Brownsburg Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsburg, Indiana.
- Location
- 1010 Hornaday Rd, Brownsburg, Indiana 46112
- CMS Provider Number
- 155206
- Inspections on file
- 26
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Brownsburg Health Care Center during CMS and state inspections, most recent first.
A QMA was observed administering medications to multiple residents by popping pills into her hand and failing to perform hand hygiene before, during, or after medication passes, despite facility policies and posted precautions requiring hand sanitization between residents. Hand sanitizer was available but not used, and the QMA continued to prepare and administer medications to other residents without proper infection control practices.
A resident with ALS and significant communication challenges was subjected to verbal and physical abuse by two CNAs, who pulled on the resident's arms despite clear signs of discomfort, moved the resident's communication device out of reach, and attempted to use a mechanical lift unnecessarily. The resident's minor family member had to intervene to stop the inappropriate care, and the CNAs made inappropriate comments and failed to respect the resident's dignity during personal care.
Multiple residents dependent on staff for ADL support, including meal service, toileting, bathing, and dressing, did not receive timely care. Observations showed residents left in bed for extended periods, in soiled briefs, or with meals out of reach. Staff interviews confirmed that low CNA staffing, especially on weekends, made it impossible to provide adequate assistance, resulting in unmet care needs for residents requiring extensive help.
Surveyors found that medications and wound treatment solutions were left unsecured in resident rooms and public areas, including over-bed tables, breakfast trays, and handrails. Multiple residents had access to unidentified pills, inhalers, creams, and supplements without documentation of self-administration assessments, physician orders, or care plans. Facility staff confirmed awareness of the policy requiring secure medication storage, but observations and record reviews showed repeated noncompliance.
Surveyors found that respiratory care equipment, such as nebulizers, oxygen tubing, and CPAP masks, was not properly cleaned or stored for several residents. Equipment was observed left unbagged on beds, on the floor, or among personal items, sometimes with medication still present. Documentation for cleaning, storage, and self-administration was missing, and facility policies for respiratory care were not followed.
The facility did not maintain sufficient nursing staff to meet residents' daily care needs, resulting in delays and missed assistance with ADLs, toileting, bathing, dressing, meals, and medication administration. Staff were often stretched across multiple hallways, leaving residents in bed for extended periods, sometimes in soiled briefs, and with meals or medications left unattended. Staff and resident interviews, along with facility records, confirmed that staffing levels frequently fell below the facility's own requirements, leading to unmet care needs.
The facility failed to provide specialized dementia care programming, leaving residents without meaningful activities. Observations showed that scheduled activities were often not conducted, and residents were left without engagement. Residents with preferences for social interaction and outdoor activities were not provided with suitable opportunities, and the activity staff lacked necessary training.
The facility failed to maintain a qualified Infection Preventionist (IP) for six months and did not ensure proper TB screenings for several residents. The Regional Director of Operations was not officially designated as the IP, and attempts to fill the position were unsuccessful. Additionally, five newly admitted residents and one previously admitted resident did not receive timely TB screenings, with some tests not read within the required timeframe.
The facility failed to accurately code a pressure ulcer on the MDS for a resident with multiple stage 3 pressure ulcers, and incorrectly coded the PASARR for another resident with major depression. These discrepancies were identified during record reviews and confirmed by the Regional MDS Coordinator.
The facility did not implement comprehensive care plans for two residents with indwelling urinary catheters. One resident with neuromuscular dysfunction of the bladder and another with neurogenic bladder both lacked documented care plans addressing their catheter needs, despite having physician's orders. The facility's policy mandates care plans be developed and updated per OBRA and MDS guidelines, which was not followed.
The facility failed to administer tube feedings according to physician's orders for two residents, resulting in inadequate nutrition. One resident experienced significant weight loss due to missed feedings and improper administration, while another resident's caloric intake was insufficient due to missed feedings. Staff interviews revealed communication issues and a lack of awareness regarding feeding orders, contributing to these deficiencies.
