Brownsburg Health Care Center

Based on observation, interview, and record review, the facility failed to ensure that alleged violations involving resident to resident physical abuse, sexual abuse, and misappropriation of resident's funds were thoroughly investigated, appropriately documented, and followed up by effective corrective actions for 5 of 6 residents reviewed for abuse (Residents D, E, F, G, and J). Findings include:1. An Indiana Department of Health facility incident report, dated 11/20/25, indicated Resident E was involved in a resident-to-resident altercation. Resident D was intrusively wandering into Resident E's room when Resident E made open hand and extended arm contact with Resident D resulting in her losing her balance causing her to hit her mouth on the handrail as she fell. Resident D was assessed and noted to have a deep laceration to upper lip, nosebleed, skin tears to top of left hand and 2nd knuckle. The NP ordered to send Resident D to the hospital for evaluation and treatment. On 1/8/26 at 10:54 a.m., a copy of the incident investigation documentation was provided by the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure residents' comprehensive care plans were implemented to address their individual needs for 6 of 18 residents reviewed for care plan implementation (Residents D, E, F, G, 3, and 70). Findings include: 1. An Indiana Department of Health facility incident report, dated 11/20/25, indicated Resident E was involved in a resident-to-resident altercation. Resident D was intrusively wandering into Resident E's room when Resident E made open hand and extended arm contact with Resident D resulting in her losing her balance causing her to hit her mouth on the handrail as she fell. Resident D was assessed and noted to have a deep laceration to upper lip, nosebleed, skin tears to top of left hand and 2nd knuckle. The NP ordered to send Resident D to the hospital for evaluation and treatment. On 1/7/26 at 2:51 p.m., Resident D's record was reviewed. She was a long term care resident who resided on the secured memory care unit with diagnoses which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide consistent, knowledgeable staffing, adequate supervision, and meaningful dementia appropriate activities on the Memory Care (MC) unit. This deficient practice had the potential to affect 14 of 14 residents residing on the Memory Care Unit. Findings include: 1. Upon initial entrance into the memory care unit on 1/5/26 at 10:30 a.m., seven residents were seated in the MC dining room with no staff present. On 1/5/26 at 10:40 a.m., Qualified Medication Aide (QMA) 13 entered the unit in a rush and indicated to the several residents gathered in the main dining/activity room, let's see what they have going on for you guys, I have no idea. She briefly looked at the posted activity calendar, then went to the nurses station and returned with a rolling cart. She indicated she was, just going to wing it, as she started passing coffee and snacks and visiting with residents. During an interview on 1/5/26 at 10:45 a.m., QMA 13 indicated she worked all over the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to date and remove expired medications from use for 3 of 4 medication carts observed for medication storage and 1 of 1 medication room observed for medication storage.Findings include:On 1/5/26 at 12:07 p.m., the 1,2 and 3 hall medication cart was observed. Resident 38 had an albuterol inhaler 0.83% in the cart with no date to indicate when it was opened. Hydrocortisone (steroid)cream was in the medication cart. The 400-hall medication cart was observed. Hydrocortisone cream was in the medication cart. Resident 8 had an insulin pen, Lantus in the cart with a date of 11/26/25. It expired. Diclofenac (nonsteroidal anti-inflammatory pain reliever) cream was stored with Miralax (laxative) oral powder. Resident 6 had hydrocortisone cream in the medication cart. He had a Novolog (insulin) kwikpen in the cart dated 12/1/25. It was expired. The 7 and 8 hall medication room had a normal saline bottle in the refrigerator. It lacked a date to indicate when it was opened. The Unit Manager indicated the saline was expired and removed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that a resident's advance directive documentation was accurate and consistent across her medical record and failed to ensure a physician's order was in place for a resident's advance directive wishes for 2 of 3 residents reviewed for advance directives (Residents 1 and 3). Findings include:1. On 1/6/26 at 11:47 a.m., Resident 1's medical record was reviewed. She had a Physician's Order for Scope of Treatment (POST) form, dated 10/23/25, which indicated she wished to have a DNR or Do Not Resuscitate advance directive status. The current physician's