BROWNSBURG, IN - A state inspection at Brownsburg Health Care Center revealed systematic staffing deficiencies that left residents waiting hours for basic care, including meals, medication administration, and assistance with personal hygiene needs.
Chronic Understaffing Creates Care Delays
Inspectors documented multiple instances where certified nursing assistants (CNAs) were absent from their assigned units, leaving remaining staff responsible for up to 30 residents simultaneously. On April 27, 2025, the scheduled CNA for the 300 and 400 hallways failed to report for duty, and breakfast trays sat undelivered until approximately 9:00 a.m.—an hour past the facility's posted breakfast service time of 8:00 a.m.
One resident reported lying in a urine-soaked brief for hours while waiting for staff assistance. When inspectors observed this resident at 9:41 a.m., he was still in bed, his breakfast untouched and cold, with unidentified pills sitting on his bedside table. The resident stated he should have been bathed, dressed, and out of bed by 8:00 a.m. He characterized weekend staffing as "pure hell."
Another resident waited from before 9:36 a.m. until after noon for a brief change, repeatedly requesting assistance from CNAs who never returned. When a qualified medication aide checked on him after noon, she confirmed his brief was soiled and expressed uncertainty about why he had not received care.
Facility Assessment Standards Not Met
The facility's own February 2025 assessment established staffing ratios of one CNA per 15 residents and outlined specific targets: seven CNAs for day shift, six for evening shift, and five for night shift. However, staffing records revealed significant gaps in meeting these self-imposed standards.
During February 2025, the facility failed to meet the seven-CNA day shift target on 22 of 28 days. Night shift fell short of the five-CNA requirement on 16 of 28 days. Similar patterns continued through March and April 2025.
When a CNA position went unfilled on the morning of April 27, staff reallocated a newly hired CNA with approximately three weeks of facility experience from the 700 and 800 hallways to cover the 300 and 400 hallways—units where she had never previously worked. This reassignment left only two CNAs responsible for 30 residents on the 700 and 800 hallways, including 15 residents who required mechanical lifts for transfers and six who needed feeding assistance.
Medical Consequences of Delayed Care
Prolonged exposure to urine-soaked briefs creates serious health risks. The moisture and bacteria present in urine break down skin integrity, leading to painful skin breakdown, pressure injuries, and increased infection risk. For elderly residents with compromised immune systems or diabetes, these conditions can progress rapidly to severe complications requiring hospitalization.
Delayed medication administration poses equally serious concerns. Medications are prescribed with specific timing requirements based on pharmacokinetic principles—how drugs are absorbed, distributed, metabolized, and eliminated. Missing scheduled doses or significant timing delays can result in inadequate therapeutic levels, breakthrough symptoms, or dangerous fluctuations in conditions like diabetes or heart disease.
Respiratory medications require particular attention to timing. One resident with congestion and breathing difficulties reported searching for a nurse at 9:25 a.m. to start her nebulizer treatment. When inspectors returned at 1:58 p.m., the nebulizer still contained liquid medication in the chamber, suggesting the treatment had not been administered. For residents with chronic obstructive pulmonary disease or asthma, delayed bronchodilator treatments can lead to respiratory distress, decreased oxygen saturation, and potential emergency situations.
Systemic Breakfast Service Failures
Inspectors observed a pattern where residents remained in bed well past breakfast service times, resulting in cold, untouched meals. The facility's posted breakfast hours were 7:30-8:30 a.m., yet multiple residents reported receiving breakfast after 10:00 a.m. or not at all.
One resident sitting in a wheelchair at 9:45 a.m. had not yet received breakfast, despite the tray sitting on a dresser out of reach. Another resident, finally assisted out of bed around 10:36 a.m., pointed to his cold breakfast and requested that at least his water be heated for hot chocolate, commenting that by the time he got out of bed "soaking wet," his breakfast was always cold.
During continuous observation from 10:42-11:03 a.m., inspectors found 13 of 25 residents on one hallway still in bed, with no CNAs or nurses visible. At 11:08-11:36 a.m. on the 700 and 800 hallways, only 4 of 30 residents were out of bed as lunch service approached.
The dietary manager confirmed staggered meal service times across different hallways, with some residents not receiving lunch until 12:45 p.m. On optimal days, only 15 residents ate in the dining room; most received trays in their rooms.
Additional Issues Identified
Inspectors documented medications left unattended at residents' bedsides rather than properly administered and documented. Nebulizer equipment was found unbagged and sitting on bare mattresses or bedding, creating contamination risks. Oxygen tubing was discovered tucked inside a resident's brief, requiring the resident to remove her brief to extract it. CNAs reported working entire shifts without breaks or meals when staffing fell short. The administrator acknowledged unfamiliarity with calculating hours per resident day (HPRD), a fundamental staffing metric.
The facility's staffing policy, dated October 2011, stated the facility would "employ sufficient nursing staff on a 24-hour basis" to meet resident needs based on assessments. However, implementation appeared inconsistent with these written standards, as evidenced by the recurring staffing shortfalls documented across multiple months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brownsburg Health Care Center from 2025-04-30 including all violations, facility responses, and corrective action plans.
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