a resident's medication regimen related to an unnamed medication being administered.
Report Facts
Residents present: 67
Total licensed capacity: 67
Medicare residents: 8
Medicaid residents: 46
Other payor residents: 13
Medication administrations: 44
Residents on A Unit: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Gatson | Administrator | Signed the report |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 28, 2023.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 2
Date: May 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407716 and IN00408215 related to allegations of abuse and failure to report and document incidents.
Complaint Details
Complaints IN00407716 and IN00408215 were investigated. The allegations involved Resident C being found touching Resident D's genitals on 5/3/23. The facility failed to report the incident immediately to the Administrator and failed to document the incident in the medical records. Interviews with staff and the Administrator confirmed these failures.
Findings
The facility failed to immediately report an allegation of abuse involving two residents and failed to document the incident in the medical records. The investigation confirmed the incident occurred but was not properly reported to the Administrator or documented in the residents' records.
Deficiencies (2)
Failure to ensure an allegation of abuse was immediately reported to the Administrator for 2 of 3 residents reviewed for reporting abuse.
Failure to ensure medical records were complete related to lack of documentation of observations of alleged abuse for 2 of 3 residents reviewed.
Report Facts
Census: 69
Total Capacity: 69
Medicare Census: 14
Medicaid Census: 43
Other Payor Census: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 9, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00407716 and IN00408215 completed on May 9, 2023.
Complaint Details
Paper compliance review related to complaints IN00407716 and IN00408215.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 10, 2023
Visit Reason
Paper compliance review to the investigation of multiple complaints (IN00395090, IN00395441, IN00400848, and IN00401857) completed on March 1, 2023.
Complaint Details
The visit was related to complaint investigations and the facility was found to be in compliance based on paper review.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
This visit was for the investigation of Complaint IN00404967.
Complaint Details
Complaint IN00404967 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation.
Report Facts
Census SNF/NF: 71
Total Census: 71
Medicare Census: 13
Medicaid Census: 47
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 6
Date: Mar 1, 2023
Visit Reason
This visit was for the investigation of complaints IN00395090, IN00395441, IN00400848, and IN00401857 at Lincolnshire Health & Rehabilitation Center.
Complaint Details
The investigation was triggered by complaints IN00395090, IN00395441, IN00400848, and IN00401857. Findings included issues with medication self-administration, ADL care, skin care reporting, nutritional documentation, medication regimen management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication self-administration procedures, timely and adequate care for dependent residents, reporting of open skin areas, documentation of nutritional intake, management of medication regimens, and infection control practices.
Deficiencies (6)
Failure to ensure a resident had a Physician's Order and assessment for self-administration of medications.
Failure to ensure dependent residents received necessary care and services in a timely manner related to incontinent care and repositioning.
Failure to report open skin areas observed during care to the nurse by CNAs.
Failure to ensure residents maintained acceptable nutritional status due to incomplete meal consumption documentation.
Failure to manage and monitor a resident's medication regimen related to unclear Physician's Order for lidocaine patch placement.
Failure to maintain infection control practices related to glove usage and hand hygiene during incontinence care.
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 16
Medicaid Census: 49
Other Payor Census: 11
Deficiency Count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in medication self-administration deficiency for leaving medications at bedside |
| CNA 1 | Certified Nursing Assistant | Named in deficiencies related to incontinent care, failure to report skin open areas, and infection control practices |
| CNA 2 | Certified Nursing Assistant | Assisted in incontinent care observations |
| LPN 4 | Licensed Practical Nurse | Involved in repositioning and medication patch removal |
| LPN 5 | Licensed Practical Nurse | Involved in repositioning and medication patch application |
| Director of Nursing | Administrator | Interviewed regarding reporting of skin open areas and infection control |
| Wound Nurse | Nurse | Conducted skin assessments and provided statements regarding skin care deficiencies |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 4
Date: Nov 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393439, which was substantiated with federal and state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00393439 was substantiated with federal and state deficiencies cited at F622, F624, F689, and F921 related to transfer and discharge requirements, preparation for safe transfer, accident hazards and supervision, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to accurately complete a Notice of Transfer form, failure to ensure safe and orderly transfer with appropriate documentation, failure to complete follow-up assessments after a resident fall, and failure to maintain a sanitary and homelike environment in resident rooms.