order, as of the record review on 1/6/26, listed her as a full code. A corresponding Advance Directive Comprehensive Care Plan, dated 10/17/25, indicated Resident 1 as a full code. During an interview on 1/7/2026 at 1:57 p.m., Registered Nurse (RN) 26 indicated she was certain Resident 1 was a full code resident. After her review of the POST, RN 26 indicated that was a big discrepancy and she would need to talk with the Director of Nursing to ensure the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to reconcile a resident's medication at the time of discharge for 1 of 4 residents reviewed (Resident 86). Findings include:On 1/7/26 at 11:39 a.m., a record review was completed for Resident 86. She had the following diagnosis which included but were not limited to chronic kidney disease, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and weakness. Resident 86's record lacked documentation her medication reconciliation after discharge. The discharged medications unaccounted for were as follows: lantus (insulin) 100 units per milliliter (u/ml), mirtazapine (antidepressant) 15 milligram (mg), torsemide (diuretic) 20 mg, trazodone (antidepressant) 50 mg, lorazepam (antianxiety medication) 0.5 mg, metoprolol (blood pressure medication) 25 mg, insulin Lispro Junior kwikpen, polymyxin B-trimethoprim (antibiotic eye drop) 10000-0.1 u/ml, acetaminophen (pain reliever) 325 mg, glucagon (medication to raise blood sugar) emergency injection 1mg, glucose oral gel 40% (medication to raise blood sugar), hydroxyzine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff provided services according to professional standards of care when a resident's wound care orders were transcribed incorrectly or not transcribed at all (Resident 5), a resident's prophylactic antibiotics were not reordered resulting in a delay in surgery (Resident K), when staff failed to administer medications at appropriate times recommended by the manufacturer (Resident 31 and 69), and when an antidepressant had an inaccurate diagnosis for use (Resident 94) for 5 of 78 residents reviewed for professional standards of care concerns. Findings include: 1. On 1/7/26 at 11:22 a.m. Resident 5's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, a pressure ulcer to the sacral (tailbone) region. Resident 5 had a recently amputated fifth toe (pinky toe) on her left foot with sutures still intact. A progress note, dated 12/23/25, indicated during a dressing change a Deep Tissue Injury (DTI) was noted below the suture site. Resident 5's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure non-pressure related wound dressings were changed appropriately and according to physician's orders for 1 of 1 residents (Resident K) reviewed for non-pressure related wound concerns.Findings include: On 1/8/26 at 12:48 p.m. Resident K's wound dressings were observed with the Director of Nursing (DON). Resident K had dressings just under their belly button and on their right outer ankle bone covering open blister wounds that were both dated 12/31/25. The dressing on their right outer ankle had visible bloody drainage on the outside of the dressing. Resident K also had dressings on his left elbow and left heel that had no date on them. On 1/9/26 at 1:16 p.m. Resident K's medical record was reviewed. He was a long-term care Resident whose diagnoses included but were not limited to non-pressure chronic ulcer of the right lower leg. Resident K had an active order to cleanse the wound on their left heel with normal saline, pat it dry and apply a foam dressing every Monday, Wednesday, Friday and every 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper wound care and positioning was done according to physician orders for 1 of 5 residents (Resident 5) reviewed for pressure ulcer concerns. Findings include:On 1/7/26 at 11:44 a.m. Resident 5's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to a pressure ulcer to the sacral (tailbone) region. Resident 5 had a recently amputated fifth toe (pinky toe) on her left foot with sutures still intact.A progress note, dated 12/23/25, indicated during a dressing change a Deep Tissue Injury (DTI) was noted below the left lateral suture site.An IU Health Wound Clinic note dated 12/29/25 indicated Resident 5 had a wound to her lateral left foot (the outer edge of the left foot stretching from the heel to the little toe). The note indicated the wound care instructions for that wound were to cleanse the wound with wound cleaner, pat dry with a gauze, paint the eschar (dead, scabbed skin) with betadine (a widely used topical antiseptic that kills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to remove a resident's supplements from his room and failed to ensure a resident's enabler bars were at a safe distance from her mattress for 2 of 5 residents