A resident with multiple sclerosis and compartment syndrome pain was admitted to a facility and assessed with severe pain. Despite a physician's order for Hydrocodone-Acetaminophen, there was a delay in accessing the medication due to a pending authorization code from the pharmacy. The facility did not document ongoing pain assessments, alternative pain management strategies, or notify the physician of the delay. The resident, upset by the lack of pain relief, discharged herself against medical advice without signing the AMA form.
A resident with multiple sclerosis and compartment syndrome pain did not receive timely pain medication due to a delay in obtaining an EDK authorization code. The on-call pharmacist's delayed response contributed to the resident discharging herself AMA after waiting over seven hours for pain relief.
The facility failed to ensure staff followed hand hygiene protocols when delivering meals to two residents under enhanced barrier precautions (EBP). A QMA was observed entering and exiting the rooms of residents with a g-tube, pressure ulcer, indwelling catheter, and wound without sanitizing hands, contrary to facility policy and room signage. A CNA confirmed the hand hygiene requirement.
A facility failed to coordinate care with hospice for a resident with new skin impairments on the bilateral lower extremities (BLE). The resident, dependent on staff for care, had reddened and edematous BLE, and hospice notes indicated new open wounds. However, these notes were not available in the facility's records, and the physician was not notified. Interviews revealed dissatisfaction with care quality, and the facility's policy on end-of-life care coordination was not effectively implemented, leading to a deficiency.
An LPN at the facility diverted at least 56 narcotic medication tablets from multiple residents, including those with dementia and Huntington's disease. The discrepancies were identified through ADU reports and Controlled Substance Accountability Sheets, leading to an investigation and the LPN's termination.
Failure to Follow Hand Hygiene and Infection Control During Medication Pass
Penalty
Summary
A Qualified Medication Aid (QMA) failed to follow infection control practices during medication administration to five residents across multiple hallways. The QMA was observed popping medication tablets out of bubble packs directly into the palm of her hand, placing them into medication cups, and administering them to residents without performing hand hygiene before, during, or after the medication pass. This practice was repeated with several residents, including after performing tasks such as blood pressure checks and handling residents' clothing, and continued as the QMA moved from one resident to another without sanitizing her hands. The QMA also documented medication administration and immediately began preparing medications for the next resident without washing or sanitizing her hands. Observations included the QMA handling medications and interacting with residents in their rooms and in common areas, such as the hallway and therapy gym, without following hand hygiene protocols. The facility's Unit Manager confirmed that staff are expected to sanitize their hands between each resident during medication passes and that medications should not be dispensed by being popped into a staff member's hand. Hand sanitizer was available on the medication cart, but was not used by the QMA during the observed period. Facility policies provided by the Administrator required hand hygiene before and after medication administration and the use of standard precautions for all residents, regardless of infection status. Enhanced Barrier Precautions and Contact Precautions signage was posted on several residents' doors, instructing staff to clean their hands before entering and after leaving rooms. Despite these policies and posted instructions, the QMA did not adhere to required hand hygiene practices during the observed medication passes.
Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
A resident with amyotrophic lateral sclerosis (ALS), dysphagia, and facial weakness experienced verbal and physical abuse by two Certified Nursing Aides (CNAs) during care. The CNAs pulled on the resident's arms despite the resident expressing discomfort and shaking his head no. The resident's communication device was moved out of reach, preventing him from communicating his needs. The resident's minor family member, who was present, had to intervene and tell the CNAs to stop pulling on the resident's arms due to pain. The CNAs also changed the resident's brief in front of the minor family member and attempted to put the resident to bed earlier than desired, using a mechanical lift when the resident was able to stand and shuffle. The resident was left in his shirt for bedtime after expressing distress. During the incident, one CNA suggested rolling the resident onto his side and dropping him to make it look like an accident. The resident was unable to lie flat in bed, but the CNAs attempted to position him that way, causing further distress. The resident became upset and wanted to call 911. Interviews with staff and the hospice case manager indicated the CNAs were unfamiliar with ALS care, and the situation escalated until the resident's adult family member intervened. The incident was self-reported by the facility, and the CNAs involved were not assigned to care for the resident following the event.
Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for multiple residents who were dependent on staff for meal service, toileting, bathing, dressing, and getting out of bed. Direct observations revealed that several residents remained in bed for extended periods, were left in soiled briefs, and did not receive timely assistance with meals or personal hygiene. For example, one resident was observed lying in bed for hours with her upper torso slumped, surrounded by paper debris, and later found sitting in a wheelchair with an untouched breakfast tray out of reach. Another resident reported not being assisted out of bed or having his brief changed by the morning shift, remaining wet for several hours, and staff confirmed delays in care. Additional observations included residents left in urine-soaked briefs, missing scheduled baths, and having cold or untouched meals placed out of reach. Some residents expressed frustration about waiting for care, especially on weekends when staffing was lower. Staff interviews corroborated these findings, with CNAs and nurses reporting that low staffing levels made it impossible to provide timely care to all residents, particularly those requiring extensive assistance or mechanical lifts. Staff also described working without breaks and being unable to get all residents out of bed or fed in a timely manner. Facility records indicated that a significant proportion of residents required assistance with feeding and toileting, yet staffing levels were insufficient to meet these needs. Staff interviews and confidential employee statements highlighted issues such as unreported call-offs, reduced CNA hours, and lack of management support during low staffing periods. The facility's own policy required care and services to be provided in a manner that maintains residents' highest practicable well-being, but observations and interviews demonstrated consistent failures to meet these standards for a substantial number of residents.
Failure to Secure Medications and Treatment Solutions
Penalty
Summary
The facility failed to ensure that all medications and wound treatment solutions were secured and not left unattended in public hallways or resident rooms for five residents. Surveyors observed multiple instances where medication cups containing unidentified pills, inhalers, and creams were left on over-bed tables, breakfast trays, or handrails, accessible to residents without proper supervision. In each case, there was no documentation of an assessment for self-administration of medications, no physician's order permitting self-administration or medications at bedside, and no care plan addressing self-administration. For example, one resident was found with a cup of unidentified pills on the bedside table, and another had a medication cup and inhaler left on a breakfast tray while sleeping in a wheelchair. Additional observations included residents with various medications, eye drops, inhalers, and supplements among their personal items, some of which lacked pharmacy labels, had unreadable labels, or no visible expiration dates. In one case, a medication cup with white cream was left on a handrail outside a resident's room. Record reviews confirmed that the medications had been documented as administered by nursing staff, but there was no evidence of proper authorization or assessment for residents to keep medications at bedside. Interviews with facility staff, including the administrator and regional nurse consultant, confirmed that staff were aware that prescription medications should not be left at bedside without an order. Facility policies provided by the regional nurse consultant required medications to be administered by licensed staff and stored securely, accessible only to authorized personnel.
Failure to Properly Clean and Store Respiratory Care Equipment
Penalty
Summary
The facility failed to properly clean and store respiratory care equipment, including nebulizers, oxygen tubing, and CPAP machines, for four residents. Observations revealed that a resident with emphysema and chronic respiratory failure had oxygen tubing placed inside her brief by a CNA, and her nebulizer mouthpiece was left unbagged on her bed. The same resident's portable oxygen concentrator was repeatedly found on and running, with the nasal cannula lying on the floor. Another resident's nebulizer mouthpiece was left unbagged and clipped to the machine with medication still in the chamber, and there was no documentation of an assessment or physician's order for self-administration or for leaving medications at the bedside. A third resident's CPAP mask was found unbagged among personal items, and the resident's record lacked physician's orders for cleaning and storage of the CPAP machine. The care plan for this resident did not include interventions or instructions for CPAP use. A fourth resident's nebulizer mouthpiece was found unbagged and covered with a soiled winter coat among personal items, and there were no physician's orders for cleaning and storage of the nebulizer equipment in the resident's record. Facility policies required proper cleaning, disinfection, and storage of respiratory equipment, including storing items in a plastic bag with the resident's name and date, and weekly observation of equipment for cleanliness. The facility did not follow these policies, as evidenced by the improper storage and lack of cleaning documentation for respiratory care equipment for the residents involved.
Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the daily needs of residents, resulting in multiple instances where residents did not receive timely assistance with activities of daily living (ADLs) such as meal service, toileting, bathing, dressing, medication administration, and getting out of bed. On several hallways, CNAs were either absent or stretched thin, with one CNA responsible for up to 13 residents and others covering multiple hallways. Staff interviews and observations revealed that residents were left in bed for extended periods, some in soiled briefs, and meals were often left untouched and out of reach. Medication administration was also delayed or improperly managed, with medications left at bedside and not always given as scheduled. Residents reported and were observed experiencing delays in receiving care, including not being assisted out of bed, not having briefs changed, and not receiving baths or meals in a timely manner. Several residents expressed that these issues were more pronounced on weekends due to staff call-offs and insufficient backup plans. Staff members confirmed that low staffing levels were a recurring problem, with some CNAs not receiving breaks or lunch due to the workload. The facility's own records indicated that staffing levels frequently fell below the numbers outlined in the facility assessment, and the administrator was not familiar with the required hours per resident day (HPRD) or how to calculate them. Documentation showed that the facility did not consistently meet its own staffing plan, with numerous days where the number of CNAs on duty was below the required minimum for each shift. The facility assessment identified a high percentage of residents needing extensive assistance with ADLs, yet the actual staffing did not align with these needs. Staff and resident interviews, as well as direct observations, confirmed that the lack of adequate staffing led to unmet care needs, delays in assistance, and compromised resident well-being.
Deficiency in Specialized Dementia Care Programming
Penalty
Summary
The facility failed to provide specialized dementia care programming for residents in the secured memory care unit, leading to a deficiency in meaningful, engaging, and diverse activities for residents diagnosed with dementia. Observations throughout the survey week revealed that scheduled activities were often not conducted, and residents were left without engagement or alternative activities. For instance, on multiple occasions, residents were observed sitting idly in the common area or in their rooms without any interaction or stimulation, despite the presence of an activity calendar that listed various activities. Residents 21, 37, 38, 50, and 63 were specifically noted to have been affected by this lack of engagement. Resident 21, who had a preference for being out of her room and engaging with others, was often left alone in her room talking to herself. Resident 37, who enjoyed being with people and participating in activities, was frequently observed with her eyes closed and not participating in any activities. Resident 38, who had a history of enjoying group activities and being outdoors, was seen sitting at a table without participating in activities, and her visitors noted the lack of suitable engagement for her. The facility's activity program was not tailored to the individual needs and preferences of the residents, as evidenced by the repeated use of the same trivia questions and coloring activities, which did not engage the residents. Additionally, the facility did not utilize the secured outdoor area for activities, and there were no scheduled pet visits or opportunities for residents to enjoy fresh air, despite these being listed as preferences in the residents' care plans. The activity director and assistants were observed to lack the necessary training and understanding of the specialized dementia care programming, further contributing to the deficiency.
Infection Preventionist Role and TB Screening Deficiencies
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) role was filled for six out of twelve months reviewed. During the entrance conference, the Executive Director (ED) indicated that the Regional Director of Operations (RDO) was acting as the IP, although he was not officially designated for this role. The RDO confirmed that he was not the IP for the facility and that no one in the building had the necessary IP certification. The ED mentioned that the last IP left the facility on an unspecified date, and subsequent attempts to fill the position with an Assistant Director of Nursing (ADON) were unsuccessful, as the candidates did not complete their IP certification. The facility also failed to ensure that all new residents were screened for tuberculosis (TB) as required. Five out of seven newly admitted residents and one previously admitted resident did not receive proper TB screenings. For instance, Resident 72, who was admitted on an unspecified date, did not receive any TB screening, and a physician's order for a tuberculin skin test was not executed. Similarly, Resident 135 received TB screening injections, but the results were not read within the required 48-72 hours. Other residents, such as Resident 134 and Resident 136, also had their TB tests administered but not read within the stipulated timeframe. Additionally, Resident 184 did not have any physician's orders for TB screenings, and no records were found of him receiving such screenings. The RDO provided a document from another facility indicating a negative TB test result, but it lacked essential details such as the location, date, and personnel involved in the test. The facility's job description for the IP role and the policy for TB screening were reviewed, indicating the responsibilities and procedures that were not adhered to, contributing to the deficiency.
