Inspection Reports for Brickyard Healthcare – Lincoln Hills Care Center
402 19TH STREET, IN, 47586
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies mainly involving Life Safety Code compliance, emergency preparedness, resident care including medication administration and infection control, and staffing qualifications. Complaint investigations were generally unsubstantiated, though some substantiated cases involved infection control and medication administration issues. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent follow-up surveys showing compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
436% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462189.
Complaint Details
Complaint IN00462189 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations 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 complaint investigation.
Report Facts
Census: 63
Total Capacity: 63
Payor Type Census: 1
Payor Type Census: 54
Payor Type Census: 8
Inspection Report
Follow-Up
Census: 65
Capacity: 86
Deficiencies: 0
Date: May 1, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/04/2025.
Findings
At this Post Survey Revisit, Brickyard Healthcare - Lincoln Hills Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including full sprinklering except for resident room closets and a metal shed used for facility storage.
Report Facts
Facility capacity: 86
Census: 65
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00452101 and an unrelated deficiency survey completed on January 28, 2025.
Complaint Details
Investigation of Complaint IN00452101 was reviewed for paper compliance.
Findings
Brickyard Healthcare - Lincoln Hills 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 for the complaint investigation and unrelated deficiency survey.
Inspection Report
Life Safety
Census: 61
Capacity: 86
Deficiencies: 19
Date: Mar 4, 2025
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations and state law.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and related regulations. Deficiencies included incomplete emergency preparedness communication plans, failure to conduct required emergency drills, incomplete generator maintenance records, life safety code violations such as improper exit lighting, missing 'No Exit' signage, obscured fire door tags, mixed sprinkler head types, corroded sprinkler heads, incomplete fire door inspections, incomplete electrical receptacle testing, incomplete patient care electrical equipment testing, and incomplete fire drill documentation.
Deficiencies (19)
Emergency preparedness communication plan lacked current names and contact information for service providers.
Failed to conduct required emergency preparedness exercises twice per year.
Failed to maintain complete and accurate monthly generator load testing records.
Failed to maintain complete weekly generator inspection records.
Lighting for 2 of 13 exit means of egress not properly maintained, risking darkness.
One door to wooden deck not posted with 'No Exit' sign.
Preventative maintenance for battery operated smoke alarms not conducted weekly as per manufacturer's instructions.
Incomplete documentation for preventative maintenance of battery operated smoke alarms.
Protection of one stairway door compromised by paint obscuring fire rating tag.
Staff not properly instructed on use of UL 300 hood fire suppression system in kitchen.
Lack of documentation for semiannual inspection of kitchen exhaust system; gap of 10 months between inspections.
Mixed sprinkler head types installed in smoke compartments.
Sprinkler heads in shower rooms covered with corrosion and not replaced; incomplete documentation of sprinkler control valve inspections.
Laundry chute door not fully self-closing and positive latching.
Failed to provide quarterly fire drill documentation for all shifts during all quarters.
Failed to ensure annual inspection and testing of all fire door assemblies; incomplete documentation.
Failed to maintain complete documentation for annual testing of nonhospital-grade electrical receptacles in resident rooms; some receptacles failed testing and were not replaced.
Failed to maintain complete and accurate monthly generator load testing records; weekly generator inspection documentation incomplete.
Failed to conduct required maintenance and maintain complete documentation for Patient Care Related Electrical Equipment testing.
Report Facts
Facility capacity: 86
Census: 61
Fire drill reports missing: 5
Resident rooms with failed receptacles: 16
Weekly generator inspections missing: 0
Semiannual kitchen exhaust inspections gap: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Named in exit conferences and plan of correction submissions |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
This visit was for an Investigation of Complaint IN00454047 and was conducted in conjunction with the Recertification and State Licensure Survey.
Complaint Details
Complaint IN00454047 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations 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 complaint investigation.
Report Facts
Census SNF/NF beds: 60
Total census: 60
Medicare census: 2
Medicaid census: 49
Other payor census: 9
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 5
Date: Feb 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted in conjunction with the Investigation of Complaint IN00454047.
Complaint Details
Complaint IN00454047 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to respect and dignity for residents, care plan implementation and revision, medication administration, staffing, and infection preventionist qualifications. No deficiencies were cited related to the complaint investigation. Corrective actions and monitoring plans were provided for each deficiency.
