Brownsburg Health Care Center

F-F695.

This citation relates to Complaints IN00452678 and IN00455563.

3.1-17(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 155206

F-F725.

This citation relates to Complaints IN00452678 and IN00455563.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 3.1-47(a)(6)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 38767

Residents Affected - Some Based on observation, interview, and record reviews, the facility failed to ensure adequate staffing levels to ensure residents received activities of daily living (ADL) care for meal service, toileting, bathing and dressing, medication administration, and getting residents out of bed for 14 of 16 residents reviewed for sufficient nurse staffing (Residents C, F, G, H, J, K, L, N, S, T, V, X, Y, and BB) and for 5 of 7 hallways (200, 400, 500, 700, and 800) observed for sufficient nurse staffing.

Findings include:

On 4/27/25 at 9:13 a.m., Certified Nursing Assistant (CNA) 5 indicated she was assigned to care for 7 residents on the 100 and 200 hallways by herself. There was no CNA in the facility to care for residents on

the 300 and 400 hallways, but she was not sure why. The nursing scheduler QMA 4 had been called in to cover for a nurse call-off on the 400 hallways, but CNA 5 had yet to hear the backup plan to cover the CNA's hours.

On 4/27/25 at 9:27 a.m., Registered Nurse (RN) 7 was observed administering medications on the 300 hallway. He indicated he usually worked double shifts on Tuesdays, Thursdays and every other weekend, and on this date he was responsible for the 100, 200, and 300 hallways. RN 7 indicated the CNA for the 300 and 400 hallways had not shown up, there were 12 residents total, and staff were handling the situation as a group. RN 7 indicated staffing problems usually happened mostly on the weekends, but the 700 and 800 hallways were usually staffed with 3 CNAs, and one would be pulled to help where needed. He indicated the day shift started at 7:00 a.m., and at that time the 5 residents on the 300 hallway were not yet out of bed.

On 4/27/25 at 9:29 a.m., CNA 8 was observed arriving on the 300 hallway. The CNA indicated, she was a new employee of about 3 weeks in the facility and had just been re-assigned this morning from the 700 and 800 hallways to the 300 and 400 hallways where she had never worked.

Observations of Resident C, included:

a. On 4/27/25 at 9:50 a.m., Resident C was observed lying in bed with her eyes closed, the head of the bed was elevated, and the resident's upper torso was slumped to the right. There was paper debris on the floor around the bed.

b. On 4/27/25 at 11:51 a.m., the resident remained in the same position with her eyes closed, the head of the bed was elevated, and the resident's upper torso slumped to the right.

c. On 4/28/25 at 9:45 a.m., the resident was observed sitting in a manual wheelchair (WC) next to the bed, sitting on a blue transfer pad. The resident indicated she had not yet had breakfast. An untouched breakfast tray of food was observed sitting on top of a small black refrigerator on a dresser, out of reach of the resident.

Observations of Resident F included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 a. On 4/27/25 at 9:36 a.m., the resident was observed lying in bed watching television (TV), his left forearm and hand resting on his waist, and a hand splint on a bedside table. The resident indicated he would like to Level of Harm - Minimal harm or be out of bed by 10:00 a.m. daily, but due to low staffing he had yet to get up or had his brief changed by the potential for actual harm morning shift, and he was wet.

Residents Affected - Some b. On 4/27/25 at 10:09 a.m., a second observation of Resident F lying in bed in the same position and he indicated he was still waiting for care.

c. On 4/27/25 at 10:37 a.m., a third observation of Resident F lying in bed in the same position when a visitor entered his room. The resident's relative indicated that it was not unusual for the resident to have to wait on care, especially on weekends.

d. On 4/27/25 at 11:48 a.m., the resident was observed lying in bed visiting with a peer. The resident indicated he had not been given care per the day shift yet and his brief was still wet.

e. On 4/27/25 at 12:02 p.m., there were no CNAs or nurses observed in the hallway. A visitor asked QMA 4 why the resident had not gotten out of bed or had his brief changed. Resident F was overheard telling QMA 4

he had asked the CNAs to change him that morning, but no one had come back. QMA 4 was observed to check the resident's brief, acknowledge it was soiled, indicated she was uncertain why he had not yet been cared for, and that she would make sure he got cleaned up and his linens changed.

