Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brownsburg Health Care Center during CMS and state inspections, most recent first.
RN 6 was observed administering late and incomplete medication passes for multiple residents while stating he was behind due to new admissions. One resident’s meds were overdue, another resident’s BG check was delayed and resulted in a BG of 459 with NP notification and lispro ordered, and two other residents had medication administration issues including missed documentation, an omitted ordered med, and an insulin dose that was not given as ordered. The DON later noted the late meds were due to the admission workload, and the record review showed missing orders and documentation for several of the medications given.
MDS assessment failed to code a resident’s falls. A resident had multiple documented falls after the prior MDS, including a witnessed fall with head lacerations and sutures, another fall with a forehead bruise, and a later fall that led to guarding of the RLE and an x-ray showing a right femur fracture. Despite these events, the discharge MDS stated there were no falls since the prior assessment, and the MDS Coordinator confirmed the falls were not coded.
A resident with dementia, mood disturbance, and repeated falls did not receive ordered orthostatic BP monitoring after a fall, with the TAR showing blank or incomplete BP documentation and no record that the NP was notified. After another fall, staff documented guarding of the RLE, inability to straighten the leg, and ongoing pain, but the x-ray was delayed and the resident was later found to have a right femur fracture. Pain documentation was also incomplete, with no documented analgesic given overnight despite continued pain.
Improper Glucometer Disinfection: An RN failed to properly clean and disinfect a glucometer after checking blood sugar for two residents. He used an alcohol prep pad on the device, later used purple top wipes without following the manufacturer’s directions, and handled the wipes with ungloved hands. The facility policy required cleaning the blood glucose monitor per manufacturer instructions and wearing gloves prior to cleaning.
A resident with multiple chronic pain-related conditions and intact cognition had an order for tramadol 50 mg five times daily at specific times, with facility policy allowing only a one-hour window around scheduled doses. Review of the eMAR showed repeated late administrations, including doses given more than two to three hours past the ordered times and two morning doses given together, causing doses to be closer together than prescribed. The resident and her daughter reported that medications were not given on time and sometimes too close together, and the resident described intermittent extreme fatigue and difficulty staying awake. A nurse practitioner documented increased fatigue, and the DON confirmed that the opioid medication had been administered outside the facility’s policy time parameters.
Surveyors found that catheter collection bags and tubing were not maintained in a sanitary manner for two residents. One resident with a suprapubic catheter and a history of UTI and sepsis had a drainage bag covered in a pillowcase lying on the floor, with tubing also on the floor, despite a care plan intervention to keep the bag off the floor. Another resident with a Foley catheter and multiple urologic conditions had a catheter bag attached to the bottom of a wheelchair, with part of the bag and tubing dragging on or resting on the floor, and the record lacked a catheter care plan. Staff and the Regional Nurse Consultant acknowledged that catheter bags and tubing should not touch the floor, and facility policy stated that collection bags must not touch the floor at any time.
Failure to Protect Residents from Physical and Sexual Abuse: The facility did not prevent one cognitively impaired resident from intrusively entering another resident’s room, where the other resident pushed her and caused serious injury including a lip laceration, nasal fracture, rib fractures, and a decline from independent walking to wheelchair dependence with staff assistance. The facility also did not prevent a cognitively impaired male resident from entering a female resident’s room, removing her clothing, and sexually assaulting her; records lacked adequate documentation, behavior monitoring, and care plan interventions for the known room intrusions, aggression, and sexually inappropriate behavior.
Inadequate RN and Memory Care Staffing: The facility did not meet its required RN PPD and repeatedly failed to staff the secured memory care unit with enough familiar staff to supervise residents and provide care. Observations found staff absent from the dining/activity area, a QMA and CNA pulled from other assignments without clear direction, and an LPN unfamiliar with the unit's residents and routines. A resident was observed unsupervised entering another resident's room, and a family member reported prior resident-on-resident aggression with serious injury. Grievances also described delayed call light response, missed showers, and ongoing staffing concerns.
Ineffective QAPI Program and Failure to Track Recurring Deficiencies: The facility failed to use its QAPI process to identify, analyze, and correct recurring quality and safety issues. Leadership reported that adverse incidents and reportable events were often handled without IDT involvement, administrative awareness, or proper investigation, tracking, or follow-up, and that the corporate AIR process was not being used. The ADM stated that QAPI meetings occurred, but he could not identify effective actions for concerns found during survey, and recurring grievances involving staffing, call light response times, staff attitude, showers, and basic care needs were not consistently trended or incorporated into QAPI.
Staff failed to maintain resident dignity and privacy when an LPN and CNA referred to residents as "feeds" during meal service and served meals on plastic trays without removing the plates, cups, and utensils to make the setting less institutional. Staff also repeatedly entered residents' rooms after knocking without waiting for permission to enter, including incidents observed by a resident and the Ombudsman.
Repeated grievances showed unresolved complaints about delayed call light response, missed showers, unmet ADL care, and staff attitude. Residents reported long waits for help, being left wet or without needed care, and being yelled at during brief changes. The DON provided grievance records showing the same issues recurring over several months, and the ADM stated the concerns had not been fully trended or systematically addressed.
Failure to Thoroughly Investigate Abuse and Misappropriation Allegations: The facility did not fully investigate or document alleged resident-to-resident physical abuse, sexual abuse, and misappropriation of a resident’s funds. Records and interviews showed incomplete incident investigations, missing IDT notes, lack of care plan revisions, no documented follow-up for resident monitoring or supervision concerns, and incomplete follow-up on safe surveys and staff allegations related to the missing debit card and cash.
