Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 13
Jun 2, 2025
Visit Reason
This visit was for the investigation of multiple complaints regarding resident care, abuse allegations, medication administration, and facility compliance.
Findings
The facility was found deficient in multiple areas including failure to notify families of changes, incomplete abuse investigations and reporting, inadequate employee screening and training, environmental maintenance issues, incomplete resident evaluations and service plans, failure to assess residents post-fall, improper medication administration, inaccurate clinical records, and incomplete transfer documentation.
Complaint Details
This investigation was triggered by multiple complaints (IN00457244, IN00458361, IN00458602, IN00458769, IN00458913, IN00458959, IN00459301, IN00459996, IN00460168) alleging failures in family notification, abuse reporting, medication administration, and resident care.
Deficiencies (13)
| Description |
|---|
| Failed to ensure residents' family/Responsible Party were notified of falls, change of status, and new physician's orders. |
| Failed to ensure the Local Long Term Care Ombudsman received a copy of an involuntary discharge notice. |
| Failed to report allegations of abuse timely to the Indiana Department of Health and failed to investigate allegations. |
| Failed to properly screen employees hired in the past four months for criminal background and reference checks. |
| Failed to ensure employees hired received abuse education, resident rights education, and orientation. |
| Failed to ensure yearly inservice education on abuse, resident rights, and dementia was completed for employees. |
| Failed to maintain a clean environment and good repair throughout the facility. |
| Failed to ensure updated evaluation of individual needs with change in resident status. |
| Failed to ensure service plans were correct and updated with changes in condition. |
| Failed to ensure residents who had fallen were assessed by a licensed nurse and follow-up assessments were completed post fall; failed to ensure assistance with meals and showers; failed to monitor elopement risk; failed to implement behavior interventions; failed to assess residents with change of status. |
| Failed to ensure residents received medications as ordered and administered by licensed nurse or qualified medication aide. |
| Failed to ensure medical records were complete and accurate related to documentation of abuse allegations and ADL care. |
| Failed to ensure a resident discharged to another healthcare facility received a transfer form with information for continuity of care. |
Report Facts
Complaint count: 9
Residents present: 98
Employees with incomplete background checks: 5
Employees without abuse education: 3
Employees without annual inservice education: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terminated CNA 10 | Certified Nursing Assistant | Named in abuse allegation and failure to complete background check and education. |
| Director of Nursing 1 | Director of Nursing | Named in findings related to family notification, abuse reporting, and employee screening. |
| Executive Director 4 | Executive Director | Involved in interviews and education related to multiple deficiencies. |
| QMA 6 | Qualified Medication Aide | Mentioned in family notification and medication administration findings. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 4
Jan 31, 2025
Visit Reason
This visit was for the investigation of complaints IN00450703, IN00450736, IN00450862, and IN00451388.
Findings
The facility was found deficient in notifying the Indiana Department of Health of a new Administrator within three working days, ensuring staff with current CPR and First Aid certification on all shifts, maintaining a clean environment in the Memory Care Unit, and properly documenting wasted narcotics with a second witness verification.
Complaint Details
This visit was triggered by complaints IN00450703, IN00450736, IN00450862, and IN00451388. State deficiencies related to these complaints were cited at tags R117, R144, and R306. The complaints were substantiated by the findings.
Deficiencies (4)
| Description |
|---|
| Failed to notify the Indiana Department of Health of a new replacement Administrator within three working days of administration vacancy. |
| Failed to ensure at least one staff member with current first aid and CPR certification was scheduled for 3 of 21 shifts reviewed. |
| Failed to maintain a clean environment related to dirty floors, dirty furniture, and a dirty bathroom in the Memory Care Unit. |
| Failed to document a wasted narcotic and have a second witness verify waste for 1 of 5 residents reviewed during medication pass observation. |
Report Facts
Shifts without CPR/First Aid certified staff: 3
Residents reviewed for narcotic waste documentation: 5
Facility census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Wiley | RDCS | Laboratory Director or Provider/Supplier Representative who signed the report. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Dec 26, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00448513, IN00448580, IN00448935, and IN00449809) regarding resident rights, transfer and discharge procedures, and misappropriation of property at Brentwood at Hobart.