reviewed for accidents (Resident 9 and 3).Findings include:1. On 1/5/25 at 10:13 a.m., Resident 9 was lying in his bed. He was unable to move his body. He used an eye gaze computer to communicate with others. On his table there was a large number of supplements. He indicated he took those supplements daily. The supplements 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.On 1/7/26 at 2:39 p.m., a record review was completed for Resident 9. He had the following diagnoses which included but were not limited to amyotrophic lateral sclerosis (ALS) (a progressive neurodegenerative disease that attacks motor neurons in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review the facility failed to ensure a resident (Resident K) received their prescribed Oxycodone for 1 of 1 residents reviewed for pain management. Findings include: On 1/5/26 at 10:45 a.m. Resident K was observed as they sat in their recliner in their room. Resident K appeared to be very thin and frail but was in good spirits and able to have a conversation. Resident K spoke fondly of the dietary staff and indicated the floor staff were good for the most part but there were a few who he didn't care for. At the time of this observation Resident K did not elaborate on those staff members who he didn't care for. On 1/8/26 at 12:22 p.m. the Ombudsman indicated Resident K told her the facility had discontinued his pain medication and issued them a 30-day notice for discharge due to drug test results that the facility determined indicated Resident K had been abusing his opiate pain medication. On 1/8/26 at 12:48 p.m. Resident K was observed as they sat in their recliner in their room. The resident became tearful and indicated when we spoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to follow Centers for Disease Control (CDC) guidance and ensure infection control practices were followed when a Qualified Medication Aid (QMA) passed medications to 5 residents (Residents E, R, S, T, and U), by touching medications and not properly sanitizing her hands. This deficient practice had the potential to affect 19 of 20 residents who resided on the 100, 200, and 300 hallways. Findings include:During a random medication observation on 9/30/25 at 9:28 a.m., QMA 9 was observed administering medications to Resident R. QMA 9 first performed a blood pressure check and used an ink pen to document the reading in the palm of her left hand. QMA 9 then popped medication tablets out of bubble packs into the palm of her left hand, placed them into a medication cup, and entered the resident's room to administer the medications. While preparing to place a transdermal patch onto Resident R's upper body, QMA 9 was observed to move both sleeves and the neck of Resident R's t-shirt while attempting to find a patch from the day before.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff for 1 of 3 resident reviewed for abuse (Resident B). This deficient practice was corrected on 6/27/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: On 6/30/25 at 10:30 a.m., a record review was completed for Resident B. He had the following diagnoses which included but were not limited to, amyotrophic lateral sclerosis (ALS) (a progressive neurodegenerative disease that affects motor nerve cells the nerve cells that control voluntary muscle movement), dysphagia (difficulty speaking), and facial weakness. The facility self-reported incident, dated 6/23/25, indicated two Certified Nursing Aides (CNA) pulled on Resident B's arms during care while he shook his head no and expressed discomfort. Resident B indicated the CNA on his right side yanked his arm in bed to pull him to the ground, but the other CNA stopped her. On 6/30/25 at 10:45 a.m., Resident B was interviewed. Resident B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for meal service, toileting, bathing and dressing, and getting residents out of bed, received those services for 8 of 15 residents reviewed for Activities of Daily Living (ADL) assistance (Residents C, F, G, H, K, L, N, and S). Findings include: 1. Observations of Resident C included: a. On 4/27/25 at 9:50 a.m., Resident C was observed lying in bed with her eyes closed, the head of the bed was elevated, and the resident's upper torso was slumped to the right. There was paper debris on the floor around the bed. b. On 4/27/25 at 11:51 a.m., the resident remained in the same position with her eyes closed, the head of the bed was elevated, and the resident's upper torso slumped to the right. c. On 4/28/25 at 9:45 a.m., the resident was observed sitting in a manual wheelchair (WC) next to the bed, sitting on a blue transfer pad. The resident indicated she had not yet had breakfast. An untouched breakfast tray of food was observed sitting on top of a small black…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all