Brownsburg Meadows: 369 Oxycodone Tablets Missing - IN
The diversion came to light on September 19, when the facility filed an incident report documenting a medication discrepancy tied to one resident's pain medication. By the end of the day, the executive director, director of nursing, the resident's physician, their power of attorney, the pharmacy, police, and Adult Protective Services had all been notified. A consumer complaint was filed. A registered nurse identified in the report as RN 6 was suspended and later terminated.
That was only the beginning of what the audit would find.
A pharmacy audit covering August 22 through September 22 reviewed narcotic records for 14 residents. Seven of those 14 were missing the required two nursing signatures on their transfer and destruction sheets. Eight were missing reconciliation forms from their narcotic logs altogether. The facility's assistant director of nursing services told inspectors that a regional director of clinical services then conducted a broader audit, pulling oxycodone records from July 1 through September 23. That audit turned up at least seven more residents with discrepancies beyond the one that triggered the original report, and approximately 348 additional tablets that couldn't be accounted for.
Combined with the initial incident, the total reached at least 369 tablets. The exact count of missing oxycodone and the complete list of affected residents were never provided to inspectors during the survey.
The gaps in the record-keeping were systematic. Medication cards and narcotic sheets for residents who had already been discharged were missing. Across all four hallways reviewed, 100, 200, 300, and 400, inspectors found evidence of diversion. A plan of action document dated September 26 described what had happened as "alleged diversion of narcotics by a licensed nurse."
Oxycodone is a Schedule II controlled substance, meaning it carries a high potential for abuse and dependence. In a nursing home setting, it is typically prescribed for residents managing serious or chronic pain. When tablets go missing, residents may receive less medication than prescribed, or none at all, without anyone flagging the gap.
The facility's own controlled substances policy, revised in October 2025 and provided to inspectors the day of the survey, described a system that should have caught this far sooner. Shift-change counts were supposed to be conducted at every medication cart, with both the outgoing and incoming nurse or medication aide signing off that the count matched and no discrepancies existed. When a physician discontinued a controlled substance, unused medication was supposed to be destroyed by the director of nursing or assistant director, witnessed by a second licensed staff member, documented in the resident's controlled substance record, and scanned into the electronic medical record. None of that process held.
The facility moved quickly once the discrepancy was discovered. By September 29, three days after the plan of action was written and more than two weeks before inspectors arrived, the facility reported it had corrected the deficiency. Because the correction was in place before the October 16 inspection began, CMS classified the violation as past noncompliance.
The remediation plan was extensive. A full audit of narcotic count sheets for every resident with routine or as-needed narcotic prescriptions was ordered, cross-referenced against pharmacy delivery records. Nurses were retrained on destruction procedures and accurate counting. A new form was created to document when narcotic cards were added or removed. The director of nursing or assistant director was required to be present for all future narcotic destructions. Audits were scheduled five times a week for eight weeks, then three times a week for four weeks, then weekly for four weeks, with monthly spot checks for six months after that, and results reported to quality assurance meetings overseen by the executive director.
CMS rated the level of harm as minimal harm or potential for actual harm, the lower end of the harm scale. That rating reflects the regulatory classification, not necessarily what residents experienced during the months when their oxycodone records were incomplete and their tablets were unaccounted for. The inspection report does not say whether any resident reported undertreated pain during that period. It does not say whether anyone asked.
The list of residents whose medications were affected, and exactly how many tablets each was shorted, was not in the record inspectors reviewed. That information was not provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brownsburg Meadows from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
BROWNSBURG MEADOWS in BROWNSBURG, IN was cited for violations during a health inspection on October 16, 2025.
A consumer complaint was filed.
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.