Findings
The facility failed to ensure residents' transfer and discharge rights were implemented properly, including lack of required documentation for pending discharges for three residents. Additionally, the facility failed to properly investigate and document grievances related to missing personal items for residents, and clinical records lacked accurate documentation regarding these grievances.
Complaint Details
The investigation involved four complaints: IN00448513 (no deficiencies cited), IN00448580 (deficiencies cited related to grievance and clinical record documentation), IN00448935 and IN00449809 (deficiencies cited related to residents' transfer and discharge rights). The complaints concerned failure to provide proper discharge notices, lack of appeal information, and failure to investigate or resolve grievances about missing personal items.
Deficiencies (3)
| Description |
|---|
| Failed to ensure resident's transfer and discharge rights were implemented related to not providing required documentation or paperwork for pending discharges for 3 of 3 residents reviewed for transfer and discharge. |
| Failed to ensure resident rights were implemented related to the investigation of missing items for 1 of 3 residents reviewed for misappropriation of property. |
| Failed to ensure clinical records were accurately documented related to the investigation of a grievance for 1 of 3 residents reviewed for misappropriation of property. |
Report Facts
Residential Census: 111
Survey dates: December 26 and 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Wiley | RDCS | Signed as Laboratory Director or Provider/Supplier Representative |
| Director of Nursing | DON | Named in relation to grievance investigations and deficiencies |
| Executive Director | Involved in review and monitoring of transfer/discharge policies and grievance processes | |
| Clinical Operations Specialist | Interviewed regarding discharge notices and grievance investigations | |
| Business Office Manager | Provided information about discharge forms and processes |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Nov 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445848.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00445848 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 11
Sep 26, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00443613 and IN00443702.
Findings
The facility was found noncompliant in multiple areas including failure to have a current Alzheimer's/Dementia Special Care Unit disclosure form, failure to ensure residents' ability to self-administer medications, incomplete and unsigned service plans, failure to assess and notify physician after falls, improper food sanitation, incomplete pharmacy drug regimen reviews, incomplete clinical records, missing transfer/discharge forms, incomplete emergency information files, missing annual health statements, and failure to test residents for tuberculosis on or prior to admission.
Complaint Details
This visit included the investigation of Complaints IN00443613 and IN00443702, with state deficiencies related to the allegations cited at R0240.
Deficiencies (11)
| Description |
|---|
| Failed to have a current Alzheimer's/Dementia Special Care Unit disclosure form. |
| Failed to ensure a resident had the ability to self-administer medications with proper physician orders and assessments. |
| Failed to ensure Service Plans were signed by the resident or representative and updated for 7 of 11 residents reviewed. |
| Failed to assess a resident and notify the Physician and responsible party following a fall, and failed to monitor oxygen use for 2 of 11 residents reviewed. |
| Failed to maintain proper food sanitation related to unlabeled and undated food items in the kitchen. |
| Failed to ensure pharmacy drug regimen reviews were completed every 60 days for 9 of 11 residents reviewed. |
| Failed to maintain clinical records that were complete and accurately documented related to urinary indwelling catheter output documentation, duplicate medication orders, and lack of orders for self-administering medications. |
| Failed to ensure a transfer/discharge form was completed for 1 of 11 resident records reviewed. |
| Failed to ensure a current emergency information file was complete, lacking hospital preference documentation for 8 of 8 residents reviewed. |
| Failed to ensure residents had an annual signed health statement indicating they were free of communicable diseases for 9 of 11 residents reviewed. |
| Failed to ensure infection control measures were in place related to not testing residents for tuberculosis on or prior to admission for 5 of 11 residents reviewed. |
Report Facts
Residents reviewed: 11
Residents affected by pharmacy review deficiency: 9
Residents affected by missing annual health statements: 9
Residents affected by missing TB testing: 5
Residential Census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Verna Meacham | Executive Director | Signed the report. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies and lack of documentation. |
| Administrator | Administrator | Interviewed regarding Alzheimer's/Dementia disclosure form and hospital preferences. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding food sanitation deficiencies. |
| QMA 1 | Qualified Medication Aide | Interviewed regarding incident reports for falls. |
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Jul 30, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00434733 completed on May 22, 2024.
Findings
Brentwood at Hobart was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00434733.
Complaint Details
Complaint IN00434733 - Corrected
Report Facts
Residential Census: 119
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 4
May 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434733 regarding allegations of neglect, improper evaluation, and safety concerns related to residents with exit-seeking behaviors and accidents.
