Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brownsburg Meadows during CMS and state inspections, most recent first.
A cognitively intact resident who used a WC for mobility reported that a male facility bus driver, running late after an outside wound care appointment, leaned over and kissed her on the forehead without her consent while she was being secured on the bus, which she found offensive and uncalled for. The driver acknowledged in a written statement that he "pecked" her on the forehead in an attempt to smooth things over after she became upset about the delay. The resident requested to speak only with the ED and contacted police, but the clinical record showed only a single psychosocial follow-up visit by social services and no further documented monitoring for psychosocial distress. The resident’s care plan and profile were not updated in the record to reflect her upset with the driver or any changes in transportation arrangements, demonstrating a failure to fully honor her right to dignity and to document appropriate psychosocial follow-up.
A nurse failed to protect a resident's narcotic medications, resulting in 21 missing Oxycodone tablets. The nurse removed the medication and documentation from the medication cart, failed to follow destruction protocols, and falsified records by claiming a witness who denied involvement. Further audit revealed additional discrepancies with Oxycodone for other residents, with hundreds of tablets unaccounted for and missing documentation.
A failure to maintain proper reconciliation and documentation of controlled substances led to the diversion of at least 369 Oxycodone tablets. A medication discrepancy was discovered involving a resident's pain medication, and subsequent audits revealed missing signatures, absent reconciliation forms, and unaccounted medication across multiple residents. Required procedures for shift change verification and destruction of narcotics were not consistently followed, resulting in significant medication loss.
A resident with significant mobility impairments and a care plan requiring two-person assistance for transfers was injured when a newly hired CNA attempted a mechanical lift transfer alone, failed to secure the resident properly, and operated the lift incorrectly. This resulted in the resident slipping, sustaining a nondisplaced avulsion fracture of the distal fibula, and experiencing additional pain and injury.
Surveyors found that staff did not consistently date insulin pens, eye drops, and a vial of folic acid when opened, and failed to remove expired tuberculin serum and insulin from medication storage areas. Multiple medication carts and rooms contained undated or expired medications, contrary to facility policy and accepted standards.
The facility did not obtain or document weights as ordered for two residents, failed to secure timely physician orders and provide wound care for a newly admitted resident with a surgical amputation, and did not follow physician's instructions for the application and removal of a nitroglycerin patch for a resident with heart failure. These deficiencies were identified through record review, observation, and interviews, and involved lapses in following established care plans and physician directives.
A resident with diabetes and kidney failure repeatedly refused medications, insulin, and meals, yet the care plan was not revised to address these ongoing behaviors. Despite documentation of refusals and interdisciplinary team awareness, the care plan lacked updated goals and interventions for her diabetic management.
Staff left medications at the bedside of two residents without required self-administration assessments, including one resident with multiple chronic conditions and another with a bottle of Dulcolax in her purse. Additionally, an RN left blood pressure medication unattended on the medication cart in a hallway with two residents present, contrary to facility policy.
A resident with a history of diabetes and UTIs was documented as having a pressure ulcer on the right heel, but multiple weekly skin assessments inconsistently recorded open areas on the left foot or heel, or failed to specify the location. Nursing staff confirmed the wound was only on the right heel, indicating the medical record did not accurately reflect the resident's condition.
A resident admitted for post-surgical care following a left BKA, with a history of atherosclerosis and PVD, did not have a baseline care plan developed to address immediate wound care needs. The resident experienced bleeding through his dressing, which was reported to staff but not promptly addressed, and the medical record lacked documentation of a baseline care plan as required by facility policy.
A facility failed to manage PICC line dressing changes for a resident admitted with orders to change the dressing weekly. Despite repeated concerns from the resident's representative, the dressing was not changed until over three weeks later. The resident was admitted with a PICC line for IV antibiotics to treat abscesses and osteomyelitis. Initial orders required weekly dressing changes, but documentation showed missed changes and no physician notification. Interviews revealed that the order was not rewritten upon admission, leading to the oversight.