Inaccurate MDS Coding for Pressure Ulcer and PASARR
Penalty
Summary
The facility failed to accurately code a pressure ulcer on the Minimum Data Set (MDS) assessment for a resident with multiple medical conditions, including paraplegia and type 2 diabetes mellitus. The resident had three stage 3 pressure ulcers, as indicated by a wound care assessment, but the MDS inaccurately recorded two stage 3 pressure ulcers and one unstageable pressure ulcer. This discrepancy was identified during a record review and interview with the Regional MDS Coordinator, who acknowledged the error. Additionally, the facility did not correctly code the Preadmission Assessment and Resident Review (PASARR) on the MDS for another resident diagnosed with dementia, anxiety disorder, and major depression. The resident's MDS indicated that a level 2 assessment was not required, despite having a level 2 assessment and a care plan indicating a positive PASSR due to major depressive disorder. This inconsistency was also noted during a record review and confirmed by the Regional MDS Coordinator.
Failure to Implement Comprehensive Care Plans for Residents with Catheters
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan for two residents with indwelling urinary catheters. Resident 68, who has diagnoses including retention of urine and neuromuscular dysfunction of the bladder, was observed with a urinary collection bag but lacked a documented care plan addressing his catheter needs. Despite having a physician's order for catheter placement and securement, the care plan did not reflect this requirement. Similarly, Resident 1, diagnosed with neurogenic bladder, also had a physician's order for a Foley catheter. She reported discomfort from the catheter, yet her care plan did not document any plan of care to address her catheter needs. The facility's policy requires the interdisciplinary team to develop and update care plans in accordance with OBRA and MDS guidelines, but this was not adhered to for these residents.
Failure to Administer Tube Feedings as Ordered
Penalty
Summary
The facility failed to ensure that tube feedings were administered according to physician's orders for two residents, leading to deficiencies in their nutritional care. Resident 134, who had a history of cerebral infarction and required a gastric tube for nutrition, experienced a significant weight loss shortly after admission. The physician's orders specified a regimen of Glucerna 1.5 bolus feedings with free water flushes, but these were not consistently administered as prescribed. On one occasion, the resident missed two scheduled feedings, and a nurse attempted to compensate by administering multiple feedings at once, which was not in accordance with the orders. Resident 74, who had a history of gastric ulcer and schizophrenia, also did not receive tube feedings as ordered. The resident's treatment administration record showed missed feedings on several occasions, resulting in insufficient caloric intake. The facility's policy required adherence to physician orders for tube feedings, including specific amounts and frequencies, but these were not followed, leading to inadequate nutrition for the resident. Interviews with staff revealed a lack of communication and awareness regarding changes in feeding orders. Nurses did not consistently receive updated orders during shift changes, and there was confusion about the responsibilities of QMAs in reminding nurses about feeding schedules. This lack of coordination contributed to the failure to provide the prescribed nutritional support to the residents, as evidenced by the discrepancies in the administration of tube feedings.
Failure in Timely Pain Management Leads to Resident's AMA Discharge
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a newly admitted resident, who had multiple sclerosis and pain in her right arm due to compartment syndrome. Upon admission, the resident's pain was assessed at a 9 out of 10, and a physician's order for Hydrocodone-Acetaminophen was entered into the system. However, there was a delay in obtaining an authorization code from the pharmacy to access the emergency drug kit, resulting in the resident not receiving her prescribed pain medication. The facility's records lacked documentation of ongoing pain assessments, non-pharmacological interventions, or alternative medications to manage the resident's pain while waiting for the controlled medication. Additionally, there was no documentation that the physician was notified of the delay in accessing the emergency drug dispenser. The resident, upset by the lack of pain management, chose to discharge herself against medical advice without signing the AMA form, and the facility did not document the reason for her discharge or her refusal to sign the form.