Care plans were not implemented or revised for multiple residents with identified needs. A resident with dementia and wandering behavior was involved in a resident-to-resident altercation that caused serious injury, but her plan lacked updates for appearance-related targeting and the injury. Another resident with dementia, delusions, and anxiety had no plan revisions for fixation on an intrusive peer. A resident with a history of sexual trauma and impaired judgment was sexually assaulted by another resident whose sexually explicit behavior was not addressed in his care plan. Two other residents with stroke-related deficits and one on diuretics also lacked care plans for dehydration risk.
Inadequate supervision and limited dementia-appropriate activities on Memory Care unit. Residents were repeatedly left unsupervised in the dining/activity area while staff were pulled in multiple directions, and some staff assigned to the unit did not normally work there or know the residents well. Activities were largely limited to coloring, reading, and TV, even when residents were disengaged or declined the activity, and there were no structured activities after 3 p.m. or evidence of routine therapeutic programming for residents with dementia.
Expired and undated medications were found in multiple med carts and a med room, including an albuterol inhaler with no open date, hydrocortisone cream, expired Lantus and Novolog insulin pens, diclofenac cream stored with Miralax, and an undated normal saline bottle in the refrigerator. The Unit Manager and an RN identified the saline and insulin pens as expired.
Advance directive documentation was inconsistent for two residents. One resident had a POST indicating DNR, but the current physician order and care plan listed full code, and an RN acknowledged the discrepancy. Another resident with multiple diagnoses, including fractures, DM2, CKD, and a prior CVA with hemiplegia, had a care plan indicating DNR but no physician order for code status in the record.
A resident with CKD, HTN, hyperlipidemia, and weakness had no documentation of medication reconciliation after discharge. The chart did not account for multiple discharged meds, including insulin, antidepressants, a diuretic, a beta blocker, eye drops, pain medication, and hypoglycemia rescue meds, and the DON said she could not find the discharge med record.
Incorrect order transcription, delayed antibiotic ordering, and medication timing errors: A resident with wound care needs had orders from the wound clinic that were not fully entered into the MAR, including a missing turning/off-loading order. Another resident’s pre-op prophylactic antibiotic was not reordered in time, delaying surgery after the original medication was found to be inappropriate due to an allergy. Two residents received levothyroxine and omeprazole after breakfast instead of before meals as recommended, and another resident’s duloxetine order listed depression even though the record later showed it was intended for RLS.
A resident with multiple non-pressure wounds had dressings observed in place that were dated several days earlier, with one dressing showing visible bloody drainage and two dressings lacking dates. The resident had active wound care orders for the abdomen, elbow, heel, and ankle, but the record showed no documentation of the target behavior of refusing wound care. The DON and Wound Nurse stated the resident often refused dressing changes and that ordered dressing changes were the responsibility of the floor nurses outside of weekly wound rounds.
Improper wound care and positioning were observed for a resident with a sacral PU, a DTI near a recent toe amputation site, and wounds to the lateral L foot and heel. Ordered dressings were not in place, no direct wound care was provided to the sutures, and the resident was observed lying on her back despite orders to off-load the sacrum by turning side to side only.
A resident with ALS, dysphagia, abnormal weight loss, and OSA had numerous supplements kept at bedside in his room without a self-administration assessment in the record. Another resident with fractures, DM2, CKD, HTN, hyperlipidemia, stroke with left hemiplegia/hemiparesis, and muscle weakness had enabler bars positioned too far from the mattress, with gaps measured at 2 inches on one side and 3 inches on the other; her care plan did not address the grab bars.
A resident with chronic pain and COPD did not consistently receive prescribed Oxycodone as documented on the EMAR and narcotic sheets, with repeated dose-count discrepancies and altered balance entries. Staff discontinued the opioid after a THC-positive, Oxycodone-negative blood test and suspected pocketing or diversion, despite a urine test that was positive for Oxycodone and discussion that blood testing may reflect therapeutic levels. The resident reported sometimes not receiving the medication as often as ordered and became tearful when discussing the issue.
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.
Late and Omitted Medication Administration
Penalty
Summary
The facility failed to have competent and sufficient staff to administer medications and insulin timely to residents as ordered for 5 of 5 residents observed during a medication pass. During the observation, RN 6 was passing medications while also stating he had two new admissions and was running behind, despite indicating he had assistance available. Resident B’s medications were already highlighted as overdue on the eMAR and were not administered until 7:22 p.m. Resident C’s blood sugar check, due at 5:00 p.m., was not completed until 7:28 p.m.; the blood sugar was 459, which was above the ordered parameters, and the NP ordered 12 units of lispro insulin. RN 6 stated he would recheck the blood sugar at 9:00 p.m. and administer the ordered insulin required at that time. RN 6 administered routine morphine to Resident E but did not sign it out after administration. For Resident D, RN 6 prepped lorazepam but did not prep the ordered omeprazole, crushed and administered the lorazepam, and did not sign it out afterward. Resident D was later yelling out and had new orders for morphine, but none was available; the DON indicated she would obtain a one-time order for oxycodone, and a pill cup with oxycodone was then seen at the cart for Resident D. For Resident F, RN 6 checked the blood sugar at 8:16 p.m. and it was 177, then administered metformin, atorvastatin, and apixaban, but the ordered 5:00 p.m. lispro insulin 5 units was not administered as ordered. The record review the next day showed no orders or notes documenting late or omitted medications for Residents C, D, or F, and Resident D’s record lacked an order for the one-time oxycodone that had been administered.