Observations of Resident G included:

a. On 4/27/25 at 9:41 a.m., the resident was observed lying in the bed awake, smelling of urine, a breakfast tray of untouched food and drinks at the bedside and a cup of unidentified pills sitting on the bedside stand near his breakfast tray. The resident indicated the staff was supposed to have changed his brief and assisted him to bathe, dress, and be out of bed by 8:00 a.m. so he could have breakfast. Resident G indicated he had been lying in a urine-soaked brief for hours waiting on staff, and now his breakfast food was cold. The resident indicated he had no idea his medications were on the bedside stand out of sight, but the nurse had already taken his blood sugar earlier that morning. Resident G indicated the weekends were the worst as there were never enough staff to care for the residents, and it was pure hell.

b. On 4/27/25 at 9:50 a.m., the Housekeeping Supervisor was observed telling CNA 8 that Resident G needed assistance with bathing and dressing when she had time.

c. On 4/27/25 at 10:36 a.m., CNA 8 was observed leaving the resident's room, and the resident was in his WC at bedside. The resident pointed to his breakfast tray and indicated the food and his water for hot chocolate were now cold. The CNA indicated she would take his water to be heated in the employee breakroom; she wanted him to at least have a hot drink as he had a cold breakfast. The resident indicated by

the time he was getting out of bed he was soaking wet, and his breakfast was cold, so he frequently sent it back.

d. On 4/27/25 at 10:37 a.m., a visitor indicated the day before, on Saturday 4/26/25, Resident G had been observed in his wheelchair, wheeling himself up and down the hallway right before noon wearing only a gown and holding his clothing awaiting care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 4/27/25 at 10:12 a.m., QMA 4 was observed passing medications on the 400 hallway, and indicated she had been called in to cover the 400 and 500 hallways, and CNA 8 had been pulled from the 700 and 800 Level of Harm - Minimal harm or hallways to cover the 300 and 400 hallways for employees that had called off. QMA 4 indicated that CNA 8 potential for actual harm had a total of 13 residents to care for between the 300 and 400 hallways, but there were only 3 residents on

the 400 hallway that needed hands on care, including Residents H, J, and K, the rest would use their call Residents Affected - Some lights to call for assistance when needed.

a. Resident H was observed lying in bed with an over the bed table in front of her, watching TV. The resident indicated she had not yet had her bath, did not believe she'd had her brief changed, and was most likely wet.

b. Resident J was observed lying in bed watching TV and wearing a gown.

c. Resident K was observed lying in bed, wearing a gown, food crumbs on his gown and bedding, positioned with his contracted right hand/arm lying on his chest, and his left arm behind his head. The resident indicated

he had fed himself the food from the breakfast tray in front of him on an over the bed tray stand. The resident indicated he had not yet had a bath or had his brief changed, and his adult brief was observed saturated with urine.

On 4/27/25 at 10:42 a.m., Resident L was observed lying in bed with her eyes closed, wearing a floral night gown. The resident indicated she went to the bathroom on her own, but was waiting on staff to help get her dressed.

On 4/27/25 at 10:51 a.m., Resident N was observed lying in bed wearing a hospital gown and watching TV.

The resident indicated she had not yet been dressed, and her brief had not yet been changed. The resident indicated it was her understanding everyone had to stay in bed that day, but she was not sure why.

During a continuous observation on 4/27/25 from 10:42 a.m. to 11:03 a.m., there were no CNA's or nurses

on the 500 hallway, and 13 of 25 residents were observed to still be in bed.

