Inspection Reports for Lincoln Hills of New Albany
326 COUNTRY CLUB DRIVE, IN, 47150
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 8, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as fall prevention, pressure ulcer management, and behavioral health interventions, as well as several Life Safety Code and emergency preparedness citations related to fire safety and facility maintenance. Complaint investigations were mostly unsubstantiated or corrected, though some substantiated complaints involved failure to provide timely care plans and appropriate supervision for residents with complex needs. Enforcement actions included identification of immediate jeopardy in July 2023 related to quality of care and a resident death, which was later resolved, and fines or license actions were not listed in the available reports. The facility’s recent inspections indicate improvement in compliance, especially with Life Safety Code and emergency preparedness standards, following earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
127 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457182 and IN00458627.
Complaint Details
Complaint IN00457182 - No deficiencies related to the allegation is cited. Complaint IN00458627 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00457182 and IN00458627 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 9
Census Bed Type - SNF/NF: 118
Census Total: 127
Census Payor Type - Medicare: 20
Census Payor Type - Medicaid: 90
Census Payor Type - Other: 17
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The visit was conducted as a paper compliance review of the Investigation of Complaint IN00452723 completed on February 27, 2025.
Complaint Details
Complaint IN00452723 was investigated and found to be corrected as of the review date March 25, 2025.
Findings
Lincoln Hills of New Albany was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation. The complaint IN00452723 was corrected.
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454603.
Complaint Details
Complaint IN00454603 - No deficiencies related to the allegations is cited.
Findings
No deficiencies related to the 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: 122
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 119
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 94
Census Payor Type - Other: 20
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00452723 and IN00452878.
Complaint Details
Complaint IN00452723 was substantiated with a Federal/State deficiency cited as F656. Complaint IN00452878 had no deficiencies related to the allegations.
Findings
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.
Deficiencies (1)
Failed to ensure a plan of care was in place timely for a resident's non-compliance with a fall intervention related to the use of hipsters.
Report Facts
Census: 133
SNF/NF beds: 124
SNF beds: 9
Medicare residents: 12
Medicaid residents: 96
Other residents: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Povinelli | Administrator | Named in plan of correction submission |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
Inspection Report
Re-Inspection
Census: 109
Capacity: 156
Deficiencies: 0
Date: Nov 14, 2024
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 10/16/24.
Findings
At this PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety Code standards.
Report Facts
Certified beds: 156
Current census: 109
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 30, 2024.
Findings
Lincoln Hills of New Albany 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 SNF beds: 5
Census SNF/NF beds: 104
Total census: 109
Medicare census: 8
Medicaid census: 79
Other payor census: 22
Inspection Report
Life Safety
Census: 115
Capacity: 156
Deficiencies: 11
Date: Oct 16, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on October 16, 2024, to assess compliance with emergency preparedness and life safety requirements.
Findings
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.
Deficiencies (11)
Failed to implement emergency power system inspection, testing, and maintenance requirements; generator showed 'low coolant temp' light.
Failed to maintain latching hardware on 1 of 1 E hall smoke barrier doors; doors unable to latch.
Failed to ensure staff had access to the shutoff switch for 1 of 1 stove/oven in the memory care activities room; disconnect located in a different room.
Failed to ensure spray pattern for sprinkler heads were not obstructed in 1 of 1 therapy closets; storage less than 18 inches from ceiling.
Failed to maintain ceiling construction around sprinkler heads and penetrations in multiple areas; multiple penetrations and missing escutcheons observed.
Failed to maintain spare sprinklers properly; 5 of 17 spare sprinkler heads not supported in the spare sprinkler cabinet.
Failed to ensure 1 of 1 bio med rooms had no impediment to closing and would resist passage of smoke; door propped open.
Failed to ensure 1 of 1 reception doors and 1 of 1 bio med room doors would latch into the frame.
Failed to conduct quarterly fire drills at unexpected times under varying conditions on 3 of 4 third shift fire drills.
Failed to ensure corridor door to room H12 was free of combustible decorations; door covered with non-flame retardant plastic covering.
Failed to maintain Emergency Power Standby System; generator showed 'low coolant temp' and failed to conduct required 36-month 4 hour run test.
Report Facts
Certified beds: 156
Current census: 115
Fire drills timing: 3
Spare sprinkler heads not supported: 5
36-month generator run test duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Signed plan of correction letter. |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter. |
| Maintenance Director | Interviewed regarding multiple deficiencies including emergency generator, fire doors, sprinkler system, and fire drills. | |
| Maintenance Supervisor | Responsible for corrective actions related to fire doors, sprinkler heads, and fire drills. |
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 5
Date: Sep 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00443610 and IN00443867.