MDS assessment failed to code resident falls
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident K by not coding falls that occurred after the prior assessment. A quarterly MDS dated 3/2/26 was in the record, and progress notes documented a witnessed fall in the dining room on 3/11/26 with a laceration to the forehead and back of head, followed by transfer to the hospital and return with three sutures to the left forehead. Additional progress notes documented a fall in the bathroom on 3/30/26 with a bruise on the forehead, and another fall on 4/17/26 when the resident stood from the dining room table, tripped, and fell on the right side. After the 4/17/26 fall, the resident was guarding the right lower extremity and would not straighten the leg, and a progress note on 4/18/26 stated the POA requested hospital transfer related to the prior fall. An x-ray dated 4/18/26 showed a right femur fracture. A discharge, return not anticipated, MDS dated 4/18/26 indicated the resident had no falls since the prior assessment, and the Corporate MDS Coordinator later confirmed the falls were not coded on the assessment. The facility used the CMS RAI manual as its MDS assessment policy, which instructs that all falls since the prior assessment be counted and coded for injury level.
Failure to complete ordered orthostatic BP monitoring and delay in evaluation of fracture after fall
Penalty
Summary
The facility failed to ensure a resident with dementia, mood disturbance, and repeated falls received ordered orthostatic blood pressure monitoring after a fall. After the resident was found on the bathroom floor with a skin tear to the right knee and a bruise to the forehead, the nurse practitioner ordered orthostatic blood pressures for three days. The treatment record showed only single blood pressure entries or blank documentation on multiple shifts, and the record lacked documentation that orthostatic blood pressures were completed as ordered. Progress notes also lacked documentation that the nurse practitioner was notified about the missing orthostatic blood pressure monitoring. The facility also failed to ensure prompt treatment after the resident fell again and later was found to have a right femur fracture. After the resident stood from the dining room table, tripped, and fell onto the right side, staff documented that the resident was guarding the right lower extremity, would not straighten the leg, and continued to complain of pain. The nurse practitioner ordered an x-ray, but the mobile x-ray company reported the earliest available time was the following afternoon, and the record lacked documentation of further follow-up with the nurse practitioner regarding the delay. The resident remained in pain and was unable to extend the leg. Pain documentation and treatment were incomplete during this period. The MAR showed pain assessments each shift, but there was no documented pain medication between an acetaminophen dose given for pain rated 6 out of 10 and an oxycodone dose given the next morning, despite a documented pain assessment of 4 out of 10 overnight. The hospital history and physical stated the family was notified the night of the fall, found the resident the next morning in bed with significant pain and only acetaminophen available, and requested additional pain medication before the resident was sent to the hospital, where an x-ray confirmed the right femur fracture.
Improper Glucometer Disinfection
Penalty
Summary
The facility failed to effectively cleanse a glucometer after use for blood sugar checks on two residents. On 5/26/26 at 7:45 p.m., RN 6 finished checking Resident B’s blood sugar, brought the monitor to the medication cart, and used an alcohol prep pad with an ungloved hand to wipe the strip insertion area for a couple of seconds. He then left the glucometer on the medication cart and continued passing medications to the resident. When asked about the cleaning procedure, RN 6 stated he was out of the wipes usually used to clean the machine. Later that evening, the DON arrived and provided a tub of purple top wipes for cleaning the glucometer, and RN 6 placed the wipes in the bottom drawer of the medication cart. At 8:15 p.m., RN 6 checked Resident G’s blood sugar without cleaning the monitor with the purple top wipes first. After returning to the medication cart, he removed a wipe and rubbed it with an ungloved hand onto the glucometer for approximately 20 seconds, then discarded the wipe and left the monitor on top of the medication cart. The manufacturer of the Even Care glucometer, Medline, recommends cleaning and disinfecting with EPA-registered disinfecting wipes, and the facility policy required cleaning and disinfecting the blood glucose monitor according to manufacturer directions and using gloves prior to cleaning.
Failure to Administer Opioid Analgesic Within Ordered Time Parameters
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to administer a resident’s narcotic pain medication, tramadol, in accordance with the physician’s orders, facility policy, and manufacturer instructions. The resident, who had diagnoses including stage 3 hypertensive chronic kidney disease, polymyalgia rheumatica, lumbago with sciatica, gout, osteoarthritis, GERD, neuropathy, hammer toes, and general discomfort, had a physician’s order for tramadol 50 mg five times daily at 1:00 a.m., 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The resident’s care plan required that pain medications be administered as ordered. The facility’s policies on liberalized medication pass times and medication administration allowed a one-hour window before or after the scheduled time, and specified that physician-ordered specific times supersede liberalized pass times. Record review of the eMAR showed multiple instances where tramadol was administered outside the allowed one-hour window, including doses given more than two and three hours late, and on one occasion two doses given together in the morning, well past the ordered 1:00 a.m. time and beyond the 6:00 a.m. time. These late and clustered administrations resulted in doses being given closer together than ordered. The resident and her daughter reported that medications were sometimes given too close together and not on time, with the resident describing episodes of extreme fatigue and difficulty keeping her eyes open occurring off and on. A nurse practitioner note documented the resident’s report of increased fatigue over several days, though she denied other symptoms and remained alert and oriented. The DON acknowledged that the opioid medication had been documented as administered outside the facility’s policy time parameters and that it should have been given timely.
