Brownsburg Meadows: Lift Transfer Fractures Resident's Ankle - IN
She had been.
The inspection, completed September 4, 2025, was triggered by complaints and resulted in a citation for actual harm. The resident, identified in the report as Resident D, was transferred using a stand-up mechanical lift by a single staff member, despite Brownsburg Meadows having its own protocol requiring two staff members for mechanical lift transfers.
The safety belt slipped during the transfer. Resident D was suspended by the belt and straps under her arms. A physician later told her she had potentially damaged her rotator cuff from being suspended that way, and he ordered occupational therapy for her shoulder.
That was not the only injury.
A representative from an orthopedic physician's office told inspectors on the afternoon of September 4 that Resident D had been seen by the orthopedic physician the day before. The diagnosis: a newly acquired acute avulsion fracture at the tip of the distal fibula. An avulsion fracture occurs when a ligament or tendon pulls away from the bone with enough force to break off a piece of it. The fracture was nondisplaced, meaning the bone fragment had not shifted out of position, but it was new. X-rays also showed a prior healed fracture in the same area, a separate, older injury.
A physical therapy evaluation had been ordered to assess Resident D's legs, specifically to help her retain the ability to stand and bear weight on her left leg.
The Director of Nursing Services saw it differently. During an interview at 11:00 a.m. on September 4, she told inspectors that in her opinion, Resident D had not been injured with a mechanical lift or during the lift process. Her account was that the resident had already been standing when the safety belt slipped, and that she had complained of foot pain.
Foot pain. Not a fracture. Not a rotator cuff injury. Not a resident suspended mid-air by straps.
The nursing director provided inspectors with a printout of the manufacturer's general information for the stand-up lift. It was undated. The document stated the lift could be used safely with one caregiver, though it also noted that certain circumstances, including patient obesity, might require two people. It placed responsibility on each facility to determine whether one or two staff members were appropriate based on the task, the patient, the environment, and the skill level of the aide performing the transfer.
Brownsburg Meadows had already made that determination. Its own protocol called for two staff members. One showed up.
The assistant director of nursing provided a Fall Management Policy dated June 2025, describing it as the policy currently in use. The policy defined a fall as unintentionally coming to rest on the ground, floor, or other lower level, and outlined requirements for fall risk care plans and communication to caregivers.
What the policy did not prevent was a resident being lifted by a single aide, slipping from the belt, and ending up with a fractured ankle and a suspected rotator cuff tear.
Resident D, following the incident, faced both occupational therapy for her shoulder and physical therapy aimed at preserving her ability to stand and bear weight on her left leg. That ability, the inspection record suggests, was not guaranteed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brownsburg Meadows from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
BROWNSBURG MEADOWS in BROWNSBURG, IN was cited for violations during a health inspection on September 4, 2025.
The inspection, completed September 4, 2025, was triggered by complaints and resulted in a citation for actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.