Brownsburg Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsburg, Indiana.
- Location
- 1010 Hornaday Rd, Brownsburg, Indiana 46112
- CMS Provider Number
- 155206
- Inspections on file
- 27
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 38 (1 serious)
Citation history
Health deficiencies cited at Brownsburg Health Care Center during CMS and state inspections, most recent first.
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.
A QMA was observed administering medications to multiple residents by popping pills into her hand and failing to perform hand hygiene before, during, or after medication passes, despite facility policies and posted precautions requiring hand sanitization between residents. Hand sanitizer was available but not used, and the QMA continued to prepare and administer medications to other residents without proper infection control practices.
A resident with ALS and significant communication challenges was subjected to verbal and physical abuse by two CNAs, who pulled on the resident's arms despite clear signs of discomfort, moved the resident's communication device out of reach, and attempted to use a mechanical lift unnecessarily. The resident's minor family member had to intervene to stop the inappropriate care, and the CNAs made inappropriate comments and failed to respect the resident's dignity during personal care.
Multiple residents dependent on staff for ADL support, including meal service, toileting, bathing, and dressing, did not receive timely care. Observations showed residents left in bed for extended periods, in soiled briefs, or with meals out of reach. Staff interviews confirmed that low CNA staffing, especially on weekends, made it impossible to provide adequate assistance, resulting in unmet care needs for residents requiring extensive help.
Surveyors found that medications and wound treatment solutions were left unsecured in resident rooms and public areas, including over-bed tables, breakfast trays, and handrails. Multiple residents had access to unidentified pills, inhalers, creams, and supplements without documentation of self-administration assessments, physician orders, or care plans. Facility staff confirmed awareness of the policy requiring secure medication storage, but observations and record reviews showed repeated noncompliance.
Surveyors found that respiratory care equipment, such as nebulizers, oxygen tubing, and CPAP masks, was not properly cleaned or stored for several residents. Equipment was observed left unbagged on beds, on the floor, or among personal items, sometimes with medication still present. Documentation for cleaning, storage, and self-administration was missing, and facility policies for respiratory care were not followed.
The facility did not maintain sufficient nursing staff to meet residents' daily care needs, resulting in delays and missed assistance with ADLs, toileting, bathing, dressing, meals, and medication administration. Staff were often stretched across multiple hallways, leaving residents in bed for extended periods, sometimes in soiled briefs, and with meals or medications left unattended. Staff and resident interviews, along with facility records, confirmed that staffing levels frequently fell below the facility's own requirements, leading to unmet care needs.
The facility failed to provide specialized dementia care programming, leaving residents without meaningful activities. Observations showed that scheduled activities were often not conducted, and residents were left without engagement. Residents with preferences for social interaction and outdoor activities were not provided with suitable opportunities, and the activity staff lacked necessary training.
The facility failed to maintain a qualified Infection Preventionist (IP) for six months and did not ensure proper TB screenings for several residents. The Regional Director of Operations was not officially designated as the IP, and attempts to fill the position were unsuccessful. Additionally, five newly admitted residents and one previously admitted resident did not receive timely TB screenings, with some tests not read within the required timeframe.
The facility failed to accurately code a pressure ulcer on the MDS for a resident with multiple stage 3 pressure ulcers, and incorrectly coded the PASARR for another resident with major depression. These discrepancies were identified during record reviews and confirmed by the Regional MDS Coordinator.
The facility did not implement comprehensive care plans for two residents with indwelling urinary catheters. One resident with neuromuscular dysfunction of the bladder and another with neurogenic bladder both lacked documented care plans addressing their catheter needs, despite having physician's orders. The facility's policy mandates care plans be developed and updated per OBRA and MDS guidelines, which was not followed.
The facility failed to administer tube feedings according to physician's orders for two residents, resulting in inadequate nutrition. One resident experienced significant weight loss due to missed feedings and improper administration, while another resident's caloric intake was insufficient due to missed feedings. Staff interviews revealed communication issues and a lack of awareness regarding feeding orders, contributing to these deficiencies.
A resident with multiple sclerosis and compartment syndrome pain was admitted to a facility and assessed with severe pain. Despite a physician's order for Hydrocodone-Acetaminophen, there was a delay in accessing the medication due to a pending authorization code from the pharmacy. The facility did not document ongoing pain assessments, alternative pain management strategies, or notify the physician of the delay. The resident, upset by the lack of pain relief, discharged herself against medical advice without signing the AMA form.
A resident with multiple sclerosis and compartment syndrome pain did not receive timely pain medication due to a delay in obtaining an EDK authorization code. The on-call pharmacist's delayed response contributed to the resident discharging herself AMA after waiting over seven hours for pain relief.
The facility failed to ensure staff followed hand hygiene protocols when delivering meals to two residents under enhanced barrier precautions (EBP). A QMA was observed entering and exiting the rooms of residents with a g-tube, pressure ulcer, indwelling catheter, and wound without sanitizing hands, contrary to facility policy and room signage. A CNA confirmed the hand hygiene requirement.
A facility failed to coordinate care with hospice for a resident with new skin impairments on the bilateral lower extremities (BLE). The resident, dependent on staff for care, had reddened and edematous BLE, and hospice notes indicated new open wounds. However, these notes were not available in the facility's records, and the physician was not notified. Interviews revealed dissatisfaction with care quality, and the facility's policy on end-of-life care coordination was not effectively implemented, leading to a deficiency.
An LPN at the facility diverted at least 56 narcotic medication tablets from multiple residents, including those with dementia and Huntington's disease. The discrepancies were identified through ADU reports and Controlled Substance Accountability Sheets, leading to an investigation and the LPN's termination.
Failure to 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 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.
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Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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