Deficiencies (5)
Failed to ensure respect and dignity was provided to a totally dependent resident; call light was not within reach for 1 of 16 residents reviewed.
Failed to ensure physician orders and care plan interventions were followed for 2 of 5 residents reviewed for unnecessary medications.
Failed to ensure a resident's care plan was revised for 1 of 5 residents reviewed for unnecessary medications; care plan was not updated to remove irrelevant areas.
Failed to provide an RN for 8 consecutive hours, seven days a week, for 4 of 26 days reviewed.
Failed to ensure a qualified Infection Preventionist was working at least part-time; documentation of hours dedicated to infection control was not available.
Report Facts
Census: 60
Total Capacity: 60
RN coverage missing days: 4
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Mentioned in relation to call light and oxygen concentrator findings |
| RN 5 | Registered Nurse | Mentioned in relation to medication administration finding |
| Director of Nursing | Director of Nursing (DON) | Provided policies, interviews, and responsible for infection preventionist duties |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on February 21, 2025.
Findings
Brickyard Healthcare - Lincoln Hills 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: 62
Capacity: 62
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452101. No deficiencies were cited related to the allegation(s), but unrelated deficiencies were identified.
Complaint Details
Complaint IN00452101 was investigated with no deficiencies cited related to the allegation(s).
Findings
The facility failed to ensure a resident's code status was known during an emergency for 1 of 2 residents reviewed. Resident D was mistakenly identified as DNR during an emergency, but the correct code status was full code, leading to delayed emergency response. The facility has since taken corrective actions including re-education and audits to prevent recurrence.
Deficiencies (1)
Failed to ensure a resident's code status was known during an emergency situation for 1 of 2 residents reviewed.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 2
Medicaid Census: 50
Other Payor Census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Signed the report |
| LPN 6 | Licensed Practical Nurse | Identified incorrect code status documentation and notified family |
| Director of Nursing | Director of Nursing | Provided facility policy and guidance on verifying residents' code status |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The visit was a Post Survey Revisit (PSR) to complete the Life Safety Code Recertification and State Licensure Survey that had previously exited on 05/13/24 and 07/10/24.
Findings
Brickyard Healthcare-Lincoln Hills Care 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
Re-Inspection
Census: 66
Capacity: 86
Deficiencies: 4
Date: Jul 10, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to verify compliance with Emergency Preparedness and Life Safety Code requirements following a previous survey conducted on 05/13/2024.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to emergency lighting testing, portable fire extinguisher inspections and maintenance, and boiler inspection certificates. Corrective actions were planned or completed but previous deficiencies had not been fully corrected.
Deficiencies (4)
Failed to ensure 1 of 1 battery backup emergency lights were tested monthly and records maintained.
Failed to inspect 1 of 1 portable fire extinguishers monthly in the assistant administrator office.
Failed to ensure 1 of 1 portable fire extinguishers had maintenance at intervals not more than one year apart; extinguisher was past due for annual inspection.
Failed to ensure 5 of 5 boilers had current inspection certificates to ensure safe operating condition.
Report Facts
Deficiencies cited: 4
Facility capacity: 86
Census: 66
Boilers inspected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Named in relation to review of findings at exit conference. |
Inspection Report
Routine
Census: 66
Capacity: 86
Deficiencies: 20
Date: May 13, 2024
Visit Reason
Routine Life Safety Code Recertification, Emergency Preparedness Survey, and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including maintenance issues with carbon monoxide detectors, locking mechanisms, emergency lighting, smoke alarms, sprinkler system installation and maintenance, fire alarm system time accuracy, fire extinguisher inspections, door latching, smoke barrier penetrations, fire dampers, fire drills, and oxygen storage safety.
Deficiencies (20)
Carbon monoxide detector in the boiler room was not properly maintained due to missing batteries.
Main floor dining closet had a slide lock that could not be opened from the inside.
Delayed egress locking arrangements in laundry and hallway doors did not release locks as required.
Battery backup emergency lights were not tested monthly as required.
Documentation for monthly testing of battery operated smoke alarms in resident rooms was incomplete.
Multiple storage rooms used for combustible materials lacked self-closing doors.
Cooktop in therapy room was powered on and locked in a box, not shut off when not in use.
Fire alarm control panel displayed incorrect time.
Sprinkler heads missing escutcheons and mixed types of sprinkler heads installed in some areas.
