Inspection Reports for
Brownsburg Health Care Center

The facility was found deficient in multiple areas including resident dignity and respect, grievance handling, advance directive documentation, abuse prevention and investigation, care planning, medication management, staffing adequacy, wound care, and quality assurance processes. Immediate jeopardy was identified related to resident-to-resident physical and sexual abuse on the memory care unit, which was later removed after corrective actions.

The complaint investigation found the facility did not follow CDC hand hygiene guidelines during medication passes. The issue was substantiated with observations and interviews confirming the deficient practice.

The facility failed to ensure proper hand hygiene during medication passes by a Qualified Medication Aid (QMA), who did not sanitize hands before, during, or after administering medications to multiple residents. This deficient practice potentially affected 19 of 20 residents on the 100, 200, and 300 hallways.

This citation relates to Complaint IN00462259. The complaint was substantiated as the facility failed to prevent abuse of Resident B.

The facility failed to protect a resident from verbal and physical abuse by two Certified Nursing Aides. The incident was self-reported, the CNAs were suspended, and corrective actions including staff education and care plan adjustments were implemented.

Complaint IN00462259 was substantiated with federal and state deficiencies cited related to abuse allegations involving Resident B. The facility self-reported the incident and corrective actions were implemented prior to the survey.

The facility failed to protect one resident's right to be free from verbal and physical abuse by staff. The incident involved two CNAs pulling on the resident's arms causing pain and other inappropriate care actions. The deficient practice was corrected prior to the survey date with suspension of involved CNAs and staff education.

The inspection was triggered by complaints IN00452678 and IN00455563 alleging inadequate ADL care, medication safety issues, respiratory equipment mismanagement, and insufficient staffing.

The facility failed to provide adequate assistance with ADLs for multiple residents, left medications unsecured at bedside, improperly cleaned and stored respiratory equipment, and did not maintain sufficient nursing staff to meet resident care needs. Observations and interviews confirmed residents were left in soiled briefs, meals were left untouched due to delayed assistance, and nebulizer and oxygen equipment were improperly stored.

Complaints IN00452678 and IN00455563 had federal/state deficiencies related to the allegations cited at F677, F689, F695, and F725. Complaint IN00456607 had no deficiencies related to the allegations.

The facility failed to ensure adequate assistance with activities of daily living (ADL) for dependent residents, proper medication and wound treatment storage, appropriate respiratory care equipment cleaning and storage, and sufficient nurse staffing levels to meet resident needs.

The facility was found not in compliance with Life Safety Code requirements, including failure to properly mark non-exit doors, lack of approved method to secure cooking appliances, resident room doors not closing and latching properly, and smoke barrier doors not closing fully. Corrective actions were implemented during the survey.

Complaint IN00445712 was investigated and federal/state deficiencies related to the allegations were cited at F684.

The facility was found deficient in multiple areas including accuracy of assessments, comprehensive care planning, coordination with hospice, tube feeding management, pain management, dementia care programming, pharmacy services, infection prevention and control, and hand hygiene compliance.

This citation relates to Complaint IN00445712.

The facility failed to coordinate treatments and services with hospice after new skin impairment areas were discovered on the bilateral lower extremities of Resident B. Hospice narrative notes were not received by the facility, and the physician was not notified of the wounds, indicating a breakdown in communication and care coordination.

The facility was found deficient in multiple areas including accurate resident assessments, comprehensive care planning, coordination with hospice care, proper administration of tube feedings, pain management, dementia care programming, emergency pharmaceutical services, infection prevention practices, and tuberculosis screening compliance.

This citation relates to Complaint IN00427538. The investigation substantiated diversion of narcotic medications by LPN 14, who was suspended and terminated. The local police and Attorney General were notified, and residents were compensated for missing medications.

The facility failed to protect residents' narcotic medications from diversion, resulting in at least 56 missing narcotic tablets from medication carts and an automated drug unit. The investigation confirmed multiple instances of medication diversion by LPN 14, who was subsequently suspended and terminated.

Complaint IN00427538 was substantiated with federal/state deficiencies cited at F602 related to narcotic medication diversion. Complaints IN00421255 and IN00431889 had no deficiencies related to the allegations.

The facility failed to ensure residents' narcotic medications were protected from diversion, resulting in at least 56 missing narcotic medication tablets. The investigation found that LPN 14 diverted narcotics from the automated drug unit and medication carts. Corrective actions included staff education, securing narcotics in blister cards or locked medication carts, and implementing stricter narcotic dispensing and counting procedures.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure of one set of smoke barrier doors to restrict smoke movement for at least 20 minutes and failure to verify transmission of fire alarm signals during 5 of 12 fire drills conducted between 6:00 a.m. and 9:00 p.m. in the last 4 quarters.

The facility was found deficient in multiple areas including quality of care related to wound treatment, accident hazard prevention, pharmacy services and medication accountability, infection control practices, payroll-based journal submission, medication storage, and personnel background checks.

The facility failed to provide appropriate wound care for a resident with non-pressure wounds, failed to implement fall interventions, failed to complete smoking assessments after significant changes, failed to ensure proper controlled substance accountability and medication destruction, failed to destroy expired vaccines, failed to submit payroll-based journal staffing data timely, and failed to properly clean glucometers between resident uses.