The facility failed to ensure a clean and safe environment for residents, with reports of unclean rooms and bathrooms, and cluttered shower rooms. Family members and residents noted inconsistent housekeeping services, and observations confirmed the presence of dirt and debris. Staffing shortages and miscommunication contributed to the failure to maintain cleanliness, despite facility policies outlining daily cleaning requirements.
Failure to Protect Resident Dignity and Document Psychosocial Follow-Up After Unwanted Contact by Bus Driver
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to dignity and to be free from unwanted physical contact during transportation. A cognitively intact resident, admitted with spinal stenosis with fusion of the lumbosacral spine and requiring partial/moderate assistance with transfers and ambulation, reported that a male facility bus driver kissed her on the forehead without her consent while she was being secured on the bus in her wheelchair after an outside wound care appointment. The resident stated she had been upset about having to wait for the bus, and the driver was talking, moving his feet as if dancing, and singing a silly song about getting a kiss to make it better before leaning forward and kissing her on the forehead. She reported that she had not asked to be kissed, that the driver did not apologize, and that she felt the behavior was offensive and uncalled for. The resident’s account was contrasted with the bus driver’s written witness statement, in which he acknowledged asking jokingly if he could kiss her on the forehead and reported that she responded, “I don’t care it don’t matter what you say to me,” after which he proceeded with the kiss. Another witness statement from the former Executive Director documented that the bus driver admitted he had been almost an hour late picking up the resident, tried to smooth things over by saying it would be alright and apologizing, and then “pecked” her on the forehead at some point after they were ready to take off. The resident had already been unhappy about the lateness and had stated she would call the police if it happened again. The resident later reported the incident and indicated it took two days for the Executive Director to get back to her. A second bus driver present during part of the transport reported not witnessing any inappropriate interaction. The facility’s documentation and follow-up related to the resident’s psychosocial status and care planning were incomplete. The admission MDS showed the resident was cognitively intact with no documented behaviors or rejection of care, and she used a manual wheelchair for mobility. A late entry nursing note referenced ongoing wound care appointments, and an event entry in the electronic record directed staff to monitor for psychosocial distress related to complaints during appointment transfers. However, progress notes showed that the Social Service Director saw the resident once for psychosocial follow-up, at which time the resident refused to speak with her and requested to speak only with the Executive Director. There was no further documented psychosocial follow-up beyond that one day. The resident’s record also lacked documentation that her care plan or profile had been updated to reflect that she was upset with the bus driver or that changes to her transportation arrangements had been made. Interviews with the DNS and ADNS confirmed that the resident had unspecified complaints, wanted to speak only with the Executive Director, and had contacted police, but the clinical record did not reflect ongoing psychosocial monitoring or care plan revisions related to the incident.
Narcotic Diversion and Documentation Failures
Penalty
Summary
The facility failed to ensure the protection of narcotic medications from diversion, resulting in 21 missing Oxycodone tablets for a resident with a history of traumatic subdural hemorrhage and chronic obstructive pulmonary disease. A physician's order was in place for Oxycodone 5 mg to be administered as needed for pain. The controlled substance record indicated that a registered nurse signed as having destroyed 21 tablets, but the documentation was incomplete, with a crumpled and partially missing form and no valid witness signature. The nurse later claimed to have destroyed the medication by mistake and stated that a qualified medication aide had witnessed the destruction, but the aide denied any involvement or witnessing of the event. Further investigation revealed that the nurse had removed the Oxycodone card and narcotic sheet from the medication cart and took them to another unit while administering flu shots, rather than following proper procedures for medication destruction. The nurse also took the narcotic sheet home and later provided a photograph of the damaged document. Surveillance footage did not show the nurse interacting with the alleged witness or destroying medications. Additionally, a broader audit uncovered discrepancies involving Oxycodone for at least seven more residents, with approximately 348 tablets unaccounted for and missing medication cards and narcotic sheets for discharged residents. The facility's policy required that all controlled substances be stored, recorded, accounted for, and destroyed according to state regulations, with destruction to be witnessed by appropriate staff. However, the nurse involved failed to adhere to these protocols, falsified records, and misappropriated resident narcotic medications. The incident was reported to the appropriate authorities, and the nurse was suspended and subsequently terminated following the investigation.