Ceiling penetrations and damaged ceiling tiles near sprinklers in multiple locations.
Corroded sprinkler head near therapy room.
Monthly inspections of portable fire extinguishers were incomplete or missing in multiple locations.
Portable fire extinguisher in assistant administrator's office was past due for annual maintenance.
Resident room door (room 70) did not latch properly.
Unsealed penetrations in smoke barrier walls near kitchen hallway, therapy room, room 63, and room 23.
Smoke barrier doors near therapy room did not close completely.
Five boilers had expired or missing Certificates of Inspection.
Fire damper in facility was not inspected or maintained as required.
Quarterly fire drills for 3rd shift were not conducted for two quarters.
Combustible materials stored within 5 feet of oxygen storage containers.
Report Facts
Deficiencies cited: 19
Facility capacity: 86
Census: 66
Boilers with expired inspection certificates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Named in relation to findings review and exit conference. |
| Director of Maintenance | Named in relation to multiple findings including carbon monoxide detector, fire alarm, sprinkler system, fire extinguishers, and other maintenance issues. |
Inspection Report
Recertification
Census: 65
Capacity: 65
Deficiencies: 14
Date: Apr 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaints IN00431372 and IN00432746.
Complaint Details
Complaint IN00431372 and IN00432746 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was cited for multiple deficiencies including failure to ensure resident dignity, failure to notify ombudsman of transfers, inaccurate MDS assessments, failure to follow care plans, inadequate supervision to prevent falls, improper infection control practices, failure to maintain safe water temperatures, and lack of staff training on intellectual and developmental disabilities.
Deficiencies (14)
Failure to ensure residents were treated with dignity and respect, including use of styrofoam dishes after suicide watch was discontinued and inappropriate staff communication.
Failure to notify the ombudsman of resident transfers or discharges for 3 of 4 residents reviewed.
Failure to ensure MDS assessments were accurate for 4 of 19 residents, including failure to indicate PASRR II status and hospice services.
Failure to ensure care was provided in accordance with the written plan of care for 2 residents who smoked, including failure to lock up smoking materials and supervise smoking.
Failure to provide care consistent with professional standards to prevent and promote healing of pressure ulcers for 2 residents, including worsening of wounds and development of a stage IV pressure ulcer.
Failure to ensure adequate supervision to prevent falls for 1 resident at risk for falls, resulting in multiple falls and inconsistent implementation of fall interventions.
Failure to post nurse staffing information with required details including facility name and actual hours worked for licensed and unlicensed nursing staff.
Failure to ensure palatable food was served; residents complained food was overcooked, dry, and tasteless.
Failure to accurately document care planned interventions for a resident; restorative walking nursing tasks were not completed as documented.
Failure to implement infection prevention and control practices including use of Enhanced Barrier Precautions and proper hand hygiene.
Failure to ensure resident call lights were accessible and within reach for residents in bed or wheelchair.
Failure to provide a safe, functional, sanitary, and comfortable environment; water temperatures in multiple rooms and shower rooms were above 120 degrees Fahrenheit and a raised toilet seat was stored on the floor.
Failure to provide in-service training for staff specific to intellectual and developmental disabilities for 5 residents identified with such needs.
Failure to ensure criminal background checks were completed through an approved source for 1 of 5 new employee files reviewed.
Report Facts
Survey dates: April 15, 16, 17, 18, 19, 22, 2024
Resident census: 65
Deficiency counts: 14
Water temperatures: 132.5
Water temperatures: 129.7
Water temperatures: 129.1
Water temperatures: 126
Water temperatures: 124.8
Water temperatures: 124.5
Water temperatures: 124.3
Water temperatures: 123.9
Water temperatures: 123.4
Water temperatures: 121.4
Water temperatures: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Signed report |
| CNA 80 | Certified Nurse Aide | Named in fall prevention and dignity findings |
| QMA 19 | Qualified Medication Aide | Named in dignity and infection control findings |
| CNA 34 | Certified Nurse Aide | Named in pressure ulcer and infection control findings |
| LPN 42 | Licensed Practical Nurse | Named in pressure ulcer and infection control findings |
| CNA 50 | Certified Nurse Aide | Named in restorative care documentation and call light findings |
| CNA 8 | Certified Nurse Aide | Named in infection control findings |
| CNA 38 | Certified Nurse Aide | Named in background check finding |
| LPN 4 | Licensed Practical Nurse | Named in staff training finding |
| CNA 36 | Certified Nurse Aide | Named in staff training finding |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on April 22, 2024.
