Inspection Reports for
Lincolnshire Health Care Center

The facility failed to ensure proper treatment and documentation of a surgical incision, adequate assessment and monitoring of bruising and skin conditions for multiple residents, and timely removal and assessment of an intravenous access site for one resident. Several residents had untreated or undocumented skin issues including bruising, scabbing, dry scaly skin, and psoriasis.

This citation relates to Complaint IN00462425. The complaint involved failure to provide adequate care for a resident with skin conditions, including lack of timely incontinence care, missing care plans, and incomplete pressure ulcer treatment.

The facility failed to ensure a resident received timely incontinence care, a comprehensive care plan for psoriasiform dermatitis, and appropriate pressure ulcer treatment as ordered by the physician. Observations revealed the resident was lying on soiled bedding, had untreated skin conditions, and lacked proper wound dressings.

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.

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.

This citation relates to Complaints IN00456433 and IN00460374. The Director of Nursing and Corporate RN Consultant acknowledged the blood sugar results were not documented and the medications were not verified as administered as ordered.

The facility failed to ensure blood sugar monitoring and administration of insulin and hypoglycemic medications as ordered for 3 residents reviewed for diabetes management. Blood sugar levels were often not obtained and medications were not administered as prescribed, with documentation gaps noted.

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.

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.

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.

This citation was related to Complaint IN00436382.

The facility was found deficient in multiple areas including failure to ensure physician orders for medication self-administration, failure to notify family of medication changes, incomplete care plan meetings and invitations, inadequate assistance with activities of daily living, improper medication administration, lack of appropriate treatment and monitoring for skin conditions, failure to provide hearing services, inadequate range of motion care, failure to provide adaptive equipment for nutrition, oxygen administration without orders, missed pain medication doses due to pharmacy issues, improper preparation of pureed food, and lapses in infection control practices.

This citation was related to Complaint IN00436382.

The facility failed to notify family or representatives of new medication orders for one resident, failed to ensure quarterly care plan meetings were completed or family representatives invited for three residents, and failed to provide pain medications as ordered for one resident.

Complaint IN00432040 and Complaint IN00432672 were investigated with no deficiencies related to the allegations cited.

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).

The facility failed to ensure correct PPE use by a staff member when providing care to a resident on Enhanced Barrier Precautions. This deficiency had the potential to affect 34 residents on one unit.

Complaint IN00429439 was substantiated with federal/state deficiencies cited at F677 related to inadequate ADL care and incontinence management.

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.

This citation relates to Complaint IN00429439.

The facility failed to ensure timely incontinence care for 2 of 3 residents reviewed, with observations showing residents left in soiled briefs for extended periods. Documentation and staff interviews confirmed inadequate checks and changes at least every 2 hours as required by facility policy.

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.

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.

The citation F 0689 relates to Complaint IN00415577. The citation F 0727 and F 0732 relate to Complaints IN00419693, IN00422944, and IN00423001. The citation F 0921 relates to Complaints IN00415074 and IN00415577.

The facility failed to ensure proper securing of wheelchairs during transport, resulting in a resident fall. The facility also failed to schedule a registered nurse for at least 8 consecutive hours daily, and failed to keep nurse staffing postings up-to-date. Additionally, the environment was found unsanitary with dirt, debris, and dried feeding residues in resident rooms.

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.

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.

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.

The facility was found deficient in multiple areas including residents' access to personal funds, incomplete care plans, inadequate activity programs, failure to monitor changes in condition, improper pressure ulcer care, insufficient catheter and colostomy care, inaccurate nurse staffing postings, medication regimen irregularities, insufficient dietary staffing, and environmental cleanliness and maintenance issues.

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.

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.

This Federal tag relates to Complaints IN00407716 and IN00408215. The complaint investigation found substantiated failures in timely reporting and documentation of an abuse incident involving two residents.

The facility failed to immediately report an allegation of abuse involving two residents to the Administrator and failed to document the incident in the medical records of the involved residents. The Director of Nursing was aware of the incident but did not ensure timely reporting or documentation.

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.

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.

This Federal tag relates to Complaints IN00395090, IN00395441, IN00400848, and IN00401857. The investigation included multiple complaints regarding medication self-administration, care timeliness, skin care, nutritional documentation, medication management, and infection control.

The facility failed to ensure a resident had a physician's order and assessment for self-administration of medications, timely incontinence care and repositioning for dependent residents, proper reporting and treatment of open skin areas, complete documentation of dietary intake for residents at nutritional risk, appropriate management of a resident's medication regimen, and adherence to infection control practices including glove use and handwashing.

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.

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.

Complaint IN00388699 was substantiated with federal/state deficiencies cited at F921. Complaint IN00389883 was unsubstantiated due to lack of evidence.

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.

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.

The facility was found to have multiple deficiencies including failure to accommodate resident needs, inadequate monitoring of skin conditions, insufficient fall precautions, improper pain management, lack of medication assessments, failure to honor food preferences, insufficient dietary staffing, unsafe food handling and storage, environmental maintenance issues, and pest control problems.