Brownsburg Health Care Center: Fall Care Failures - IN
They didn't hear anything overnight.
When they arrived at the facility the next morning, at 7:30 a.m., they found the resident lying in bed in significant pain. The x-ray company hadn't come yet. The only pain medication available was acetaminophen. The resident had already been assessed at a pain level of 4 out of 10 during the night shift, but the medication administration record showed no pain medication was given between 6:59 p.m. on April 17 and 8:45 a.m. on April 18, nearly fourteen hours.
The family asked for something stronger. Arrangements were made to send the resident to the hospital instead.
The hospital's history and physical, dated April 18, confirmed what the family had suspected through the night: a hip fracture. A physician discussed the risks and benefits of surgery. The family chose comfort care. Two days later, the resident's power of attorney called the facility to say the resident was being transferred to a hospice facility.
Federal inspectors, conducting a complaint investigation on May 27, documented the sequence of events and found the facility had failed to respond to the fall the way its own nurses said it should have been handled.
Licensed Practical Nurse 13 told inspectors that when a resident falls, the nurse assesses the resident while they are still on the floor. If the resident is guarding, not extending the leg, and reporting pain — signs consistent with a possible hip fracture — the resident should not be moved. They should be sent to the hospital immediately. The LPN said an intervention to prevent further falls should have been put in place right away as well.
The facility's own corporate consultant, a registered nurse, said the same thing when inspectors interviewed her that morning. If a resident fell and was guarding or not extending their leg and complaining of pain, she said, they should not have been moved from the floor and should have been sent out to the hospital.
The inspection report does not say who made the decision to move the resident. It does not say whether anyone assessed the resident for signs of guarding or leg extension before they were lifted. What it says is that the resident was found in bed the next morning, in significant pain, waiting for an x-ray company that had not yet arrived.
The same corporate consultant told inspectors she had also reviewed the resident's orthostatic blood pressure documentation and found problems there too. A single number had been recorded on the treatment administration record, rather than a full blood pressure reading. She said she wasn't sure why. She also said she could find no documentation that the nurse practitioner had been notified about the orthostatic blood pressure readings. When she spoke with the nurse practitioner directly, the NP said she didn't remember the resident specifically, and that issues like that were normally reviewed at the next scheduled visit.
The Executive Director provided inspectors with a copy of the facility's Fall Evaluation and Prevention policy, last revised in August 2020. The policy states that the facility will evaluate residents for fall risk and develop prevention interventions. It also states that residents should not be moved until a licensed nurse has evaluated their condition.
What the policy describes and what happened to this resident in the hours after April 17 are not the same thing.
The family had chosen this facility to care for their relative. They trusted a phone call in the middle of the night to tell them what they needed to know. They waited until morning, drove to the building, and found someone they loved lying in pain in a bed, waiting for an x-ray machine that wasn't there yet, with nothing stronger than acetaminophen on hand.
They made the arrangements themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brownsburg Health Care Center from 2026-05-27 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: August 12, 2026 · Our methodology
BROWNSBURG HEALTH CARE CENTER in BROWNSBURG, IN was cited for violations during a health inspection on May 27, 2026.
They didn't hear anything overnight.
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.