Findings
Brickyard Healthcare - Lincoln Hills was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00427204.
Complaint Details
Investigation of Complaint IN00427204; the facility was found to be in compliance.
Findings
Brickyard Healthcare - Lincoln Hills 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 for the complaint investigation.
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 1
Date: Mar 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429891 and IN00427204. Complaint IN00427204 resulted in deficiencies cited related to infection prevention and control, while complaint IN00429891 had no deficiencies cited.
Complaint Details
Complaint IN00427204 was substantiated with deficiencies cited related to infection prevention and control. Complaint IN00429891 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure infection control measures were implemented according to the plan of care for a resident with an active urinary tract infection (Resident B). Staff failed to don appropriate personal protective equipment, specifically gown and gloves, when providing care requiring advanced barrier precautions. The facility policy requires gown and gloves for all interactions involving contact with residents on contact precautions.
Deficiencies (1)
Failure to implement infection prevention and control measures according to the plan of care for a resident with an active UTI, including failure to wear appropriate personal protective equipment (gown and gloves) when providing care requiring advanced barrier precautions.
Report Facts
Census: 67
Total Capacity: 67
Medicare Residents: 5
Medicaid Residents: 51
Other Residents: 11
Plan of Correction Completion Date: Apr 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Signed report as facility representative |
| CNA 4 | Named in infection control deficiency for failure to wear gown and gloves when providing care to Resident B | |
| DON | Director of Nursing | Provided facility policy on Transmission-Based (Isolation) Precautions |
| Infection Preventionist | Interviewed regarding contact precautions and PPE requirements |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00417373 and included a COVID-19 focused infection control survey.
Complaint Details
Complaint IN00417373 was substantiated with deficiencies related to infection prevention and control practices, specifically hand hygiene failures.
Findings
The facility failed to ensure infection control practices to mitigate the spread of COVID-19 during 2 of 3 observations of care, including failure of staff to perform hand hygiene after glove removal and inadequate handwashing duration.
Deficiencies (1)
Failure to perform hand hygiene after removing gloves and inadequate handwashing duration during care of residents.
Report Facts
Census: 69
Medicare residents: 7
Medicaid residents: 53
Other residents: 9
Handwashing scrub time observed: 4
Handwashing scrub time policy: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Signed the report |
| LPN 4 | Named in hand hygiene deficiency during resident care | |
| CNA 2 | Named in hand hygiene deficiency during resident care | |
| CNA 3 | Named in hand hygiene deficiency during resident care | |
| RN 6 | Named in hand hygiene deficiency and interview about handwashing scrub time |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00417373 and the Covid-19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00417373 was completed with findings of compliance.
Findings
Brickyard Healthcare - Lincoln Hills 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 for the complaint investigation and Covid-19 survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00394412.
Complaint Details
Investigation of Complaint IN00394412; paper compliance review completed with findings of compliance.
Findings
Brickyard Healthcare - Lincoln Hills 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: 64
Capacity: 64
Deficiencies: 1
Date: Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00394412, which was substantiated with related federal and state deficiencies cited.
Complaint Details
Complaint IN00394412 was substantiated. The deficiency related to improper insulin administration was cited at F658.
Findings
The facility failed to ensure that insulin medications were administered according to manufacturer's guidance, specifically failing to prime insulin pens prior to administration for one resident receiving insulin.
Deficiencies (1)
Failure to prime NovoLog FlexPen and Basaglar KwikPen insulin pens prior to administration to Resident E.
Report Facts
Census: 64
Total Capacity: 64
Medicare Residents: 9
Medicaid Residents: 42
Other Payor Residents: 13
Units of insulin not primed: 2
Insulin Pen Audit Frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Director of Nursing | Interviewed regarding insulin pen priming policy and nursing practices |
| LPN 6 | Licensed Practical Nurse | Observed failing to prime NovoLog FlexPen prior to insulin administration |
| LPN 3 | Licensed Practical Nurse | Observed failing to prime Basaglar KwikPen prior to insulin administration |
Inspection Report
Re-Inspection
Census: 61
Capacity: 86
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/17/22.