Failure to Reconcile and Account for Controlled Substances Resulting in Diversion
Penalty
Summary
The facility failed to maintain an effective system for the reconciliation of controlled medications, resulting in the diversion of at least 369 Oxycodone tablets across all four hallways reviewed. A medication discrepancy was identified with a resident's pain medication, prompting notification of the Executive Director, Director of Nursing Services, physician, Power of Attorney, pharmacy, police, and Adult Protective Services. A registered nurse was suspended and later terminated following the investigation. A pharmacy audit covering a one-month period revealed that 7 out of 14 residents audited did not have the required two nursing signatures on Transfer/Destruction sheets, and 8 out of 14 residents were missing Reconciliation Forms from the narcotic logs. Additional discrepancies were found during a broader audit, with at least 7 more residents affected and approximately 348 Oxycodone tablets unaccounted for. Medication cards and narcotic sheets for discharged residents were also missing. Interviews confirmed that the Regional Director of Clinical Services conducted a narcotic audit specifically for Oxycodone discrepancies, and the findings included missing documentation and unaccounted medication. The facility's policy required shift change verification of controlled substances and proper documentation for destruction, but these procedures were not consistently followed. The lack of adherence to established protocols for storage, documentation, and destruction of controlled substances led to the diversion and unaccounted loss of narcotic medications.
Improper Mechanical Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who required assistance with transfers was not properly transferred using a mechanical lift, resulting in a fall and injury. The resident, who had a history of osteopenia, osteoporosis, paraparesis, monoplegia of the right lower limb, obesity, and was dependent on a wheelchair, required substantial to maximum assistance for bed mobility and transfers. The care plan specified that two staff members should assist with transfers using a stand-up lift. However, on the day of the incident, a newly hired CNA responded alone to the resident's call light and attempted to transfer the resident without a second staff member present. During the transfer, the CNA did not properly secure the torso belt or strap the resident's legs, resulting in the resident slipping within the lift. The CNA, appearing flustered, pressed the wrong control button, causing the lift to lower instead of raising the resident. The resident ended up in a crouched position with her right foot bent at an odd angle and was unable to stand back up. The CNA attempted to move the resident onto the bed but was unsuccessful, and additional staff had to be summoned to assist. The resident was ultimately placed on the floor and subsequently diagnosed with a nondisplaced avulsion fracture at the tip of the distal fibula, as well as new right shoulder pain attributed to the incident. The facility's protocol and the mechanical lift safety policy required two trained staff members for all mechanical lift operations, regardless of the manufacturer's general information, which allowed for one caregiver in some circumstances. The CNA had received orientation and signed acknowledgment of this policy, which also outlined disciplinary actions for non-compliance. Despite this, the transfer was attempted by a single CNA, contrary to both facility policy and the resident's care plan, directly leading to the resident's fall and injury.
Failure to Date and Remove Expired Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to properly date insulin pens, eye drops, and a vial of folic acid when opened, and did not remove expired tuberculin serum and insulin from medication storage areas. Specifically, multiple medication carts and rooms contained insulin pens, a bottle of brimonidine eye drops, and a vial of folic acid that were undated, as well as a vial of tuberculin serum and insulin that were expired but still present in the refrigerator. These findings were confirmed through direct observation and interview with the Director of Nursing, who acknowledged ongoing audits to ensure proper dating of medications. The facility's policy requires medications and biologicals to be dated upon opening and expired items to be removed, but these procedures were not consistently followed.