Improper Handling of Urinary Catheter Bags and Tubing
Penalty
Summary
Surveyors identified a failure to maintain sanitary conditions for urinary catheter collection bags and tubing for two residents. For one resident with a suprapubic catheter and diagnoses including UTI, obstructive and reflux uropathy, urinary retention, and hydronephrosis, observation showed the catheter drainage bag covered in a pillowcase and lying on the floor, with the tubing also on the floor and then running up under the bed sheet. A QMA stated during the observation that the catheter bag and tubing should not be on the floor and that the bag should be secured to the bed frame with both the bag and tubing kept off the floor. The resident’s care plan, revised earlier in the year, included an intervention to maintain the drainage bag off the floor, and a recent hospital discharge summary documented UTI and sepsis and ordered methenamine hippurate for UTI prevention. For another resident with a Foley catheter and diagnoses including kidney stones, obstructive and reflux uropathy, mild cognitive impairment, acute kidney failure, and bladder cancer, surveyors observed the catheter bag attached to the bottom of the wheelchair with the lower portion of the bag dragging on the floor while the resident was being assisted down the hallway. Later, the same resident was seen seated near the nurses’ station with the catheter bag hanging from the wheelchair and the bottom of the bag and part of the tubing resting on the floor. The clinical record for this resident included documentation of recent urinary retention and obstruction, a clamped catheter bag for urine specimen collection, and an order for phenazopyridine for urinary discomfort, but lacked a care plan entry for the urinary catheter. The Regional Nurse Consultant stated that catheter bags and tubing should not be placed or rested on the floor and should be handled in a sanitary manner, and the facility’s catheter care policy specified that collection bags must not touch the floor at any time.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse involving resident-to-resident physical aggression and resident-to-resident sexual abuse. One cognitively impaired resident with diagnoses including unspecified dementia, mild cognitive impairment, and unsteadiness on feet was repeatedly observed intrusively wandering into another resident’s room. The other resident, who had diagnoses including vascular dementia, delusional disorder, and generalized anxiety disorder, had a history of psychosis, delusional thinking, and aggressive behaviors, including being upset when peers entered her room. The records for both residents lacked documentation of the known targeting, the repeated room intrusions, and interventions to prevent harm between them. On 11/20/25, the wandering resident entered the doorway of the other resident’s room and was pushed with open hands and extended arms, causing her to lose balance and fall into a handrail. She sustained a deep upper lip laceration, nosebleed, skin tears to the left hand, and was later found at the hospital to have a nasal fracture and fractures of the 6th, 7th, and 8th ribs. After returning from the hospital, she declined from walking independently to requiring staff assistance for transfers and ambulation in a wheelchair. Survey observations also found both residents left alone in common areas without staff supervision, and staff interviews confirmed that the aggressive resident had a known history of not wanting the other resident in her room, while the wandering resident frequently intrusively entered other residents’ rooms. The facility also failed to prevent resident-to-resident sexual abuse involving a cognitively impaired male resident and a cognitively impaired female resident. The male resident entered the female resident’s room, removed her pants and briefs, and began masturbating while touching her. The female resident had a history of sexual trauma, was moderately cognitively impaired, and after the incident was documented to have increased anxiety, reduced engagement, and a departure from her previously consistently happy demeanor. Records for both residents lacked documentation of adequate follow-up, behavior monitoring, care plan revisions, and interventions tied to the prior inappropriate room entry, the sexual assault, and the residents’ behaviors leading up to the incident.
Inadequate RN and Memory Care Staffing
Penalty
Summary
The facility failed to provide RN coverage at the level required by its facility assessment and did not maintain adequate staffing on the secured memory care unit. The assessment required a minimum RN PPD of 0.54 hours daily, but staffing schedules showed the facility did not meet that minimum on multiple dates. The Regional Nurse Consultant stated there should be at least two staff members on the memory care unit at night, yet the schedules showed the unit was not staffed with an adequate number of staff for night shift on multiple dates, leaving one CNA or one QMA to provide nursing and nursing assistant duties for 14 residents. During observations on the memory care unit, staff were frequently absent from the main dining/activity room or were pulled from other assignments. On one morning, no staff were present in the dining/activity room while residents were seated there, and a QMA entered hurriedly and stated she had been pulled to multiple assignments and was going to "wing it." A CNA later stated she had been pulled to help on the unit but had never worked there before and had not been given an assignment sheet. On another observation, seven residents were in the dining/activity room with no direct care staff present, and staff were observed moving in and out while medications were passed and ADL care was provided. Additional observations and interviews showed staff unfamiliarity with the unit and resident needs. An LPN assigned to the memory care unit stated she did not usually work there and was not sure about residents' routines, preferences, or behaviors. A resident was later observed unsupervised walking from her room into another resident's room and then into the dining room. A family member reported that one resident had experienced three falls in the prior year, including an incident in which another resident pushed her, causing facial and rib fractures and stitches to her lip. Grievances from July through December 2025 also documented repeated complaints about call light response time, staff attitude, missed or delayed showers, and ongoing staffing concerns, including residents being told staff were too busy or the facility was too short staffed to provide care as scheduled.
Ineffective QAPI Program and Failure to Track Recurring Deficiencies
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic quality and safety issues. During interview, the Regional Director of Operation and Regional Nurse Consultant stated that under prior administration, required corporate and facility processes for incident reporting, investigation, and interdisciplinary team oversight were not followed. They reported that adverse incidents and reportable events were often handled without IDT involvement, administrative awareness, or appropriate investigation, tracking, or follow-up, and that the corporate Adverse Incident Reporting process was not being used. They also stated that leadership turnover and administrative leave occurred without effective transition plans or delegation of responsibilities to maintain oversight. The Administrator, who had been in the building for about a week, reviewed the QAPI documentation and stated that although QAPI meetings were held regularly, he could not identify effective actions to address many concerns identified during the survey period. He reported that ad hoc reviews had recently been started for issues such as boiler safety, resident smoking practices, medication storage, and housekeeping, but these reviews were reactive and limited in scope rather than part of a comprehensive, data-driven QAPI program. He acknowledged that grievances involving staffing, call light response times, staff attitude, showers, and basic care needs had been recurring but were not consistently trended, analyzed, or incorporated into QAPI, and that staffing concerns had been identified at least three times in the prior 12 months without a formal action plan or PIP being initiated.