medications and wound treatment solutions were secured in the public hallway and in the resident rooms for 5 of 5 residents reviewed for potential accidents (Residents G, S, T, Y, and BB). Findings include: 1. On 4/27/25 at 9:41 a.m., Resident G was observed lying in the bed awake, and a cup of unidentified pills sitting on an over the bed table beside the bed. The resident indicated he had no idea his medications were on the bedside stand as they were out of sight. Resident G's record was reviewed on 4/29/25 at 10:45 a.m. Diagnoses on Resident G's profile included, but not limited to, type 2 diabetes mellitus, age related physical disability, overactive bladder, depression, and muscle weakness. The admission MDS and state optional assessments, completed on 2/27/25, assessed Resident G as having the ability to make himself understood and to understand others. He had no signs or symptoms of delirium, behavior, or rejection of care. A BIMS score 15/15 indicated the resident was cognitively intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to properly clean and store nebulizer (small machine that turns liquid medication into a mist that can be easily inhaled) and oxygen equipment for 4 of 4 residents reviewed for respiratory care (Residents S, V, X, and Z). Findings include: 1. On 4/27/25 at 11:15 a.m., Resident S was observed sitting in a manual wheelchair (WC) at the bedside. The resident had a nasal cannula for oxygen in her nose attached to a bedside concentrator and gestured to her oxygen tubing which she took out of her brief, and indicated Certified Nursing Assistant (CNA) 15 had put the oxygen tubing inside her brief and the resident had untaped her brief to get the tubing out. The resident gestured to her nebulizer sitting on the bed beside her and the nebulizer handheld mouthpiece was unbagged and lying in the middle of the bed among her bedding. A portable oxygen concentrator was observed on a bedside table on the back side of the bed, in the on position, and the attached nasal cannula was laying on the floor. The resident indicated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record reviews, the facility failed to ensure adequate staffing levels to ensure residents received activities of daily living (ADL) care for meal service, toileting, bathing and dressing, medication administration, and getting residents out of bed for 14 of 16 residents reviewed for sufficient nurse staffing (Residents C, F, G, H, J, K, L, N, S, T, V, X, Y, and BB) and for 5 of 7 hallways (200, 400, 500, 700, and 800) observed for sufficient nurse staffing. Findings include: On 4/27/25 at 9:13 a.m., Certified Nursing Assistant (CNA) 5 indicated she was assigned to care for 7 residents on the 100 and 200 hallways by herself. There was no CNA in the facility to care for residents on the 300 and 400 hallways, but she was not sure why. The nursing scheduler QMA 4 had been called in to cover for a nurse call-off on the 400 hallways, but CNA 5 had yet to hear the backup plan to cover the CNA's hours. On 4/27/25 at 9:27 a.m., Registered Nurse (RN) 7 was observed administering medications on the 300 hallway. He indicated he usually worked double shifts…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure specialized dementia care programming was implemented to provide meaningful, engaging and diverse activities and/or opportunities for residents with a diagnosis of dementia for 5 of 15 residents who resided in the specialized secured memory care (MC) unit, (Residents 21, 37, 38, 50 and 63). Findings include: Activities, events, and opportunities for MC unit residents were observed throughout the survey week. Those observations were reconciled with the posted Activity Calendar and special events hosted by the facility that week. While all residents were periodically observed, special focus was directed to Residents 21, 37, 38, 50 and 63. Observations and interviews below are organized by days 1-5, with morning, afternoon, or evening activities specified, as well as two special events hosted by the facility. Day 1, 10/21/24 scheduled activities for MC unit: 9:30 a.m., Morning Social 10:00 a.m., Coffee & Snax 10:30 a.m. Current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) role was filled for 6 of 12 months reviewed, and all new residents were screened to control infections for tuberculosis (TB) for 5 of 7 newly admitted residents reviewed for implementation of TB screenings (Resident 133, 134, 135, 136, and 184) and one previously admitted resident who did not receive TB screenings for 1 of 3 previously admitted residents (Resident 72). Findings include: 1 During the entrance conference, on 10/21/24, the Executive Director (ED) indicated the Infection Preventionist (IP) was their Regional Director of Operations (RDO). During an interview, on 10/28/24 at 11:08 a.m., the RDO indicated, although he had his IP certification from the CDC, he was not the IP for this facility but their RDO. He assisted with their survey readiness. He indicated he had asked all leadership members, including the Director of Nursing (DON) to get their IP certifications. He indicated this facility did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to code a pressure ulcer correctly on the Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed (Resident 72) and failed to code Preadmission Assessment and Resident Review (PASARR) correctly on the MDS for 1 of 1 resident reviewed (Resident 14). Findings include: 1. On 10/24/24 at 11:39 a.m., a record review was completed for Resident 72. He had the following diagnoses which included but were not limited to paraplegia, pressure ulcer of sacral region stage 3 (a full-thickness wound that extends through the skin and into the subcutaneous fat, but not into the muscle, tendon, or bone), essential hypertension (HTN), and type 2 diabetes mellitus. Resident 72 had a wound care assessment dated [DATE]. It indicated he had three pressure ulcers. A stage 3 to his sacrum, a stage 3 to his left medial (middle) knee and a stage 3 to his right medial knee. His MDS, dated [DATE], indicated he had two stage 3 pressure ulcers and one unstageable (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure a comprehensive resident centered care plan was implemented for two residents related to their indwelling urinary catheters for 2 of 3 residents reviewed for urinary catheters (Residents 68 and 1). Findings include: 1. On 10/21/2024 at 10:39 a.m. Resident 68 was observed. He was propped up on his left side in his bed. There was a sign on his door which indicated he was in enhanced barrier precautions. A urinary collection bag was hung on the side of the bed. On 10/23/2024 at 12:32 p.m., Resident 68's medical record was reviewed. He was a long term care resident who's diagnoses included but were not limited to, retention of urine and neuromuscular dysfunction of the bladder (a condition where the muscles and nerves of the bladder do not work together properly). He had a current physician's order for placement and securement of a urinary foley catheter. Resident 68's comprehensive care plans were reviewed and lacked documentation of a plan of care to address his need for a catheter. 2. On 10/21/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to coordinate treatments and services with hospice after new skin impairment areas were discovered on the bilateral lower extremities (BLE) for 1 of 2 residents reviewed for change of condition (Resident B). Findings include: On 10/22/2024 at 9:50 a.m., Resident B was observed as she laid in bed. Here eyes were closed and she was positioned on her back. On 10/22/2024 at 10:12 a.m., Certified Nursing Aide (CNA) 23 and an unidentified CNA were observed as they changed Resident B's brief. During her care, Resident B's BLE were observed to be reddened and edematous which extended from below her knees to the top of her ankles. Both CNAs indicated Resident B was totally depended on staff for all care. On 10/22/2024 at 10:23 a.m., Registered Nurse (RN) 120 indicated she changed Resident Bs' dressings in the morning and any time the dressing was soiled or loose. RN indicated that the resident had stopped eating, and that the hospice nurse came in more frequently to check on the resident and to do wound care since the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all tube feedings were completed according to physician's orders for 2 of 2 residents reviewed for tube feeding (Resident 74 and 134). Findings include: 1. On 10/25/24 at 12:28 p.m., Resident 134's record was reviewed. Her diagnoses included but were not limited to the after-effects of cerebral infarction (stroke) including hemiparesis (weakness and paralysis) on her right dominant side, gastrostomy (g-tube for consuming nutrition), and diabetes mellitus (blood sugar disorder). A progress note, dated 10/17/24 at 9:28 p.m., indicated Resident 134 arrived at the facility after suffering an acute cerebral vascular accident (CVA, stroke). She was to have nothing by mouth (NPO) and had a gastric tube (g-tube). Her sister indicated all medications and Glucerna were provided via her g-tube. Her admission weight was 243 pounds. On 10/23/24, her weight was 235.4. She lost 7.6 pounds in 6 days. Her physician's orders, dated 10/18/24, included but were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure a resident, (Resident 82) who was newly admitted from the hospital, received appropriate and timely interventions to assess and treat her pain, which resulted in her choice to discharge from the facility against medical advice (AMA) for 1 of 1 