Brownsburg Health Care Center
BROWNSBURG HEALTH CARE CENTER in BROWNSBURG, IN — inspection on May 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview, on 5/27/26 at 11:21 a.m., the Corporate MDS Coordinator indicated she reviewed the discharge MDS assessment, dated 4/18/26, and indicated the resident's falls were not coded on the assessment.
The falls should have been included on the MDS assessment.
The facility used the
the facility policy for MDS assessment accuracy.
The CMS MDS RAI manual, version 3.0, dated October 2025, indicated, J1900: Number of Falls Since.Prior Assessment.Coding Instructions for J1900: Determine the number of falls that occurred since.prior assessment.and code the level of fall-related injury for each.
Code each fall only once.
This citation relates to Intake 3002927. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(1) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155206 05/27/2026
Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112
During an interview, on 5/27/26 at 10:03 a.m., Licensed Practical Nurse (LPN) 13 indicated an intervention should have been put in place immediately to prevent further falls.
When a resident fell, the nurse assessed the resident while they were still on the floor. If there was a potential hip fracture, such as guarding or not extending the leg, and pain, the resident should not have been moved off the floor and should have been sent to the hospital immediately.
During an interview, on 5/27/26 at 10:35 a.m., the Registered Nurse (RN) Corporate Consultant indicated if a resident fell and was guarding or not extending their leg and complaining of pain, then they should not have been moved from the floor and been sent out to the hospital.
During an interview, on 5/27/26 at 2:18 p.m., the Registered Nurse (RN) Corporate Consultant indicated she reviewed the resident's orthostatic blood pressure documentation.
She was not sure why a single number was all that was documented on the TAR instead of the full blood pressure.
During an interview, on 5/27/26 at 2:40 p.m., the RN Corporate Consultant indicated she was not able to find documentation the NP was notified regarding the orthostatic blood pressures.
The RN Corporate Consultant indicated she talked to the NP, and the NP had not remembered regarding Resident K specifically, but things like that were normally reviewed at the next NP visit. On 5/27/26 at 12:23 p.m., the Executive Director (ED) provided a document titled, Fall Evaluation and Prevention, last revised August 2020, and indicated it was the policy currently being used by the facility.
The policy indicated, .Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention.The IDT team will review the plan of care and update the interventions as appropriate.
The policy also indicated, .Procedure.Evaluate the resident promptly in order to identify and treat injuries.
The resident should not be moved until the licensed nurse has evaluated their condition.
This citation relates to Intake 3002927. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)
155206 05/27/2026
Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112
way that maximizes each resident's well being.
sufficient staff to administer medications and insulin timely to residents as ordered for 5 of 5
include:On 5/26/26 at 7:08 p.m., Registered Nurse (RN) 6 was observed at the medication cart. He indicated he was passing medications.
The electronic medication administration record was on the computer screen for Resident B. He had medications hi-lighted in red indicating they were overdue. RN 6 prepped Resident B's medications and administered them to the resident at 7:22 p.m. RN 6 indicated he had two new admissions and was running behind.
When asked if other nursing staff helped him so he wouldn't be late, he indicated he had assistance available. On 5/26/26 at 7:28 p.m., RN 6 indicated he needed to check Resident C's blood sugar that was due at 5:00 p.m. He took out the monitor and checked Resident C's blood sugar. It was 459, outside of his ordered parameters.
Per his sliding scale orders, it indicated to notify the physician if blood sugar was greater than 400. RN 6 left the cart to notify the Nurse Practitioner (NP) due to the high blood sugar.
The NP ordered 12 units of lispro insulin, and the insulin was administered as ordered. RN 6 indicated he would redo his blood sugar at 9:00 p.m. as ordered and administer the ordered amount of insulin required. On 5/26/26 at 7:45 p.m.