Complaint Details
Complaint IN00443610 and IN00443867 were investigated with no deficiencies related to the allegations cited.
Findings
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.
Deficiencies (5)
Failed to promptly resolve grievances made by the Resident Council and discuss resolutions at subsequent meetings.
Failed to ensure residents received their mail on Saturdays when delivered to the facility.
Failed to provide care and services to prevent development and worsening of pressure ulcers, resulting in a Stage 4 pressure ulcer for Resident 18.
Failed to ensure a hot liquid assessment was completed for a resident with a decline in function.
Failed to ensure narcotics were documented on the Controlled Drug Record of administered narcotics for 6 residents.
Report Facts
Residents present: 109
Resident Council meetings with unresolved grievances: 3
Residents in facility: 109
Residents observed for medication storage: 68
Residents with narcotic documentation issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Named in narcotic documentation deficiency for multiple residents |
| LPN 4 | Licensed Practical Nurse | Named in narcotic documentation deficiency for Resident 54 |
| DON | Director of Nursing | Interviewed regarding hot liquid assessment and narcotic documentation |
| Wound Physician | Provided wound care and assessment for Resident 18 | |
| Kim Povinelli | HFA | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436489 and IN00437866.
Complaint Details
Complaint IN00436489 - No deficiencies related to the allegations are cited. Complaint IN00437866 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00436489 and IN00437866 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 9
Census Bed Type - SNF/NF: 108
Total Census: 117
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 92
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430939.
Complaint Details
Investigation of Complaint IN00430939 found no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 125
Census Bed Type - SNF: 10
Census Bed Type - SNF/NF: 115
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 95
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425363.
Complaint Details
Complaint IN00425363 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00425363 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 8
Census Bed Type - SNF/NF: 100
Total Census: 108
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 85
Census Payor Type - Other: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00422843 completed on December 18, 2023.
Complaint Details
Investigation of Complaint IN00422843 completed on December 18, 2023; paper compliance review found facility in compliance.
Findings
Lincoln Hills of New Albany 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: 118
Capacity: 118
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422843 and IN00424143 at Lincoln Hills of New Albany.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure appropriate treatment/service for dementia-related behaviors for Resident B.
Report Facts
Census: 118
Total Capacity: 118
Medicare Census: 12
Medicaid Census: 78
Other Payor Census: 28
Deficiency Completion Date: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Signed Plan of Correction letter |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 156
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
An investigation of Complaint Number IN00420897 was conducted by the Indiana Department of Health in conjunction with a Post Survey Revisit to the Life Safety Code Recertification and State Licensure Survey.
Complaint Details
Complaint Number IN00420897 was investigated and a Federal/State deficiency related to the allegation was cited at K712.
Findings
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.
Deficiencies (1)
The facility failed to ensure a fire drill report during the past one month included complete transmission of a fire alarm signal to the monitoring company/fire department during the past twelve months.
Report Facts
Facility capacity: 156
Census: 121
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Present during record review and exit conference |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter |
Inspection Report
Re-Inspection
Census: 121
Capacity: 156
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/27/23 was conducted in conjunction with the investigation of Complaint #IN00420897.
Complaint Details
Investigation of Complaint #IN00420897 was conducted in conjunction with the survey.
Findings
At this PSR to the Life Safety Code survey, Lincoln Hills of New Albany 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 detached wooden storage structures.
Report Facts
Facility capacity: 156
Census: 121
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419590, IN00420393, and IN00420490 at Lincoln Hills of New Albany.
Complaint Details
Complaints IN00419590, IN00420393, and IN00420490 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00419590, IN00420393, and IN00420490 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 120
Census Payor Type: 120
Inspection Report
Re-Inspection
Census: 120
Capacity: 120
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 29, 2023.
Findings
Lincoln Hills of New Albany 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 SNF beds: 11
Census SNF/NF beds: 109
Total census: 120
Census Medicare: 25
Census Medicaid: 84
Census Other payor: 11
Inspection Report
Life Safety
Census: 118
Capacity: 156
Deficiencies: 12
Date: Sep 27, 2023
Visit Reason
Life Safety Code Recertification and Emergency Preparedness Survey conducted by the Indiana Department of Health on September 27, 2023.
Findings
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.
Deficiencies (12)
Means of egress through 1 of 2 locked exit courtyard gate was not readily accessible due to a combination lock on the outside.
Means of egress through 1 of 10 locked exit doors was not readily accessible; D-Hall exit door was magnetically locked and code was not posted.
1 of 10 sets of smoke barrier doors had impediment to closing caused by a wet floor sign.
Walking surface for 1 of 10 exit discharge areas was raised 5 to 6 inches due to a tree root pushing up the sidewalk.