Dignity and Privacy Violations During Meal Service and Room Entry
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when staff used demeaning, task-oriented language during meal service on the secured memory care unit. During a dining observation, a rolling lunch cart was brought to the unit and an LPN and CNA began passing lunch trays. The CNA asked if there were any "feeds" in the area, and the LPN responded that there were three "feeds" and pointed to Residents D, 48, and 53. The residents' meals were served on plastic trays, and the lunch plates, cups, and utensils were not removed from the tray to make the meal service more homelike and less institutional. The CNA stated she had never worked in memory care and asked about "feeds" because she did not know the residents' names. The facility also failed to ensure residents were given the opportunity to accept or decline entry into their rooms. Resident H stated staff regularly entered the room without knocking or waited only briefly after knocking before coming in. While the resident was voicing concerns, an unidentified staff member knocked twice and entered without waiting for a reply or invitation, quickly set down the resident's lunch tray, apologized, and left. In another interview, Resident K and the Ombudsman observed an unidentified staff member knock twice and open the door without waiting for a response; the staff member apologized and closed the door. The Ombudsman stated that three different staff members had done the same thing while she was in the room with Resident K.
Repeated Grievances for Delayed Care, Staff Attitude, and Staffing Concerns
Penalty
Summary
The facility failed to identify repeated grievances and implement effective corrective actions to address ongoing resident complaints related to personal care services, responsiveness to call lights, hygiene care, and staff interactions. A review of grievances from July 2025 through December 2025 showed multiple repeated complaints across residents, including delayed or unanswered call lights, staff attitude concerns, missed or delayed showers, and complaints that staff were unavailable or too busy to provide care. Examples included a resident who reported that staff never came when he requested help with his tube feed, a resident who reported long waits for bathroom assistance and poor staff attitudes, a resident who became soaked after staff did not return after clearing a call light, and residents who reported being yelled at or treated in a fearful manner during brief changes. The grievance records also showed repeated complaints about missed showers and staffing concerns, with residents reporting that showers were not received, shower days were missed, or they were told the facility was too short staffed to provide care at the scheduled time. The Administrator stated the facility had experienced repeated grievance concerns related to staffing, staff attitude, delayed call light response times, missed showers, and unmet ADL care, and acknowledged these concerns had not yet been fully trended or systematically addressed due to recent turnover and his short tenure. The facility policy required grievances to be promptly investigated, documented, reviewed by the Administrator, and corrected to prevent further violations of resident rights, but the records reviewed showed repeated responses that referenced staff discipline or education without documentation of those actions or evidence of monitoring and sustained corrective measures.
Failure to Thoroughly Investigate Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate, document, and follow up on alleged resident-to-resident physical abuse involving two residents. An Indiana Department of Health incident report dated 11/20/25 indicated one resident intrusively entered another resident’s room, and the second resident made open-hand contact with extended arms, causing the first resident to lose balance and strike her mouth on a handrail as she fell. The injured resident was noted to have a deep upper lip laceration, a nosebleed, and skin tears to the left hand, and the nurse practitioner ordered transfer to the hospital for evaluation and treatment. The investigation documentation was completed by the DON but did not include when the investigation began or ended. The investigation file included a witness statement from a QMA who reported seeing one resident push the other in front of her door, causing the resident to fall face-first and bleed from an upper lip split. The written description stated the residents were separated, assessed, and that the injured resident was sent to the ER, while the other resident was placed on one-to-one supervision and had labs, urine testing, and a psych evaluation ordered. However, the injured resident’s record lacked documentation that monitoring of the lip for infection was implemented, and neither resident had evidence of Activities review, revised Activities care plans, or IDT notes in the chart. Neither resident’s care plan was updated. The facility also failed to thoroughly investigate and document an alleged resident-to-resident sexual abuse incident involving two other residents. An incident report dated 7/27/25 stated one resident entered another resident’s room and was behaving socially inappropriately, with staff observing the resident’s pants open; the resident was redirected, placed on direct observation for 48 hours, and police were notified. Interviews later showed the DON had not conducted additional or ongoing assessments after returning from vacation, and staff reported there was no education or in-service after the incident. A QMA described finding one resident seated with pants and underwear pulled down while the other resident was naked from the waist down, with the first resident masturbating and touching the other resident between the legs. The LPN who assessed the victim stated the resident could not recall what happened, police were called, and the accused resident was moved to a new room, but the record lacked documentation of a comprehensive IDT investigation, analysis of supervision failures or resident vulnerabilities, and revised care plans or enhanced supervision. The facility also failed to thoroughly investigate and document an alleged misappropriation of a resident’s funds. An incident report dated 12/22/25 stated a resident reported a missing debit card and $20, police were called, and the accused employee was suspended and an investigation initiated. The resident’s record showed the resident was cognitively intact with a BIMS score of 13. The soft file contained a grievance form, a state reportable form, a statement from the former SW, unrelated write-ups for a CNA, a termination letter, and safe surveys from the resident’s unit. The file lacked follow-up with two residents who answered yes to whether they had witnessed a staff member take something that did not belong to them, and it lacked attempts to follow up with non-verbal residents’ family members or POAs. The record and soft file also lacked documentation of the verbal termination notification for the accused CNA, and there was no documentation supporting reimbursement of the missing $20.