Failure to Provide Timely Pain Medication from EDK
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, identified as Resident 82, who required pain medication from the emergency medication kit (EDK). Resident 82, who had been diagnosed with multiple sclerosis and pain in the right arm due to compartment syndrome, was admitted to the facility from a local hospital. A physician's order for narcotic pain medication was entered into her medical record in the afternoon, but she did not receive the medication for over seven hours. As a result, Resident 82 discharged herself against medical advice due to the lack of pain relief. The delay in providing the necessary medication was attributed to the facility's failure to obtain an authorization code for the EDK in a timely manner. The on-call pharmacist received multiple text messages from the facility requesting the EDK code, but her phone was on silent mode, leading to a delay of 1 hour and 20 minutes in her response. The facility's procedure guideline indicated that the E-kit should be checked for the medication, and if not available, the pharmacy should be contacted for further instructions. However, this process was not effectively executed, resulting in the deficiency.
Failure to Follow Hand Hygiene Protocols for EBP Residents
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff when providing lunches to residents under enhanced barrier precautions (EBP). On multiple occasions, a Qualified Medication Aide (QMA) was observed delivering meals to two residents, one with a g-tube and pressure ulcer, and another with an indwelling catheter and wound, without performing hand hygiene before entering or after leaving their rooms. This was contrary to the facility's hand hygiene policy and the signage on the EBP rooms, which required hand sanitization before entering and upon exiting the rooms. A Certified Nursing Aide (CNA) confirmed the requirement for hand hygiene in these situations.
Failure to Coordinate Care with Hospice for Resident's Skin Impairments
Penalty
Summary
The facility failed to coordinate treatments and services with hospice for a resident with new skin impairments on the bilateral lower extremities (BLE). Observations revealed that the resident, who was totally dependent on staff for care, had reddened and edematous BLE. Despite the presence of a physician's order to cleanse and apply silicone cream to the BLE, there was a lack of communication and coordination between the facility and hospice regarding the resident's condition. Hospice narrative notes indicated the presence of new open wounds and compromised skin integrity, but these notes were not available in the facility's records, and the physician was not notified. Interviews with staff and family members highlighted dissatisfaction with the quality of care provided. The Regional Nurse Consultant admitted that hospice had not sent the necessary narrative notes, and the facility had not reached out to request them. The facility's policy on end-of-life care required coordination with hospice, but this was not effectively implemented, leading to a deficiency in care for the resident. The lack of communication and documentation contributed to the oversight in addressing the resident's deteriorating condition.
Narcotic Medication Diversion by LPN
Penalty
Summary
The facility failed to ensure residents' narcotic medications were protected from diversion, resulting in at least 56 missing narcotic medication tablets. The Director of Nursing (DON) observed that an LPN had pulled multiple controlled substance medications from an automated drug unit (ADU), which did not reflect the medications documented as administered. This discrepancy was identified through ADU reports and Controlled Substance Accountability Sheets, which showed that the LPN had dispensed more narcotic tablets than were necessary for the residents' prescribed treatments. Resident C, who had diagnoses including dementia with psychotic disturbance and severe blindness, was prescribed hydrocodone-acetaminophen for pain. However, the Medication Administration Record (MAR) lacked documentation that the resident was administered the medication as needed (prn) for pain, despite the ADU reports showing multiple instances of the LPN dispensing the medication. Similarly, Resident D, who had Huntington's disease and quadriplegia, was also prescribed hydrocodone-acetaminophen. The MAR for Resident D also lacked documentation of prn administration, even though the ADU reports indicated that the LPN had dispensed the medication multiple times. Further investigation revealed additional instances of drug diversion by the LPN, affecting other residents as well. The LPN had signed out more narcotic pills than required and had even signed a narcotic destruction sheet without a witness, which prompted the initial investigation. The DON conducted interviews, pain assessments, and reviewed ADU reports, concluding that the LPN had diverted at least 56 narcotic pills. The local police, the physician, and family members were notified, and the LPN was terminated following the investigation.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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