Deficiencies (4)
Failed to ensure a Notice of Transfer form was completed accurately for a resident transferred to the hospital.
Failed to ensure a safe and orderly transfer for a resident with transfer documentation not sent with the resident to the hospital.
Failed to complete follow-up assessments after a resident fall, investigate circumstances of the fall, and assess for injuries.
Failed to maintain a sanitary and homelike environment related to dirty floors, walls, privacy curtains, broken/missing floor tile, peeling veneer on over bed tables, peeling floor grips, and broken plastic slats on air conditioner/heater in 4 of 25 rooms observed.
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 21
Medicaid Census: 49
Other Payor Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Gatson | Administrator | Signed the report and plan of correction |
| Employee 1 | Provided statement regarding resident transfer and family interactions | |
| Employee 2 | Provided statement regarding family confrontation and resident care | |
| Employee 3 | Interviewed regarding resident care assignment | |
| Employee 4 | Agency Employee | Reported resident found on floor and assisted resident back to bed |
| Employee 5 | Agency Employee | Observed resident on floor and provided statement |
| Employee 6 | Agency Employee | Assisted resident off floor and provided statement |
| Employee 7 | Observed resident on floor after family alerted staff | |
| Employee 8 | Observed resident on floor and provided statement | |
| Employee 9 | Agency Employee | Reported on midnight shift and fall interventions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00393439 completed on November 7, 2022.
Complaint Details
Investigation of Complaint IN00393439; paper compliance review found facility in compliance.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00388699 completed on September 26, 2022.
Complaint Details
Investigation of Complaint IN00388699 completed with paper compliance review.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 1
Date: Sep 26, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00388699 and IN00389883. Complaint IN00388699 was substantiated with related deficiencies cited, while complaint IN00389883 was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00388699 was substantiated with federal/state deficiencies cited at F921. Complaint IN00389883 was unsubstantiated due to lack of evidence.
Findings
The facility failed to maintain a sanitary and homelike environment in 6 of 18 resident rooms observed, with dried beige substances on floors and feeding pump poles, torn floor mats, and peeling veneer on overbed tables. The Director of Housekeeping and Maintenance acknowledged these issues and corrective actions were taken immediately.
Deficiencies (1)
Facility failed to maintain a sanitary and homelike environment related to dried beige substances on floors and feeding pump poles, torn floor mats, and peeling veneer on overbed tables in 6 of 18 rooms observed.
Report Facts
Census: 70
Total Capacity: 70
Medicare Census: 13
Medicaid Census: 49
Other Payor Census: 8
Rooms with deficiencies observed: 6
Rooms audited weekly: 5
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping and Maintenance | Acknowledged the presence of dried beige substances, torn mats, and peeling veneer; responsible for cleaning and maintenance | |
| Housekeeping Director/Designee | Responsible for auditing rooms weekly for 6 months to ensure no dried tube feedings on feeding pump poles, floor mats, and overbed tables |
Inspection Report
Life Safety
Census: 74
Capacity: 100
Deficiencies: 3
Date: Aug 8, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included a missing sprinkler escutcheon in the dining room, failure to document generator transfer times during monthly load tests, and improper use of a power strip as a substitute for fixed wiring in the B Wing nurse station.
Deficiencies (3)
Failed to maintain the ceiling construction by missing escutcheon around a sprinkler head in the dining room.
Failed to document the transfer time to the alternate power source on monthly load tests for 12 months.
Failed to ensure the B Wing nurse station did not use flexible cords as a substitute for fixed wiring.
Report Facts
Certified beds: 100
Census: 74
Generator load tests missing transfer time documentation: 12
Residents potentially affected by sprinkler deficiency: 20
Residents potentially affected by power strip deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed missing sprinkler escutcheon and lack of generator transfer time documentation; involved in corrective actions | |
| Administrator | Reviewed findings at exit conference | |
| Corporate Operations personnel | Confirmed power strip usage at B Wing nurse station |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
Lincolnshire Health and Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaints IN00370366 & IN00373423.
Complaint Details
Investigation of Complaints IN00370366 & IN00373423 was completed.
Findings
Lincolnshire Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
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