Care plans not implemented or updated for wandering, aggression, sexual behaviors, and dehydration risk
Penalty
Summary
The facility failed to ensure comprehensive care plans were implemented and updated to address the individual needs of multiple residents. For Resident D, who had diagnoses including unspecified dementia, mild cognitive impairment, and unsteadiness on feet, the record showed severe cognitive impairment and a care plan for wandering into other residents’ rooms that was not initiated until after the incident. The care plan intervention was limited to protecting the rights and safety of others, and the record lacked implementation or revision to address that she was often perceived by other residents as a man because of her appearance or that she was targeted because of peers’ perceived threat. After Resident D intrusively entered Resident E’s room, Resident E made open hand and extended arm contact with her, causing Resident D to lose balance and strike her mouth on the handrail. Resident D sustained a deep upper lip laceration, nosebleed, skin tears to her left hand and knuckle, and the hospital discharge summary documented a laceration requiring sutures, a nasal bone fracture, and fractures of the 6th, 7th, and 8th ribs. Her record lacked documentation of care plan interventions related to the lip laceration and lacked care plan updates after the incident. Resident E, who had vascular dementia, delusional disorder, and generalized anxiety disorder, had a psychiatric history that included major depression, dementia, psychotic/delusional disorder, hallucinations or delusions, and prior inpatient psychiatric hospitalization. A psychiatric note documented that she complained about a fellow resident who wandered into other rooms and touched her while laughing, and staff confirmed that Resident D did intrusively wander into other residents’ rooms. Staff also reported that Resident E had been more anxious lately. The record lacked documentation of follow-up, interventions, or care plan revisions to address her complaints about an intrusive peer and her increased anxiety. After the altercation with Resident D, Resident E was sent to an inpatient psychiatric hospital, and her comprehensive care plans lacked implementation or revision to include her concerns and fixation toward Resident D or her preference to keep peers out of her room. Resident F and Resident G were involved in a sexual incident in Resident F’s room. Resident F had diagnoses including unspecified dementia, recurrent major depressive disorder, and cognitive impairment, and her record included a psychiatric care plan note stating she had a history of sexual trauma as a child. A psychiatric consult also documented that she had allowed another resident into her room without supervision during which the resident cut her hair, and that she later expressed regret and distress with impaired judgment and delayed emotional processing. During the incident, a QMA observed Resident G with his pants and underwear pulled down, masturbating, and with one hand between Resident F’s legs while Resident F was naked from the waist down. Resident G admitted to touching himself and Resident F and said he thought it was okay because she did not tell him to stop. Resident G’s record documented that he entered a female resident’s room and began masturbating, but his comprehensive care plan lacked interventions to address sexually explicit behavior toward a peer and lacked measures to prevent future incidents. The facility also failed to develop care plans for other residents’ identified needs. Resident 3, who had diagnoses including cerebral infarction with left hemiplegia and hemiparesis, muscle weakness, and fractures of both legs, was observed lying in bed with her bedside table and fluids positioned on her left side, making the fluids inaccessible to her. Her record lacked a care plan and interventions to address the potential for dehydration. Resident 70, who had hemiplegia and hemiparesis following cerebral infarction and dysphagia, was prescribed furosemide and spironolactone and was observed nonverbal, lying in bed, with dry-appearing mouth and unable to follow directions to take a drink from fluids placed on her bedside table. Her record lacked a care plan addressing the potential for dehydration related to diuretic use.
Inadequate supervision and limited dementia-appropriate activities on Memory Care unit
Penalty
Summary
The facility failed to provide consistent, knowledgeable staffing, adequate supervision, and meaningful dementia-appropriate activities on the Memory Care unit. On 1/5/26, seven residents were seated in the MC dining room with no staff present when the unit was first entered. A QMA then came onto the unit, stated she had no idea what was planned, briefly looked at the activity calendar, and said she was "just going to wing it" while passing coffee and snacks. During interviews, staff stated they were short staffed, that they were pulled to help in memory care, and that some staff assigned to the unit did not normally work there and did not know the residents well. The report also documented repeated periods when residents on the MC unit were left without supervision. On 1/7/26, several residents were seated in the main dining/activity room with no staff supervision, and Resident C exited her room and entered another resident's room unsupervised. On 1/9/26, the LPN repeatedly left medication administration tasks to monitor residents in the dining room because of the lack of staff supervision. Later that morning, the admission coordinator left for a pre-scheduled meeting while the nurse was passing medications and the CNA was giving showers, leaving seven residents unsupervised in the main dining/activity room. On 1/9/26, a resident stated she needed to use the bathroom, and the LPN told her she would have to wait for someone else to return because staff could not leave the dining room unattended. On 1/12/26, the nurse was off the unit and the CNA was in a resident's room providing care, leaving five residents in the main dining/activity room unsupervised and with no structured activity occurring. Activities on the MC unit were largely limited to repetitive coloring pages, daily Chronicle readings, and television, regardless of resident interest or engagement. Residents were observed declining coloring, yet staff continued placing coloring pages in front of them and coloring themselves while residents remained disengaged. One resident was observed falling asleep at the table with a crayon in her hand while others sat disengaged with the television on. Staff stated the Activity Director was out sick and that activities were usually limited to coloring and reading, with several residents sleeping a lot and not enjoying the activities offered. The activity calendar showed no structured activities after 3:00 p.m. and no evidence of routine therapeutic programming or alternative interventions for residents with dementia-related sundowning. The facility policy for the Secured Care Neighborhood stated that the unit would provide therapeutic staffing, consistent staff members, and a comprehensive activity program designed to meet the individual needs of residents with cognition or dementia-related illness.