Lighting for 2 of 10 exit means of egress was inadequate; one area lacked sufficient lighting due to fence size and missing bulb at another exit.
Staff were not properly instructed in the use of the UL 300 hood fire suppression system in the kitchen; kitchen staff did not know to pull the fire suppression system pull station before using fire extinguisher.
2 of 64 hard wired smoke detectors were installed too close (12 inches) to air supply vents, which could adversely affect operation.
Fire alarm system control panel had incorrect date and time displayed.
A 20x20 foot fabric canopy outside the Memory Care Unit was not sprinkled and lacked fire retardant documentation.
Sprinkler heads in laundry dryer/folding room were covered with corrosion and needed replacement; one sprinkler head near dining room exit was empty with no color in glass bulb.
1 of 22 portable fire extinguishers lacked current 6-year maintenance documentation; extinguisher outside room G7 was last maintained in 2015 and was past due.
1 of over 20 wet location electrical receptacles (west unit Pantry) had a GFCI receptacle with an open ground and did not break electrical circuit when tested.
Report Facts
Certified beds: 156
Current census: 118
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Named in relation to the inspection and plan of correction. |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Named in relation to the inspection and plan of correction. |
| Maintenance Supervisor | Interviewed regarding multiple deficiencies including egress doors, fire alarm system, sprinkler heads, and electrical issues. | |
| Kitchen staff #1 | Cook | Interviewed regarding fire suppression system knowledge. |
Inspection Report
Renewal
Census: 125
Capacity: 125
Deficiencies: 5
Date: Aug 29, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on August 23, 24, 25, 28 and 29, 2023.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to ensure the physician was notified when a resident's blood sugar readings fell outside the physician ordered parameters for 1 of 3 residents reviewed.
Failed to ensure interventions were implemented for falls and to ensure safe transfer procedures for a resident requiring maximum assistance.
Failed to follow appropriate infection control guidelines related to perineal care for 3 of 6 residents reviewed.
Failed to ensure appropriate pain management interventions were implemented for 1 of 2 residents reviewed for pain.
Failed to ensure the physician was notified when a dialysis resident's weight was above the physician-ordered set parameters for 1 of 7 residents reviewed.
Report Facts
Census: 125
Total Capacity: 125
Blood sugar readings out of range: 7
Weight gains requiring physician notification: 12
Pain medication doses without documentation: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Signed Plan of Correction letter |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter |
Inspection Report
Follow-Up
Census: 122
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00412136 completed on July 10, 2023, and was conducted in conjunction with the PSR for unrelated deficiencies cited during investigations of Complaints IN00404123 and IN00407228 completed on June 9, 2023.
Complaint Details
Complaint IN00412136 was investigated and found corrected.
Findings
Lincoln Hills of New Albany 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 Investigation of Complaint IN00412136. Both the complaint and unrelated deficiencies were corrected.
Report Facts
Census bed type: 11
Census bed type: 111
Census total: 122
Census payor type: 30
Census payor type: 88
Census payor type: 12
Inspection Report
Follow-Up
Census: 122
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) for the unrelated deficiency cited during the investigation of Complaints IN00404123 and IN00407228 completed on June 9, 2023, and was in conjunction with the PSR to the Investigation of Complaint IN00412136 completed on July 10, 2023.
Complaint Details
This visit was related to complaints IN00404123, IN00407228, and IN00412136. The unrelated deficiency and complaint issues were corrected.
Findings
Lincoln Hills of New Albany 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 Unrelated Deficiency and the Investigation of Complaints IN00404123, IN00407228, and IN00412136.
Report Facts
Census bed type - SNF: 11
Census bed type - SNF/NF: 111
Total census: 122
Census payor type - Medicare: 30
Census payor type - Medicaid: 88
Census payor type - Other: 12
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 3
Date: Jul 10, 2023
Visit Reason
This visit was for the investigation of Complaint IN00412136 regarding allegations of substandard quality of care and immediate jeopardy at Lincoln Hills of New Albany.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to ensure prompt physician notification of a resident's change in condition (Resident E).
Failed to ensure professional standards of care related to implementation of physician orders and provision of medically necessary emergent care (Resident E).
Failed to ensure appropriate care and monitoring for a resident with respiratory failure and hypercapnia, resulting in death (Resident E).