Observations of Resident S included,

a. On 4/27/25 at 11:15 a.m., Resident S was observed sitting in a manual wheelchair at bedside, wearing a hospital gown with a fleece cardigan over her shoulders, her bare feet resting on the floor, and emitting a deep congested tight cough. The resident had a nasal cannula for oxygen in her nose attached to a bedside concentrator and gestured to her oxygen tubing which she took out of her brief, and indicated the CNA had put the oxygen tubing inside her brief and the resident had untaped her brief to get the tubing out. A tray of breakfast food was observed sitting on an over the bed table untouched. The resident indicated she preferred to eat breakfast after being out of bed, but most often did not get up until around 10:00 a.m., and by then the food was cold. The resident gestured to her nebulizer sitting on the bed beside her and the nebulizer handheld mouthpiece was unbagged and lying in the middle of the bed among her bedding. Resident S indicated the nurse had put the nebulizer handpiece on the bedside table that morning, and after

she was assisted out of bed, CNA 17 handed her the nebulizer handpiece, spilled half of the medication, and turned on the machine, therefore she did not get her full treatment. A portable oxygen concentrator was observed on a bedside table on the back side of the bed, in the on position, and the attached nasal cannula was laying on the floor. The resident indicated she used the portable concentrator when going out of her room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 b. On 4/28/25 at 10:02 a.m., Resident S was observed lying in bed on her right side facing the wall. A portable oxygen concentrator was observed on a bedside table on the back side of the bed, in the on Level of Harm - Minimal harm or position, and the attached nasal cannula was laying on the floor. An untouched breakfast tray was sitting on potential for actual harm a table near the doorway out of the resident's reach.

Residents Affected - Some c. On 4/28/25 at 1:56 p.m., Resident S was observed sitting in a WC at bedside, wearing a hospital gown and her bare feet on the floor, sleeping, a TV remote in her right hand, and a breakfast tray in front of her with the food untouched. A plastic medication cup with 5 unidentified medications and an Anoro Ellipta inhaler (bronchodilator) sat on the breakfast tray. A tray of lunch foods sat on the bed near the resident with

the food untouched. A nebulizer sat on the bed beside the resident with the mouthpiece on the bare mattress. A portable oxygen concentrator was observed on a bedside table on the back side of the bed, in

the on position, the attached nasal cannula was laying on the floor.

d. On 4/28/25 at 2:23 p.m., Registered Nurse (RN) 14 observed the medications sitting on the resident's breakfast tray and indicated QMA 4 had administered the medications that morning, and staff knew better than to leave medications at bedside.

On 4/27/25 at 11:33 a.m., Resident T was observed at bedside reading a book, and indicated on Friday 4/25/25 she had not received her bedtime medications until she called up front, and a nurse came and gave her the medication right at shift change at 11:00 p.m.

On 4/27/25 a continuous observation of the 700 and 800 hallways from 11:08 a.m. to 11:36 a.m., 4 of 30 residents were out of bed. CNA 17 did not respond when asked why most of the residents would be in bed for lunch, instead indicated there were 2 more residents that she would be getting up for lunch.

On 4/27/25 at 11:42 a.m., there were 4 residents observed sitting in WCs in the back dining room awaiting lunch.

During an interview on 4/27/25 at 11:52 a.m., the Dietary Manager (DM) indicated the front dining room was no longer used for meals as residents in the front preferred to eat in their rooms. She indicated meals were served at 12:00 p.m. on the 600 hallways, at 12:15 p.m. on the 700 and 800 hallways, around 12:35 p.m. on

the 100, 200, and 300 hallways, and around 12:45 p.m. on the 400 and 500 hallways. The DM indicated, on

a good day 15 residents ate meals in the back dining room.

On 4/27/25 at 1:15 p.m., CNA 5 who was responsible for residents on the 100 and 200 hallways was observed most of this day one on one (1:1) with Resident D at the front of the facility, to include entertaining her and feeding her lunch.

On 4/27/25 at 1:45 p.m., nurses on the day shift were observed passing medications, documenting, and walking up and down the hallways. There was no observation of nurses providing direct resident care or assisting CNAs who were providing direct resident care.