Expired and Undated Medications Found in Medication Carts and Medication Room
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because multiple medication storage areas contained expired or undated items. On 1/5/26 at 12:07 p.m., the 1, 2, and 3 hall medication cart contained Resident 38’s albuterol inhaler with no date showing when it was opened, and hydrocortisone cream was also stored in the cart. The 400-hall medication cart contained hydrocortisone cream, Resident 8’s Lantus insulin pen dated 11/26/25 and expired, diclofenac cream stored with Miralax oral powder, and Resident 6’s hydrocortisone cream along with a Novolog kwikpen dated 12/1/25 and expired. The 7 and 8 hall medication room refrigerator contained a normal saline bottle with no open date, and the Unit Manager stated the saline was expired. RN 7 stated the insulin pens were expired.
Advance Directive Documentation and Code Status Orders Inconsistent
Penalty
Summary
The facility failed to ensure that a resident's advance directive documentation was accurate and consistent across the medical record and failed to ensure that a physician's order was in place for another resident's advance directive wishes. For one resident, the medical record contained a POST form dated 10/23/25 indicating a DNR status, while the current physician's order listed the resident as full code and the corresponding advance directive care plan also identified the resident as full code. During interview, an RN stated she was certain the resident was full code, then acknowledged the POST created a significant discrepancy and said it would need to be addressed with the DON. For another resident with diagnoses including fractures of both legs, type 2 diabetes mellitus, hypertension, chronic kidney disease, hyperlipidemia, cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side, and muscle weakness, the record lacked a physician's order for code status. The resident's care plan, dated 10/22/25, indicated DNR status, but on 1/12/26 the DON stated an order was added for DNR. The facility's Advanced Directives policy stated that at admission staff or designee will inquire about the existence of an advance directive and provide written information to adult residents concerning the right to accept or refuse medical treatment.
Missing Discharge Medication Reconciliation
Penalty
Summary
The facility failed to reconcile a resident’s medications at the time of discharge for 1 of 4 residents reviewed. Resident 86 had diagnoses including chronic kidney disease, hypertension, hyperlipidemia, and weakness. A record review on 1/7/26 showed the resident’s chart lacked documentation of medication reconciliation after discharge, and the discharged medications were unaccounted for, including lantus insulin, mirtazapine, torsemide, trazodone, lorazepam, metoprolol, insulin lispro junior kwikpen, polymyxin B-trimethoprim eye drops, acetaminophen, glucagon emergency injection, glucose oral gel, hydroxyzine, and refresh tears ophthalmic solution. During an interview on 1/8/26, the DON stated she could not find record of the resident’s discharged medications.
Incorrect order transcription, delayed antibiotic ordering, and medication timing errors
Penalty
Summary
The facility failed to ensure services were provided according to professional standards of care when Resident 5’s wound care orders were not accurately transcribed into the medical record. Resident 5 was a long-term care resident with diagnoses including a pressure ulcer to the sacral region and a recently amputated left fifth toe with sutures still intact. The record showed multiple wound care instructions from the hospital wound clinic for the left foot and heel, including cleansing, betadine application, specific dressings, and scheduled dressing changes. The wound clinic also ordered that Resident 5 be off-loaded from the sacrum completely by turning side to side every two hours and spending no time on her back while in bed, but the current MAR lacked that order. The wound nurse stated she was responsible for transcribing new wound care instructions and was unaware of the turning/off-loading order. The facility also failed to ensure prophylactic antibiotics were reordered for Resident K, which delayed surgery. Resident K stated the facility told them the antibiotics needed before surgery had not arrived from the pharmacy, and the surgeon pushed the procedure from Friday to Monday because of the delay. The Unit Manager stated the surgery center had originally ordered amoxicillin, but the resident was allergic to it, so ciprofloxacin was ordered instead and was expected to be delivered that night. The Unit Manager stated she did not know why the new medication had not been ordered or why no one followed up on it. Medication administration practices were also not consistent with manufacturer recommendations for two residents, and one antidepressant order had an inaccurate diagnosis. For Resident 31, levothyroxine was administered after breakfast and with other medications, while the NP stated it should be given before breakfast and by itself, and the pharmacist stated it should be administered consistently in the morning on an empty stomach 30 to 60 minutes before meals. For Resident 69, omeprazole was administered after breakfast and with other medications, while the pharmacist stated it should be given 30 to 60 minutes before a meal. For Resident 94, duloxetine was ordered for depression, but the record lacked a depression diagnosis; the DON later documented that the medication was actually for RLS, and the diagnosis was changed from depression to RLS.
Failure to Change Wound Dressings According to Orders
Penalty
Summary
The facility failed to ensure non-pressure related wound dressings were changed according to physician orders for one resident with multiple wounds. Resident K, a long-term care resident with diagnoses including a non-pressure chronic ulcer of the right lower leg, had active wound orders for the left heel, mid abdomen, left elbow, and right outer ankle. On 1/8/26, the resident’s dressings were observed with the DON and included dressings dated 12/31/25 on the mid abdomen and right outer ankle, with visible bloody drainage on the outside of the ankle dressing. The left elbow and left heel dressings had no dates on them. The medical record review on 1/9/26 showed orders for cleansing and dressing changes for the wounds on the left heel, mid abdomen, left elbow, and right outer ankle at specified frequencies, including daily and every Monday, Wednesday, and Friday. The DON stated the resident often refused dressing changes and had been away from the facility from 12/31/25 to 1/5/26, but expected the dressings to have been changed immediately upon return or as soon as the resident allowed. The Wound Nurse stated weekly wound rounds were her responsibility, while other ordered dressing changes were the floor nurses’ responsibility. Behavior monitoring records for December 2025 and January 2026 lacked documentation that the resident had exhibited target behaviors, including refusing wound care.