resident reviewed for pain. Findings include: On 10/25/24 at 12:40 p.m., a closed record review was completed for Resident 82. She had the following diagnoses which included but were not limited to, multiple sclerosis (MS, a chronic disease that damages the central nervous system and often causes pain), and pain in right arm due to compartment syndrome, (a serious condition that occurs when pressure increases in a muscle compartment, which can restrict blood flow and cause pain). A nursing progress note, dated 8/10/24 at 12:50 p.m., indicated Resident 82 admitted to the facility, from a local hospital and she was alert and oriented to person, place, time and situation. On 8/10/24 at 2:49 p.m., a pain assessment was completed. It indicated her pain intensity in the past 24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to ensure an alternative or additional emergency pharmaceutical services were available to obtain an authorization code for a resident, (Resident 82) when she began to experience pain and needed medication from the emergency medication kit (EDK) for 1 of 1 residents reviewed for pharmacy services. Findings include: On 10/25/24 at 12:40 p.m., a closed record review was completed for Resident 82. She had the following diagnoses which included but were not limited to, multiple sclerosis (MS, a chronic disease that damages the central nervous system and often causes pain), and pain in right arm due to compartment syndrome, (a serious condition that occurs when pressure increases in a muscle compartment, which can restrict blood flow and cause pain). Resident 82 was admitted to the facility from a local hospital on 8/10/24 at 12:50 p.m. A physician's order for a narcotic pain medication had been entered into the medical record at 3:19 p.m., but by 10:47 p.m., more than 7 hours later that night, she still had not received pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff provided lunches according to policy for enhanced barrier precaution residents (Resident 17 and 77). Findings include: 1. On 10/21/24 at 12:38 p.m., Qualified Medication Aide (QMA) 6 was observed removing Resident 77's lunch from the lunch cart. She did not perform hand hygiene before entering or after leaving her room. Resident 77 was on enhanced barrier precautions (EBP) due to g-tube (for long-term nutrition) and pressure ulcer (skin injury caused by prolonged pressure on an area of the body). On 10/21/24 at 12:39 p.m., QMA 6 was observed removing Resident 17's lunch from the lunch cart. She did not perform hand hygiene before entering or after leaving her room. Resident 17 was on EBP due to her indwelling catheter and wound. On 10/21/24 at 12:45 p.m., QMA 6 was observed entering Resident 17's room with an additional lunch item. She did not complete hand hygiene before entering or upon exiting her room. On 10/21/24 at 1:53 p.m., Certified Nursing Aide (CNA) 8 indicated when staff members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in at least 56 missing narcotic medication tablets, from 4 of 4 medication carts and 1 of 1 automated drug unit (ADU - an electronic drug dispensary machine) reviewed for misappropriation of medications (Residents C and D). The deficient practice was corrected on 2/16/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An Indiana State Department of Health Survey Report System report, dated 2/1/24, indicated the Director of Nursing (DON) observed Licensed Practical Nurse (LPN) 14 had pulled multiple controlled substance medications from an [NAME], the controlled substances pulled did not reflect the medications that were documented as having been administered. 1. On 5/23/24 at 10:56 a.m., Resident C was observed sitting in a wheelchair (wc) in her room. She was alert and talkative, but there were signs of confusion as she talked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure mandatory staffing information for the payroll-based journal (PBJ) was submitted by the required deadline for 1 of 1 quarters reviewed for PBJ submission. Findings include: The facilities Certification and Survey Provider Enhanced Reports, (CASPER) was reviewed. The report indicated 1-star staffing had been triggered for the 2nd quarter of 2023. During an interview on 9/12/23 at 11:43 a.m., the Regional Director of Operations (RDO) indicated, PBJ data was submitted out of the company's home office in Florida. Unfortunately, an administrative error had been made when the individual home-office staff responsible for the data submission missed the deadline by one day. The company filed an appeal which was denied by the Centers for Medicare and Medicaid Services (CMS).