Observations of Resident V included,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 a. On 4/28/25 at 9:25 a.m., Resident V was observed lying in bed working on word puzzles. The resident indicated she was looking for a nurse to start her nebulizer treatment, the resident was slightly short of Level of Harm - Minimal harm or breath and wheezy when speaking. potential for actual harm b. On 4/28/25 at 1:58 p.m., Resident V's nebulizer machine was observed sitting on the bedside table on the Residents Affected - Some backside of the bed and the handheld mouthpiece was unbagged and clipped to the machine. The handheld mouthpiece was observed to have nebulizer liquid medication in the medication chamber.

On 4/28/25 at 10:01 a.m., observation of QMA 4 passing medications on the 800 hallway, and 2 CNAs working together on the 700 and 800 hallways. QMA 4 indicated, a CNA had called off that morning and the 3rd CNA from the 700 and 800 hallways had been moved to cover. QMA 4 indicated that the facility was not currently hiring more staff as all positions had been filled. There used to be more pro re nata (prn - as needed) staff, but due to not working at least 1 shift per month, those positions had been terminated. QMA 4 indicated that if all staff came in to work their scheduled shifts there was no need to hire more staff. QMA 4 indicated 2 aides were working together to care for the 30 residents on the 700 and 800 hallways, of which 15 required mechanical lifting from bed. She would come out of her office and assist when residents were being mechanically transferred.

During an interview on 4/28/25 at 2:11 p.m., CNA 15 indicated she was working on the 700 and 800 hallways as one of two 2 CNAs that day, and lower staffing of CNAs generally happened 2-3 times weekly. CNA 15 indicated she had not sat down all day and had not had a break or lunch as there were 30 residents on the hallways of which 6 residents required assistance for eating and 15 required mechanical lifts for transfers. CNA 15 indicated it was not possible to get all 30 of the residents out of bed timely for lunch, and she had just finished getting her last resident out of bed.

During an interview on 4/28/25 at 2:15 p.m., CNA 16 indicated she was working on the 700 and 800 hallways as one of two 2 CNAs that day. She indicated it took time management to get everyone done during the time allotted on her shift. If management were in the facility, line staff could request help, but if management was not in the facility the staff did the best they could; just one resident at a time.

During an interview on 4/28/25 at 2:23 p.m., RN 14 indicated on days like today with just a nurse and 2 CNAs on the 700 and 800 hallways, no one got a break. They just banded together and did the best they could. It was not possible to get everyone taken care of, fed, and out of bed timely.

Confidential interviews were conducted during the course of the survey:

a. The employee indicated when a CNA had not come in to work on a weekend, the remaining staff member for the hallway was not notified and was left to care for 30 residents that required assistance with eating, being changed and toileted, total dependent residents, and heavy lifting. The manager on duty, Qualified Medication Aide (QMA) 4, was out of town and couldn't come in and help.

b. The employee indicated multiple residents were making complaints to the ADM about staff refusal to assist with changing wet briefs, refusing to empty urinals, and residents being left soiled and for the following shift to care for.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 c. The employee indicated nursing assistant hours had been cut, leaving two CNAs to work on 4 hallways, and the 500 hallways had been staffed with one CNA to care for multiple residents requiring showers and Level of Harm - Minimal harm or mechanical lifts for transfers. potential for actual harm

During an interview on 4/30/25 at 2:35 p.m., CNA 5 indicated she had worked the front 100 and 200 hallways Residents Affected - Some on 4/27/25. She had been unaware of the CNA scheduled to work the 300 and 400 hallways had called off until around 9:00 a.m. when the DM asked if she needed assistance passing the breakfast trays on the 300 and 400 hallways. The breakfast trays were usually delivered to the hallways to be passed no later than 8:00 a.m. and were still in the dietary transport cart.

A dietary mealtime posting indicated breakfast 7:30 a.m. - 8:30 a.m., lunch 12:00 p.m. - 1:00 p.m., and dinner 5:30 p.m. - 6:30 p.m.