Findings
At this Post Survey Revisit, Brickyard Healthcare-Lincoln Hills Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Facility capacity: 86
Census: 61
Inspection Report
Re-Inspection
Census: 65
Capacity: 65
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 9/28/22.
Findings
Brickyard Healthcare--Lincoln Hills Care 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 PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 65
Total Capacity: 65
Medicare Census: 4
Medicaid Census: 46
Private Pay Census: 10
Other Pay Census: 5
Inspection Report
Routine
Census: 64
Capacity: 86
Deficiencies: 17
Date: Oct 17, 2022
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple Life Safety Code deficiencies including issues with emergency generator testing documentation, lint accumulation in laundry dryer room, corridor obstructions, exit discharge tripping hazard, emergency lighting documentation, exit signage, battery-operated smoke alarm testing documentation, hazardous area door self-closing, sprinkler system maintenance, fire department connection signage, unsecured electrical panels, laundry chute door operation, fire drill documentation, smoking area maintenance, fire door inspections, generator load test documentation, improper use of power strips, and unsecured oxygen cylinders.
Deficiencies (17)
Failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during the past 12 months.
Laundry area dryer room enclosure was substantially covered with dryer lint.
2 of 11 corridor means of egress were obstructed by a lift and recliner.
Walking surface at north exit from lower level west hall had a two inch level change creating a tripping hazard.
Incomplete documentation for testing of battery backup emergency lights monthly and annually.
1 of over 30 exit signs was not illuminated.
Incomplete documentation for preventative maintenance of battery operated smoke alarms in all resident rooms.
Corridor doors to 4 hazardous areas did not self-close and latch properly.
Ceiling tiles missing in wheelchair storage, activity storage, and key rooms; sprinkler heads covered with lint/dirt; lack of fire department connection signage.
2 electrical panels in corridors were unsecured and unlocked.
Laundry chute door was not fully self-closing and positively latching.
Fire drill documentation incomplete for quarterly drills on multiple shifts and lacked evidence of alarm transmission to monitoring company.
Cigarette butts and trash improperly disposed of in smoking areas.
Annual inspection and testing of oxygen room fire door assembly and stairway fire door assemblies not documented.
Failed to maintain complete written record of monthly generator load testing including percent of nameplate KW.
Power strip used as substitute for fixed wiring in staff Dietary Office.
Oxygen cylinders in transfilling/storage room were not properly secured from falling.
Report Facts
Deficiencies cited: 16
Facility capacity: 86
Census: 64
Fire drill shifts missing documentation: 3
Fire drill quarters missing documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Pennington | Executive Director | Named in relation to exit conference and findings review. |
| Maintenance Director | Participated in interviews and acknowledged deficiencies throughout the report. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 65
Deficiencies: 7
Date: Sep 28, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 25 to 28, 2022.
Findings
The facility was found deficient in multiple areas including failure to complete timely care plan conferences and revise care plans, inadequate fall prevention interventions, improper respiratory care, serving cold and bland food, unsanitary food storage and handling, lapses in infection control practices, and failure to maintain a clean and comfortable environment.
Deficiencies (7)
Failed to ensure care plan conferences were completed and plans of care revised for multiple residents.
Failed to implement interventions and provide supervision to prevent falls for 2 residents; nonskid strips were missing or lacked grip.
Failed to ensure residents received necessary respiratory care; oxygen orders not followed and humidification bottles empty.
Failed to provide appetizing and palatable meals; food served cold and bland.
Failed to ensure food was stored and handled in a sanitary manner; unlabeled/uncovered food, dust on vents, ice buildup in freezer, damaged ceiling.
Failed to ensure infection control practices during medication administration and incontinence care; staff handled medications with bare hands, failed to sanitize insulin pen ends, and failed to change gloves between tasks.
Failed to maintain a clean, comfortable, and homelike environment; missing baseboard trim, holes in walls, unclean restrooms, non-functioning light, and uncovered personal hygiene items in shared restrooms.
Report Facts
Census: 65
Total Capacity: 65
Fall incidents: 8
Oxygen flow rate: 2
Oxygen flow rate: 3.5
Food temperature: 85
Food temperature: 120
Food temperature: 105
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Feb 21, 2025
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Jan 28, 2025
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Apr 22, 2024
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Mar 5, 2024
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Dec 27, 2023
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Dec 27, 2023
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Sep 28, 2022
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