Findings
The facility failed to ensure a resident was free from neglect related to inadequate supervision of a resident with exit-seeking behaviors resulting in serious injuries from elopement. The facility also failed to timely update service plans, ensure safe transfers, and maintain complete clinical records including assessments and physician orders for elopement alert devices.
Complaint Details
Complaint IN00434733 was substantiated with state deficiencies cited at R0052, R216, R240, and R349 related to neglect, evaluation, health services, and clinical records.
Deficiencies (4)
| Description |
|---|
| Failed to ensure a resident was free from neglect related to ineffective supervision of a resident with exit-seeking behaviors resulting in fractures from elopement. |
| Failed to timely update a resident's Service Plan with interventions related to exit seeking and wandering. |
| Failed to ensure a resident was free from accidents and hazards related to improper transfer resulting in a fall. |
| Failed to ensure clinical records were complete related to lack of assessment or physician's order for a WanderGuard device. |
Report Facts
Residential Census: 117
Survey Dates: 2
Fall incident date: Apr 25, 2024
Completion date for corrective actions: Jul 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Ciak | Regional Director of Operations | Signed the inspection report. |
| CNA 2 | Witnessed resident wandering and reported missing resident alert. | |
| Executive Director | Executive Director | Provided multiple interviews regarding resident supervision, service plan updates, and incident details. |
| QMA 1 | Qualified Medication Aide | Interviewed about resident wearing WanderGuard and exit attempts. |
| CNA 1 | Involved in improper transfer leading to resident fall. | |
| Housekeeper 1 | Turned off WanderGuard alarm without checking outside. | |
| Maintenance Director | Demonstrated how windows could be removed leading to elopement risk. | |
| Activity Director | Observed resident sitting outside during WanderGuard alarm. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Apr 3, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00427514 and IN00430896 regarding alleged deficiencies at the facility.
Findings
The facility failed to notify a resident's responsible party of a change in condition and new medication orders, and failed to maintain accurate and accessible clinical records related to monitoring bruises, skin conditions, and fall follow-ups for multiple residents. Neurological checklists were not consistently completed after resident falls as required by policy.
Complaint Details
The investigation was triggered by complaints IN00427514 and IN00430896. The complaints involved failure to notify responsible parties of changes in condition and medication orders, and failure to maintain proper clinical documentation and follow-up after resident falls. The complaints were substantiated with cited deficiencies.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a resident's responsible party was notified of a change in condition for 1 of 1 resident reviewed (Resident B). |
| Failed to ensure records were accurately documented and readily accessible related to monitoring bruises, skin conditions, and fall follow-ups for 3 of 6 residents reviewed (Residents B, E, and F). |
Report Facts
Residential Census: 119
Dates of survey: Survey conducted on April 3 and 4, 2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Williams | Administrator | Signed as the facility administrator on the report. |
| Executive Director | Interviewed regarding notification of responsible parties and neurological checklist completion. | |
| Director of Nursing | Interviewed and responsible for reviewing new orders, progress notes, and skin assessments; involved in plan of correction. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 5
Jan 31, 2024
Visit Reason
This visit was for the investigation of Complaints IN00421009 and IN00426601. Complaint IN00421009 had no deficiencies related to the allegations, while Complaint IN00426601 had state deficiencies related to the allegations cited at R240 and R349.
Findings
The facility was found deficient in ensuring annual dementia training for staff, completion and signing of resident service plans, provision of necessary ADL assistance related to showers, presence of physician diet orders, and accuracy and completeness of clinical records related to skin discoloration documentation.
Complaint Details
Complaint IN00421009 - No deficiencies related to the allegations are cited. Complaint IN00426601 - State deficiencies related to the allegations are cited at R240 and R349.
Deficiencies (5)
| Description |
|---|
| Failed to ensure annual dementia training had been completed for 2 of 3 employees reviewed (CNA 1 and CNA 2). |
| Failed to ensure resident service plans were completed and signed by the resident or representative for 2 of 5 service plans reviewed (Residents C and E). |
| Failed to ensure dependent residents received necessary ADL assistance related to showers as scheduled for 3 of 3 residents reviewed (Residents B, C, and F). |
| Failed to ensure Physician Orders for a diet were in place for 2 of 5 residents reviewed (Residents C and D). |
| Failed to ensure clinical records were accurate and complete related to lack of documentation of discoloration of unknown origin on a resident's hand (Resident B). |
Report Facts
Residential Census: 119
Employees reviewed for dementia training: 3
Employees not completed dementia training: 2
Service plans reviewed: 5
Service plans missing signatures: 2
Residents reviewed for ADL care: 3
Residents missing diet orders: 2
Residents reviewed for diet orders: 5
Residents reviewed for injury documentation: 1
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 9
Aug 16, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00404588, IN00405063, IN00408004, and IN00409458.
