Brownsburg Health Care Center: Medication Delays, Missing Records - IN
At that level, the standing orders were clear: notify the physician if blood sugar exceeded 400. The nurse left the medication cart to reach the nurse practitioner, who ordered 12 units of insulin. The insulin was given. But the delay, and the dangerously elevated reading, would not appear anywhere in the resident's records the next morning.
Inspectors from the Centers for Medicare and Medicaid Services visited Brownsburg Health Care Center on May 27, 2026, following a complaint. What they documented the evening before was a single registered nurse, identified in the report as RN 6, running a medication pass that had fallen apart.
At 7:08 p.m., RN 6 was at the medication cart. The electronic medication record on his screen showed medications for one resident highlighted in red, the system's signal that they were overdue. He administered those medications at 7:22 p.m. He told the inspector he had two new admissions that evening and was running behind. He acknowledged that assistance had been available to him.
The blood sugar check for the diabetic resident, Resident C, had been due more than two hours earlier.
A second diabetic resident, Resident F, also had a blood sugar check scheduled for 5:00 p.m. RN 6 got to him at 8:16 p.m. The reading was 177. RN 6 prepared several of the resident's medications and gave them. The ordered insulin, five units of lispro, was not administered. RN 6 told the inspector he would speak to the nurse practitioner about it since another blood sugar check was coming at 9:00 p.m.
The insulin was simply not given.
At 7:55 p.m., RN 6 was preparing medications for Resident D when he discovered the morphine was out of stock. It had been used on another resident earlier in the day. He prepared the resident's lorazepam instead, crushed the tablet, and administered it. He did not sign the lorazepam out after giving it. He did not prepare the omeprazole that was also ordered. The morphine went unaddressed.
Seventeen minutes later, Resident D was yelling out. He had new orders for morphine, and there was none available to give him.
The Director of Nursing walked past the cart at 8:15 p.m. carrying a pill cup. She said it was oxycodone for Resident D, obtained through a one-time order from the nurse practitioner. The resident received it. But when inspectors reviewed the records the next morning, there was no order documented for that oxycodone. The medication had been administered without a written order in the chart.
RN 6 had also given morphine to a fifth resident, Resident E, at 7:45 p.m. He did not sign it out after administering it.
The Director of Nursing told inspectors at 8:10 p.m. that she would call the nurse practitioner to make her aware of the late medications. She attributed the delays to RN 6 admitting new residents that evening.
When inspectors reviewed the records the following morning, they found no documentation, no orders, no notes, for the late or omitted medications affecting Residents C, D, or F. The missing oxycodone order for Resident D was not there. The Director of Nursing, told of these gaps at 2:13 p.m. on May 27, said she would go back and enter the orders.
The facility provided inspectors with its own medication administration policy, which states that medications are to be given within one hour of the scheduled time. For medications with a physician-specified time, the window narrows to thirty minutes before or after.
Resident C's blood sugar had gone unchecked for more than two hours past its scheduled time, reaching 459 before anyone looked. Resident F never received his insulin. Resident D was yelling in pain in his room while the nurse at the cart had nothing to give him.
Inspectors cited the facility for failing to maintain competent and sufficient staff to administer medications and insulin in a timely manner as ordered. The deficiency covered all five residents observed during the single medication pass.
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.
At that level, the standing orders were clear: notify the physician if blood sugar exceeded 400.
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.