Failure to Follow Physician Orders for Weights, Wound Care, and Medication Administration
Penalty
Summary
The facility failed to obtain and document resident weights as ordered for two residents. One resident with dementia and a risk for unintentional weight loss had a physician's order for weekly weights, but weights were not obtained on several specified dates. Another resident with diagnoses including CHF and diabetes had a physician's order for daily weights with instructions to notify the physician if there was a significant weight gain. Multiple daily weights were missing from the medication administration record (MAR) over two months, and documentation of refusals was only added after the issue was brought to management's attention. The care plan for this resident was also updated after the deficiency was identified. A newly admitted resident with a recent below-the-knee amputation (BKA) did not have physician's orders in place for wound care upon admission, despite hospital discharge instructions specifying daily dressing changes. The resident and his wife reported ongoing bleeding from the surgical site, and observations confirmed a soiled dressing and blood-stained sheets. No dressing changes or wound treatments were documented over the weekend following admission, and a physician's order for wound care was not entered until several days later. The facility's policy required obtaining and transcribing physician orders upon admission, which was not followed in this case. The facility also failed to follow physician's orders for the application and removal of a transdermal nitroglycerin patch for a resident with Alzheimer's disease, hypertension, and heart failure. The resident was found at the hospital with two nitroglycerin patches, one of which was expired, despite an order specifying the patch should be on for 12 hours during the day and off for 12 hours at night. Documentation did not indicate that the physician was notified of the error, and the resident's care plan lacked person-centered interventions related to heart failure and nitroglycerin use. The facility did not have a specific policy for this medication, but the expectation was to follow physician's orders and update care plans as needed.
Failure to Revise Care Plan for Diabetic Management Refusals
Penalty
Summary
The facility failed to revise the care plan for a resident with diabetes mellitus type II and kidney failure to address her ongoing refusals of medications, insulin, and meals, which are critical components of her diabetic management. Multiple nursing progress notes documented the resident's repeated refusals of evening medications, blood glucose checks, and insulin administration over several months. The interdisciplinary team (IDT) was aware of these refusals and attributed some to the resident's delusions about contracting illness from sharing a room, but the care plan was not updated to reflect these behaviors or to implement new goals and interventions specific to her diabetic management challenges. The resident's care plan, dated several months prior, only addressed her risk for adverse effects of hyperglycemia and hypoglycemia related to her diabetes and use of glucose-lowering medication. Despite ongoing documentation of her refusals and the IDT's awareness of the issue, the care plan lacked any revisions to include her history of refusing medications, insulin, and meals. This omission was identified during a review of her medical record and care plan, as well as through interviews and observations conducted by surveyors.
Medications Left Unattended and at Bedside Without Assessment
Penalty
Summary
Facility staff failed to prevent potential accidents by leaving medications at the bedside of two residents without conducting self-administration assessments. One resident, who had diagnoses including cerebral infarction, type 2 diabetes, difficulty swallowing, hyperlipidemia, and hypertension, was found with a cup containing seven pills on his bedside table. The resident stated that the nurse left the medications for him to take, but he had not yet done so due to an upset stomach. Review of the resident's record confirmed that no self-administration assessment had been completed. In another instance, a rehabilitation resident with a history of malignant neoplasm of the larynx, constipation, and UTI was found with a bottle of Dulcolax in her purse, also without a self-administration assessment on file. Additionally, a registered nurse was observed leaving a cup containing blood pressure medication unattended on top of the medication cart during a medication pass. At the time, two unidentified residents were present in the hallway, creating the potential for unauthorized access to the medication. Facility policy requires that medications not be provided at bedside without a physician's order and approval by the interdisciplinary team and administration, which was not followed in these instances.
Inaccurate Documentation of Pressure Injury Location
Penalty
Summary
The facility failed to ensure accurate documentation of a pressure injury for one resident. The resident, who had diagnoses including Type 2 Diabetes and urinary tract infections, was observed with a pressure-relieving boot on his right heel. Medical records and progress notes consistently indicated the presence of a pressure ulcer on the right heel. However, multiple weekly skin assessments documented open areas on the left foot or left heel, and some assessments did not specify which heel was affected. This inconsistency in documentation was not aligned with the resident's actual condition, as confirmed by both the RN and the DON, who stated that the resident only had a pressure ulcer on the right heel. The inaccurate documentation was identified through review of the resident's medical record and interviews with nursing staff. The facility's policy required accurate and organized documentation of all resident information in the medical record, but this was not followed in the case of this resident. The discrepancies in the skin assessments led to conflicting information about the location of the pressure ulcer, which was not corrected at the time of the survey.