Improper wound care and positioning for resident with pressure ulcers
Penalty
Summary
The facility failed to ensure proper wound care and positioning were completed according to physician orders for a resident with a sacral pressure ulcer and a recently amputated left fifth toe with sutures still intact. The resident’s record showed a progress note on 12/23/25 identifying a deep tissue injury below the left lateral suture site, and wound clinic notes on 12/29/25 documented wounds to the lateral left foot and left heel with specific treatment orders for cleansing, topical products, absorbent dressings, and securement. The same wound clinic note also ordered the resident to be off-loaded from the sacrum completely by turning every two hours side to side only, with no time spent on her back while in bed. During observation on 1/9/26, the resident was found lying on her back in bed with pressure relieving boots on both feet. When the wound nurse removed the old dressings, the heel and lateral left foot dressings did not contain the ordered ABD pads, and the heel dressing did not have the ordered gauze with Iodosorb gel. The wound nurse stated this was wrong and that the floor nurse who completed the last dressing change must have done it incorrectly. The wound nurse also tore one piece of silver alginate in half for use on the deep tissue injury, discarded the other half, and no wound care was provided directly to the sutures. Two wedge pillows were observed on the resident’s dresser, and after the dressing changes the resident was left on her back.
Unsafe Medication Storage and Grab Bar Placement
Penalty
Summary
The facility failed to remove a resident’s supplements from his room. On 1/5/25 at 10:13 a.m., the resident was observed lying in bed, unable to move his body and using an eye gaze computer to communicate. A large number of supplements were on his table, and he indicated he took them daily. The supplements observed included IS [NAME], biocidin liquid, para 3, LB/GB Complex, Inflammatone, HM-ET Binder, ProbioMed 50, IS [NAME], primal multi, olive oil, vitamin D, Para 1, cyanocobalamin, menaquinone, argine (L argine), and magnesium. Record review showed diagnoses including ALS, dysphagia, abnormal weight loss, and obstructive sleep apnea. His record lacked a self-administration assessment for medications, and his care plan stated he preferred to buy supplements online from Amazon and keep them in his room on the table in a basket. MD orders were reflected on the MAR, and the DON later indicated the supplements were removed from bedside. The facility also failed to ensure a resident’s enabler bars were at a safe distance from her mattress. On 1/7/26 at 2:59 p.m., the DON was informed of concerns that the grab bars were too far from the mattress and could create a potential for entrapment. The Regional Nurse Consultant, DON, Medical Records, and Unit Manager went to the room, where the frame was identified as a bariatric frame that had been pulled in. Medical Records adjusted the frame to a regular-sized frame, and the gaps between the grab bar and mattress measured 2 inches on the left and 3 inches on the right. The Unit Manager lowered the grab bars. Record review for the resident showed diagnoses including fractures of both legs, type 2 diabetes mellitus, hypertension, chronic kidney disease, hyperlipidemia, cerebral infarction with left-sided hemiplegia and hemiparesis, and muscle weakness. Her care plan did not address the grab bars, and the facility did not provide a side rails policy at exit.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure a resident with chronic pain and COPD received prescribed Oxycodone as ordered. Resident K had an active order for Oxycodone 15 mg four times daily for moderate to severe pain, but review of the EMAR and narcotic sign-off sheets showed repeated discrepancies between documented administrations and the narcotic counts. On multiple dates in December, the EMAR reflected four doses given while the narcotic sheet reflected fewer doses, and the balance on the narcotic sheet was altered on 12/25/25 with a note that was difficult to read. The record also showed a note that 3 Oxycodone tablets were received by the resident’s father on 1/1/26. Resident K told the Ombudsman and surveyor that the facility had discontinued the pain medication after drug testing and that he feared retaliation if he spoke openly. He stated the blood drug test was positive for THC and negative for Oxycodone, and he reported that sometimes he did not receive the medication as often as prescribed. The DON stated the NP discontinued the Oxycodone because staff suspected the resident was pocketing the medication to sell or trade for marijuana, and the DON said they assumed this based on the negative Oxycodone blood test and positive THC result. The record showed a urine drug test obtained on 12/23/25 was positive for THC and Oxycodone, while the blood drug test collected on 12/24/25 and resulted on 1/2/26 was positive for THC and negative for Oxycodone. The DON and Corporate RN discussed that blood testing could reflect therapeutic levels and that a negative result might occur even when a prescribed medication is being taken, but the DON stated they did not explore other explanations for the discrepancy. Resident K’s Oxycodone was discontinued on 1/6/26, and the resident and father were informed of discharge due to alleged illegal drug use policy violations.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brownsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brownsburg Meadows | 1.1 mi | ★★★★★ | 4 | 0 |
| Brooke Knoll Village | 3.9 mi | ★★★★★ | 10 | 0 |
| Wellbrooke Of Avon | 4.3 mi | ★★★★★ | 5 | 0 |
| Eagle Valley Meadows | 4.5 mi | ★★★★★ | 3 | 0 |
| Westside Retirement Village | 5.1 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.