A list of residents per hallway that require assistance with feeding documented 12 of 78 (15%) residents: one

on 300, three on 500, three on 600, and five on 700/800.

A list of residents per hallway that required extensive to total assistance with toileting, documented 51 of 78 (65%) residents: one on 100, three on 200, three on 400, eight on 500, ten on 600, and twenty-two on 700/800.

The Facility Assessment, dated 2/3/25, and provided by the Administrator (ADM) on 4/28/25 at 4:07 p.m., indicated there were 56 residents requiring assistance with dressing, 72 requiring assistance with bathing, 56 requiring assistance with transfers, 72 requiring assistance with eating, 56 requiring assistance with toileting, 35 requiring assistance with mobility, and 25 requiring assistance with respiratory treatments. The facility assessment indicated that the staffing ratio was to be 1:15 CNA/Resident and 1:32 Licensed Nurse/Resident. The facility assessment indicated that the hours per resident day (HPRD) was to be 3.48 hours, with 0.44 HPRD to be RN, 2.45 HPRD to be CNA/QMA, and 0.48 could be a combination. The Facility Assessment indicated that the facility's Nurse Staffing Plan was to have 2 to 4 LPN or RNs and 5 CNAs on night shift, 2 to 4 LPN or RNs and 7 CNAs on day shift, and 2 to 4 LPN or RNs and 6 CNAs on evening shift.

During an interview on 4/30/25 at 12:00 p.m., the ADM indicated she was unaware of what the HPRD was and how it was calculated. She was not at the facility when the facility assessment was created. The ADM indicated the Per Patient Day (PPD) goal was to be around 2.8 or 3.0.

The PPD report for February 2025 through April 2025 was reviewed. The report indicated that in February 2025 there was one day out of 28 days the PPD was less than 2.8 when on 2/15/25, it was 2.77. In March there were 5 days out of 30 days where the PPD was less than 2.8. On 3/1/25 it 2.78, on 3/2 it was 2.72, on 3/16 it was 2.74, on 3/22 it was 2.74, and on 3/29 it was 2.73.

The schedules worked were provided on 4/28/25 at 2:40 p.m. by the ADM. The schedules for February 2025 were reviewed to determine if CNAs were staffed per the Facility Assessment numbers of seven CNAs on day shift, six CNAs on evening shift, and five CNAs on night shift. There were 22 days out of 28 days on day shift that the facility did not have seven CNAs. There were 4 days out of 28 days that the facility did not have six CNAs on evening shift. There were 16 days out of 28 days that the facility did not have five CNAs on night shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 155206 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155206 B. Wing 04/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 The schedules for March 2025 were reviewed to determine if CNAs were staffed per the Facility Assessment numbers. There were 9 days out of 31 days on day shift that the facility did not have seven CNAs. There Level of Harm - Minimal harm or were 4 days out of 31 days that the facility did not have five CNAs on night shift. potential for actual harm

The schedules for April 2025 were reviewed to determine if CNAs were staffed per the Facility Assessment Residents Affected - Some numbers. There were 9 days out of 28 days that the facility did not have seven CNAs on day shift. There were 18 days out of 28 days that the facility did not have five CNAs on night shift.

On 4/30/25 at 12:02 p.m. the Administrator (ADM) provided a Nursing Department - Staffing, Scheduling, & Posting policy, dated 10/24/11, and indicated the policy was the one currently being used by the facility. The policy indicated, .I. The Facility will employee sufficient Nursing Staff on a 24-hour basis that meet the appropriate competencies, skill set and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. II.

In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs and will account for the number, acuity and diagnoses the facilities resident populations .C.

The Facility will employee and schedule sufficient nursing staff as determined by resident assessments and individual plans of care. i. Nursing staffing will take into account the number, acuity, and diagnosis of the Facility's resident population. This will be documented in the Resident Assessment. D. The Facility will utilize

the Facility Assessment to identify competency needs of Nursing Staff

Cross reference