RN 6 administered routine ordered morphine to Resident E. He did not sign the morphine out after administering the medication. On 5/26/26 at 7:55 p.m., RN 6 prepped Resident D's medications. He indicated that morphine was out of stock due to using on another resident earlier in the day. He prepped the resident's lorazepam. He did not prep the omeprazole that was ordered. He crushed the lorazepam (an antianxiety) tablet and administered it to the resident. He did not sign the lorazepam out after administering it. On 5/26/26 at 8:10 p.m., The Director of Nursing (DON) indicated she would call the NP to make her aware of RN 6 administering late medications due to admitting new residents.
On 5/26/26 at 8:12 p.m., Resident D was yelling out. He had new orders for morphine but there was none available to administer to him.
The DON indicated she would call the NP and get a one-time order for oxycodone (a pain medication) for Resident D. On 5/26/26 at 8:15 p.m., the DON walked by the cart with a pill cup and indicated it was oxycodone for Resident D. On 5/26/26 at 8:16 p.m., RN 6 was prepping Resident F's medications.
Resident F needed his blood sugar checked at 5:00 p.m. RN 6 checked Resident F's blood sugar and it was 177. He prepared his medications metformin (for blood sugar), atorvastatin (for high cholesterol), and apixaban (a blood thinner) and administered the medications.
His ordered insulin Lispro 5 units was not administered as ordered for 5:00 p.m. RN 6 indicated he would talk to the NP about the blood sugar as it was due to be checked again at 9:00 p.m.
On 5/27/26 at 11:12 a.m., the Resident's records were reviewed.
The records did not contain orders or notes for Resident C, D or F medications being administered late or omitted.
Resident D's record lacked an order for the one-time oxycodone that was administered. On 5/27/26 at 2:13 p.m., the DON indicated she would go back and put orders in for the residents. A policy titled, Medication Administration and General Guidelines was provided by the DON on 5/27/26 at 2:41 p.m. It indicated, .Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise).
Before or after meals orders are administered precisely as ordered.
Unless other specified by the physician, routine medications are administered according to the established medication administration schedule for the facility.
This citation relates to Intake
- 410 IAC (Indiana Administrative Code) 16.2-3.1-14(i)
155206 05/27/2026
Brownsburg Health Care Center 1010 Hornaday Rd Brownsburg, IN 46112
include:On 5/26/26 at 7:45 p.m., RN 6 had just finished checking Resident B's blood sugar. He brought
strip insertion area for a couple of seconds.
Then he left the monitor sitting on the medication cart and continued passing medications to the resident.When asked about cleaning procedures, RN 6 indicated he was out of the wipes they usually used to clean the machine.On 5/26/26 at 8:10 p.m., the Director of Nursing (DON) arrived and provided a tub of purple top wipes to cleanse the glucometer machine with. RN 6 placed the wipes in the bottom drawer of the medication cart.On 5/26/26 at 8:15 p.m., RN 6 went to Resident G to check his blood sugar without cleaning the monitor with the purple top wipes. RN 6 returned to the medication cart after checking Resident 6's blood sugar and pulled out the tub of wipes. He pulled out a wipe and rubbed it with an ungloved hand onto the glucometer monitor for approximately 20 seconds, then placed the wipe in the trash and left the monitor on top of the medication cart.Per the manufacturer of the Even Care glucometer machine, Medline, they recommend cleaning and disinfecting using a EPA-registered (U.S.
Environmental Protection Agency) disinfecting wipes.
The purple top wipes were PDI wipes (Professional Disposables International).
The tub contained directions indicating .Contact Time: Allow surface to remain wet for 1 full minute.A policy titled Blood Glucose Monitoring was provided by the DON on 5/27/26 at 2:41 p.m. It indicated, .If the blood glucose monitor is multi-patient use: A. clean and disinfect the blood glucose machine according to manufacturer's directions with an appropriate cleaning product.
The disinfection solvent should be effective against HIV (Human Immunodeficiency Virus), Hepatitis C, and Hepatitis B virus.
Note that 70% of ethanol solutions are not effective against viral blood borne pathogens. B. If the manufacturer of the device in use does not specify how the device should be cleaned and disinfected, then it should not be shared or reused with a different resident. C. [NAME] gloves prior to cleaning the blood glucose monitor. D.
Following the cleaning, remove gloves and wash hands.This citation relates to Intake 3002927.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.