Report Facts
Survey dates: 5
Resident census: 120
Medicare residents: 15
Medicaid residents: 89
Other payor residents: 16
Licensed beds - SNF: 11
Licensed beds - SNF/NF: 109
Total licensed beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Signed Plan of Correction letter dated 08/01/2023. |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter. |
| NP 9 | Nurse Practitioner | Provided clinical interview and assessment regarding Resident E's condition and care. |
| DON | Director of Nursing | Provided multiple interviews regarding nursing expectations and actions related to Resident E. |
| LPN 7 | Licensed Practical Nurse | Provided care and observations related to Resident E on the day of incident. |
| CNA 5 | Certified Nurse Aide | Reported observations of Resident E's condition and response to call light. |
| LPN 10 | Licensed Practical Nurse | Administered medications and provided observations on the night Resident E passed. |
| Dialysis RN 8 | Dialysis Registered Nurse | Reported concerns about Resident E's responsiveness and condition during dialysis. |
| CEO of Clinical | Chief Executive Officer | Provided interview regarding NP services and EMS transport cancellation. |
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
This visit was for the investigation of Complaints IN00404123 and IN00407228. No deficiencies related to the allegations were cited, but an unrelated deficiency was identified.
Complaint Details
Complaint IN00404123 and IN00407228 were investigated with no deficiencies related to the allegations cited. The deficiency found was unrelated to the complaints.
Findings
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.
Deficiencies (1)
Failed to ensure a hot liquid assessment was completed for a resident with a decline in function, leading to a burn injury from spilled coffee.
Report Facts
Census bed type: 130
Medicare census: 28
Medicaid census: 86
Other payor census: 16
SNF beds: 10
SNF/NF beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Povinelli | Administrator | Signed the plan of correction and correspondence |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
Inspection Report
Follow-Up
Census: 126
Capacity: 156
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/29/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Lincoln Hills of New Albany 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 detached wooden storage structures.
Report Facts
Facility capacity: 156
Census: 126
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of three complaints (IN00391638, IN00389798, and IN00387110) related to the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to obtain a physician's order and ensure safe usage of warm compresses resulting in second-degree burns to a resident's back.
Report Facts
Census: 126
SNF/NF Beds: 116
SNF Beds: 10
Medicare Residents: 20
Medicaid Residents: 87
Other Residents: 19
Burn wound size: 22
Burn wound size: 18
Burn wound size: 5
Burn wound size: 20
Burn wound size: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in deficiency for improper application of warm compresses causing resident injury and received written warning and education. |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility response. |
Inspection Report
Re-Inspection
Census: 125
Capacity: 125
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and investigation of Complaint IN00383068 completed on July 29, 2022.
Complaint Details
Complaint IN00383068 - Corrected
Findings
Lincoln Hills of New Albany 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 and investigation of Complaint IN00383068.
Report Facts
Census Bed Type: 125
Census Payor Type - Medicare: 25
Census Payor Type - Medicaid: 82
Census Payor Type - Other: 18
Inspection Report
Life Safety
Census: 122
Capacity: 156
Deficiencies: 6
Date: Aug 29, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
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.
Deficiencies (6)
Failed to ensure 1 of 1 kitchen range hood extinguishing system was maintained in proper working order.
Failed to ensure sprinkler heads in 1 of 10 smoke compartments were not loaded and covered with foreign material.
Failed to ensure the ceiling in 1 of 10 sprinklered smoke compartments was maintained to allow sprinkler heads to function to their full capability.
Failed to ensure 1 of 7 resident room corridor doors on the D Hall would close completely and latch into its door frame.
Failed to ensure 2 of 9 smoke barrier walls were protected to maintain the smoke resistance of the smoke barrier.
Failed to ensure 2 of over 20 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock.
Report Facts
Certified beds: 156
Current census: 122
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Named in correspondence and exit conference |
| Kim Povinelli | HFA, Administrator | Named in correspondence and exit conference |
| Director of Facilities | Interviewed regarding deficiencies and corrective actions | |
| Maintenance Assistant | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 5
Date: Jul 29, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00378436 and IN00383068.
Complaint Details
Complaint IN00378436 was substantiated with no deficiencies cited. Complaint IN00383068 was substantiated with a Federal/State deficiency cited at F689 related to the allegations.
Findings
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.
Deficiencies (5)
Failure to ensure interventions were implemented for falls and safe transfer procedures, resulting in bilateral knee fractures for a resident requiring maximum assistance.
Failure to ensure proper catheter care and monitoring of indwelling urinary catheter bags for residents with catheters.
Failure to follow physician orders for notification and ensure daily weights were obtained for residents with nutrition/hydration concerns.
Failure to ensure oxygen concentrator filters were applied and maintained for residents requiring respiratory care.
Failure to ensure appropriate behavioral care planning and interventions for a resident with a history of resident to resident aggression.
Report Facts
Census: 135
Weight gain: 4.4
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Audit frequency: 5
Audit duration: 4
Audit duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Povinelli | HFA | Signed Plan of Correction letter |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter |
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