Brownsburg Health Care Center: Falls Miscoded After Fracture - IN
That is what inspectors found when they reviewed records at Brownsburg Health Care Center this spring.
The resident, identified in inspection records only as Resident K, had a quarterly assessment completed on March 2, 2026. Nine days later, on March 11, she fell in the dining room and hit her head. The fall was witnessed. Progress notes from that day show she had a laceration on her forehead and the back of her head. She was sent to the hospital and came back with three sutures on the left side of her forehead.
She fell again on March 30, in the bathroom. A bruise on her forehead.
On April 17, she stood up from the dining room table, tripped, and went down on her right side. Staff noted no visible injury at first, but the resident was guarding her right leg and would not straighten it. The next day, April 18, her power of attorney requested she be sent to the hospital because of the fall. An x-ray taken that day showed a fracture of the right femur, the thighbone.
Also on April 18, the facility completed a discharge assessment, the official clinical document that would follow Resident K out of the building and into whatever came next. Under the section that asks how many falls a resident has had since the prior assessment, the answer recorded was none.
Three falls. Three sutures. One fractured femur. Zero falls documented.
The corporate MDS coordinator, interviewed by inspectors on May 27 at 11:21 in the morning, confirmed what the records showed. She had reviewed the discharge assessment herself. The falls had not been coded. They should have been, she said.
The MDS, or Minimum Data Set, is the standardized clinical assessment that Medicare and Medicaid use to track resident health and safety across nursing homes nationwide. The falls section exists precisely to capture what happened to a resident between one assessment and the next. A fracture from a fall is among the most serious outcomes the form is designed to record.
When a resident leaves a facility, that discharge assessment travels with them. It informs whoever receives them, whether a hospital, a rehabilitation center, or a family, about what the person's recent history looks like. A discharge record showing no falls for a resident who just fractured her femur in a fall is not a paperwork technicality. It is a gap in the clinical picture that follows the patient.
Inspectors cited the deficiency as causing minimal harm or the potential for actual harm, the lower end of the federal harm scale. The finding covered one of three residents whose fall documentation was reviewed during the complaint inspection, which was completed May 27, 2026.
The facility's own policy on MDS accuracy points to the federal assessment manual published by the Centers for Medicare and Medicaid Services. That manual, updated in October 2025, instructs facilities to count every fall since the prior assessment and to code the level of injury for each one. The discharge assessment for Resident K did neither.
What Resident K's record does not show is whether anyone caught the omission before inspectors arrived. The corporate coordinator acknowledged it only after the review was already underway.
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 13, 2026 · Our methodology
BROWNSBURG HEALTH CARE CENTER in BROWNSBURG, IN was cited for violations during a health inspection on May 27, 2026.
That is what inspectors found when they reviewed records at Brownsburg Health Care Center this spring.
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.