Failure to Develop Baseline Care Plan for New Admission with Surgical Wound
Penalty
Summary
A newly admitted resident with a recent left below-the-knee amputation (BKA) and a history of atherosclerosis and peripheral vascular disease was not provided with a baseline care plan to address his immediate medical needs upon admission. Observations revealed that the resident experienced bleeding through his surgical dressing, which soiled his sheets, and both he and his wife reported the issue to several staff members. Despite these reports, the resident did not receive a dressing change until the bleeding had stopped on its own. A review of the resident's medical record confirmed the absence of a baseline care plan addressing his post-surgical wound care needs. Facility policy requires that an interdisciplinary baseline care plan be developed within 48 hours of admission to address immediate health and safety needs, including physician's orders and resident-centered interventions. The lack of such a care plan for this resident resulted in a failure to promptly address his surgical wound care needs during the critical initial period following admission.
Failure to Manage PICC Line Dressing Changes
Penalty
Summary
The facility failed to manage the PICC line dressing changes for Resident C, who was admitted with orders to change the dressing weekly. Despite these orders, the dressing was not changed until over three weeks later, close to the resident's discharge. The resident's representative repeatedly raised concerns with the Infection Preventionist nurse and floor nurses, even presenting a picture of the dressing coming loose during a care plan meeting. However, the facility did not act on these concerns until much later. Resident C was admitted with a PICC line for IV antibiotics to treat extradural and subdural abscesses, osteomyelitis of the vertebra, and an elevated white blood count. The resident was cognitively intact and able to communicate effectively. The initial physician's orders required the PICC line dressing to be changed every seven days, but documentation showed that the dressing was not changed as scheduled, and there was no notification to the physician about the missed order. Interviews with the Infection Preventionist nurse and the ADNS revealed that the night shift nurses were responsible for changing the dressings, but the order was not rewritten upon admission, leading to the oversight. The facility's policy required PICC line dressings to be changed every seven days or as needed, using sterile technique, and the site to be assessed every eight hours for signs of infection. However, these protocols were not followed, resulting in the deficiency.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the lack of regular cleaning in residents' rooms and bathrooms, as well as the cluttered and unclean state of the shower rooms. Interviews with family members of residents revealed that housekeeping services were not provided consistently, with one family member noting that a grievance had been filed due to the unclean conditions. Observations confirmed that rooms and bathrooms were not cleaned routinely, with dirt, dust, and debris present, and toilets left uncleaned. The Executive Director was observed mopping a hallway due to a staff shortage, indicating that the facility was understaffed in housekeeping. The Housekeeping Supervisor confirmed that there was no set schedule for cleaning, and staffing issues had led to rooms being missed for cleaning. During an environmental tour, multiple shower rooms were found to be cluttered with equipment and soiled items, with floors left dirty and uncleaned. The Housekeeping Supervisor acknowledged the lack of a deep cleaning schedule and the failure to maintain cleanliness in these areas. Residents expressed concerns about the cleanliness of the shower rooms, with one resident avoiding the use of the shower rooms due to their unclean state and the risk of infection. The facility's policy outlined daily cleaning requirements, but these were not being met, as evidenced by the observations and interviews conducted. The lack of adequate housekeeping staff and miscommunication among staff contributed to the failure to maintain a clean and safe environment for the residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brownsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brownsburg Health Care Center | 1.1 mi | ★★★★★ | 42 | 1 |
| Brooke Knoll Village | 4.8 mi | ★★★★★ | 10 | 0 |
| Wellbrooke Of Avon | 5.3 mi | ★★★★★ | 5 | 0 |
| Eagle Valley Meadows | 5.6 mi | ★★★★★ | 3 | 0 |
| Majestic Care Of Avon | 5.8 mi | ★★★★★ | 18 | 0 |
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