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed on ensure narcotic and non-narcotic drugs were received, administered, and accounted for with facility Controlled Substance Accountability Sheets and Medication Disposition Sheets according to policy to prevent possible drug diversion for 6 of 6 residents who passed away in the facility (Resident 66, 68, 119, 121, 122, and 123). Findings include: 1. On [DATE] at 3:36 p.m., Resident 119's record was reviewed. She was admitted to the facility on [DATE], and expired in the facility on [DATE] at 5:55 a.m. Her diagnoses included, but were not limited to, acute myeloid leukemia (AML) (bone marrow disorder) and diabetes mellitus (DM) (blood sugar disorder). Her physician ordered medication included, but were not limited to, lorazepam (anti-anxiety) liquid 2 mg/mL give 0.5 mL by mouth every 2 hours as needed for anxiety, and morphine sulfate (severe pain relief) 20 mg/mL give 0.25 mL by mouth every one hour as needed for pain related to AML. A pain care plan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with non-pressure wounds received treatments upon her admission to the facility for 1 of 1 residents reviewed for non-pressure wounds (Resident 52). Findings include: On 9/11/23 at 10:24 a.m., Resident 52 was observed as she was assisted out of bed and into her recliner chair. She wore an oversized nightgown and as she repositioned herself in the bed, the back of her thighs were observed. The skin was discolored, darker in color than the surrounding healthy tissue and closer to the edge of her brief, was redder in color. During an interview on 9/11/23 at 10:30 a.m., Resident 52 indicated she had previously lived in an assisted living facility, until she developed wounds on her bottom, in her groin area and under the skin fold of her stomach. She went to the hospital, and they got a lot better but she had spent so much time in the bed, her legs were weak. She was transferred to the nursing home for rehab to regain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement interventions added post fall for a resident (Resident 57) for 1 of 1 resident reviewed for falls, and failed to complete a smoking assessment after a resident had a significant change (Resident 40) for 1 of 1 residents reviewed for smoking. Findings include: 1. On 9/13/23 at 1:30 p.m., a comprehensive record review was completed for Resident 57. He had diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease), vascular dementia, psychotic disturbance, essential hypertension, age related physical disability, muscle weakness, and abnormalities of gait and mobility. Resident 57 had a fall on 8/2/23 at 5:00 a.m. He was calling out that he had to use the bathroom. When staff entered the room, they found him lying on the floor with his back next to the bed. He had bruising to this chest and top of right hand, along with abrasions to his left and right buttock and right upper extremity (arm). On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to destroy expired and outdated tuberculin serum and single dose influenza vaccinations for 1 of 3 medication rooms observed. Findings include: On [DATE] at 1:16 p.m., the rehab medication room refrigerator was observed with the IDON (Interim Director of Nursing). There were 4 boxes of individual influenza serum that had an expiration date on the boxes for [DATE]. There were 2 bottles of tuberculin serum that were opened but lacked a date to indicate when the bottles were opened. On [DATE] at 1:32 p.m., the IDON removed the tuberculin serum and influenza serum from the refrigerator and indicated they should be dated and removed when expired. On [DATE] at 11:37a.m., the IDON provided a copy of the information insert of the tuberculin serum. The serum was named Aplisol. It indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation may effect potency. 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure the glucometer was cleaned prior to resident use, before being placed in a staff member's pocket, cleaned appropriately before being put away, and before it being used on the next resident for 2 of 2 residents observed for glucometer use (Resident 32 and 29). Finding include: On 9/13/23 at 7:38 a.m., Qualified Medication Aide (QMA) 14 was observed taking the glucometer out of the 400 hall medication cart (med cart). She did not clean it before taking Resident 32's blood sugar (BS). Afterward, she dropped it into the right pocket of her scrub shirt. Back at the medication cart, she did not clean it and laid it on top of the medication cart. On 9/13/23 at 7:40 a.m., QMA 14 was observed putting it into the top drawer of the medication cart without further cleaning. On 9/13/23 at 3:23 p.m., Resident 32's record was reviewed. Her diagnoses included, but were not limited to, diabetes mellitus (DM) (blood sugar disorder) and dementia (progressive brain disorder). A physician's order indicated to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.