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Complaint Investigation

Hutsonwood At Brazil

Inspection Date: August 14, 2025
Total Violations 1
Facility ID 155503
Location BRAZIL, IN
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Inspection Findings

F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the time she left to go home. She had told Transporter 2 to assume Resident B was having her surgery on Monday, 8/11/25. When the DON arrived to the facility on Monday at around 8:30 a.m., she did not realize Transporter 2 had not taken the resident to the hospital. The surgery department had called RN 3 and indicated the resident had not shown up for her procedure. Transporter 2 had not shown up to take her to her appointment. During an interview on 8/14/25 at 1:18 p.m., Transporter 2 indicated on Friday afternoons,

he reviewed the following weeks schedule and had noticed Resident B was in the hospital. He asked Unit Manager (UM) 4 and the DON if Resident B returned to the facility, would she be going to have the surgery

on Monday morning, 8/11/25. He had been told by UM 4 that Resident B had already had her procedure when she was in the hospital. The DON indicated she would confirm things and would contact him if the surgery was a go or no-go. He did not hear back from the DON or any staff at the facility. He arrived on Monday, 8/11/25, at his usual time, 8:00 a.m., and believed the surgery had already been completed while

the resident was in the hospital. The staff informed him that Resident B had missed her surgery.During an

interview on 8/14/25 at 1:37 p.m., UM 4 indicated she had already gone home by the time Resident B returned from the hospital on Friday, 8/8/25. Transporter 2 had come into the DON's office Friday afternoon, 8/8/25, and reviewed transports for Monday, 8/11/25. The DON had told Transporter 2 they would not know for sure about Resident B's surgery until she returned with her discharge paperwork. UM 4 indicated the hospital had not contacted the facility for report prior to transfer back to the facility by the time she left the facility for the weekend. During a telephone interview on 8/14/25 at 2:01 p.m., RN 3 indicated she looked where they kept the appointment paperwork for the day and saw Resident B was scheduled for surgery that morning. The Surgery Center had called that morning, and she asked if she should hold her morning medications. The Surgery Center staff indicated she could take her morning medications, but to hold her morning insulin injection. RN 3 got the resident ready and she was up in her wheelchair, and ready to go when Transporter 2 arrived approximately 7:45 a.m. She noticed at 7:55 a.m., he had not left the facility for transport yet. Transporter 2 indicated he had spoken to the DON and the surgery for that morning had been cancelled. RN 3 returned the resident to her bed and administered her insulin dose. The resident's spouse arrived a little bit later and asked why she had not arrived for her surgery. He was very upset because the procedure was not cancelled. She interrupted the staff's morning meeting to let the Administrator and DON know the resident's husband was there to talk with them regarding his wife being a no-show for her surgery.

She felt when Transporter 2 had told her the surgery was cancelled, she should have called the DON at that time to confirm. She felt bad about not confirming, but he had seemed so sure of the cancellation. She had not had access to the discharge paperwork from the resident's hospital stay, as they had been given to

the DON or UM 4 to be reviewed and entered into the electronic health record after the weekend. She had explained to Transporter 2 that she had been contacted by the Surgery Center and the surgery was confirmed. A current facility policy, dated 1/1/25, titled, Transporting a Resident (Facility Van), provided by

the DON on 8/14/25 at 3:33 p.m., included the following: Policy: It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips

the facility deems necessary.A current facility policy, dated 1/1/25, titled, Consulting Physician/Practitioner Orders, provided by the DON on 8/14/25 at 3:33 p.m., included the following: Policy Explanation and Compliance Guidelines: .2 For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: .b. Document the verification order by entering the order into the EMRThis citation relates to Intake 2586289.3.1-37(b)

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📋 Inspection Summary

HUTSONWOOD AT BRAZIL in BRAZIL, IN inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRAZIL, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HUTSONWOOD AT BRAZIL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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