Findings
The facility was found deficient in multiple areas including failure to promptly notify physicians and responsible parties of changes in resident conditions, inadequate fire and disaster drills with local fire department, incomplete criminal background checks for new employees, sanitation issues in kitchen and resident environment, incomplete semi-annual evaluations and service plans, improper food handling and menu management, inaccurate clinical records including insulin administration and fall monitoring, and inadequate infection control practices.
Complaint Details
This inspection included investigation of Complaints IN00404588, IN00405063, IN00408004, and IN00409458. Deficiencies were cited related to complaints IN00405063 and IN00408004. Complaints IN00404588 and IN00409458 had no deficiencies related to allegations.
Deficiencies (9)
| Description |
|---|
| Failure to promptly notify physician and responsible party of significant decline or change in treatment for residents. |
| Failure to hold fire and disaster drills in conjunction with local fire department at least every 6 months. |
| Failure to ensure criminal history checks for new employees included statewide background search through Indiana State Police. |
| Kitchen and resident environment not clean and in good repair; dirt, debris, lime buildup, discolored light covers, splitting wood floors. |
| Failure to complete semi-annual evaluations for residents every 6 months. |
| Failure to ensure service plans were signed by residents or responsible parties and updated to reflect changes such as hospice care. |
| Failure to store, serve, and prepare food under sanitary conditions including uncovered food, dirty equipment, undated food, and lack of RD approved menus and recipes. |
| Failure to maintain complete, accurate, and accessible clinical records including improper insulin administration documentation, lack of neurological checks after falls, and incomplete monitoring of wounds and skin issues. |
| Failure to establish and implement infection control program including lack of infection tracking and trending, inappropriate antibiotic use without culture confirmation, and inadequate infection monitoring. |
Report Facts
Residents reviewed: 8
Residents reviewed: 13
Residents reviewed: 8
Residents reviewed: 8
Residents present: 101
Fire drills required: 12
Fire drills required: 1
Insulin doses signed out late or by uncertified staff: 25
Antibiotic days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Williams | Executive Director | Signed report |
| QMA 1 | Mentioned in insulin administration documentation issues | |
| QMA 5 | Mentioned in insulin administration documentation issues | |
| Director of Nursing | DON | Provided interview and corrective action plans related to insulin administration, fall monitoring, infection control |
| Administrator | Provided multiple interviews regarding deficiencies and corrective actions | |
| Dietary Food Manager | Interviewed regarding kitchen sanitation and menu/recipe issues |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Mar 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00393124 and IN00396501.
Findings
No deficiencies related to the allegations in complaints IN00393124 and IN00396501 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00393124 and IN00396501 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Residential Census: 101
Inspection Report
Census: 83
Deficiencies: 0
Oct 27, 2022
Visit Reason
This visit was for a Quality Assurance Walk Through Survey.
Findings
Brentwood at Hobart was found to be in compliance with 410 IAC 16.2-5 in regard to the Quality Assurance Walk Through Survey.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00387249 and IN00388069. Complaint IN00387249 was substantiated and related to a state deficiency, while Complaint IN00388069 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure an allegation of abuse was reported timely to the Indiana Department of Health for 2 of 3 sampled residents. Specifically, an incident occurring on 7/29/22 was reported late on 8/1/22, beyond the required 24-hour reporting period.
Complaint Details
Complaint IN00387249 was substantiated with a state deficiency cited at R0090. Complaint IN00388069 was unsubstantiated due to lack of evidence.
Deficiencies (1)
| Description |
|---|
| Failure to report an allegation of abuse timely to the Indiana Department of Health for 2 of 3 sampled residents. |
Report Facts
Residential Census: 101
Incident date: Jul 29, 2022
Report date: Aug 1, 2022
Plan of Correction Completion Date: Sep 3, 2022
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