Brownsburg Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents' quarterly smoking assessments and store residents smoking supplies in a safe secure location for 5 of 5 residents reviewed for smoking (Resident K, L, M, N, and O).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Resident R received dementia specific supervision, monitoring, interventions, and protections resulting in repeated attempts by Resident Q to enter Resident R's room for 1 of 3 residents reviewed for dementia care and the deficient practice affected 3 of 3 residents residing on the dementia unit (Residents Q, R, and S).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an effective QAPI plan that identified, investigated, analyzed, and corrected persistent dementia related safety concerns on the secured memory care unit. This deficient practice had the potential to affect all 11 of 11 residents residing on the secured memory care unit.

Inspectors wroteA. Based on observations, interviews, and record review, the facility failed to ensure that Resident R, who resided on the secured memory care unit, had access to grievance forms or had grievances submitted on her behalf for 1 of 3 residents reviewed for resident rights. This deficient practice had the potential to affect 11 of 11 residents who resided on the secured memory care unit. B. Based on observation, record review, and interview, the facility failed to ensure a grievance related to a resident's mattress causing her discomfort and pain was submitted and investigated for 1 of 3 residents reviewed for resident rights (Resident F).

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the residents' rights to be free from physical abuse by a Certified Nursing Aide (CNA) and verbal abuse by a Housekeeping Supervisor for 2 of 9 residents reviewed for abuse (Residents Q and H). This deficient practice was corrected on 6/13/26, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's discharge was adequately planned and safe for 1 of 5 residents reviewed for discharges (Resident D).

Inspectors wroteBased on interview and record review, the facility failed to ensure a 30-day notice was issued to a resident prior to a facility-initiated discharge for 1 of 5 discharges reviewed (Resident D).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's change in condition was treated in a timely manner, was effectively monitored, and was communicated accurately to the medical provider for 1 of 10 residents reviewed for quality of care (Resident J).

Inspectors wroteBased on record review and interview, the facility failed to ensure a urinary tract infection (UTI) was treated timely for 1 of 5 residents reviewed for transfers and discharges (Resident J).

Inspectors wroteBased on observation, record review, and interview, 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 1 of 1 medication observation (Residents B, C, E, D, and F).

Inspectors wroteBased on record review and interview, the facility failed to ensure falls were coded on a Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accidents (Resident K).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received ordered monitoring of orthostatic blood pressures and failed to ensure prompt treatment for a fracture after a fall for 1 of 3 residents reviewed for accidents (Resident K).

Inspectors wroteBased on observation and interview, the facility failed to effectively cleanse a glucometer (used to check blood sugar) after its usage for 1 of 1 glucometer observed (Residents B and G).

Inspectors wroteBased on interview and record review, the facility failed to administer narcotic medication in accordance with physician's orders and manufactures instructions resulting in lethargy and increased tiredness for 1 of 3 residents reviewed for medication administration (Resident C).

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain sanitary conditions for catheter collection bags and tubing to prevent contamination for 2 of 2 residents reviewed for quality of care (Residents B and E).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent physical abuse between two dementia residents resulting in Resident D obtaining a laceration to the upper lip, nasal fracture, fractures to the 6th, 7th, and 8th ribs, and subsequent change in condition related to weakness from her hospitalization where she is no longer able to walk independently and requires staff assistance to be transported in a wheelchair (Residents D and E) for 1 of 6 residents reviewed for abuse. In addition to the residents in immediate jeopardy, the facility failed to implement effective supervision and interventions to prevent resident-to-resident sexual abuse when a cognitively impaired male resident, (Resident G) entered a cognitively impaired female resident's room (Resident F) removed her pants and briefs and began to masturbate while touching her. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide RN coverage per the facility assessment, failed to ensure adequate staffing on the memory care (dementia) unit, and failed to ensure adequate staffing to answer call lights and provide showers. This deficient practice had the potential to affect 78 of 78 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic quality and safety issues. This failure resulted in the facility's inability to prevent recurrence of known problems and contributed to harm-level and Immediate Jeopardy deficiencies. This deficient practice had the potential to affect 78 of 78 residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were treated with respect and dignity by allowing staff to refer to residents using demeaning and task-oriented labels ( feeds/feeders) during meal service and failed to ensure residents were provided the opportunity to accept or decline entry into their rooms when staff walked in without knocking or waiting for a reply. This deficient practice had the potential to affect 4 of 5 residents reviewed for dignity (Residents D, 48, 53, and 37).

Inspectors wroteBased on record review and interview, the facility failed to identify repeated grievances and implement effective corrective actions to alleviate ongoing resident complaints related to personal care services, responsiveness to call lights, hygiene care, and staff interactions which demonstrated that corrective measures were ineffective and systemic issues were not addressed for 6 of 6 months of grievances reviewed.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).