Brownsburg Meadows
BROWNSBURG MEADOWS in BROWNSBURG, IN — inspection on October 16, 2025.
Found 2 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
indicated the Regional Director of Clinical Services conducted a narcotic audit, specifically looking for
348 tablets unaccounted for.
The medication cards and narcotic sheets for discharged residents were
Documentation, Inventory and Destruction policy, revised 10/25, and indicated the policy was the one currently being used by the facility.
The policy indicated, Purpose of the Policy: To prevent diversion, improper use and accidents related to controlled substances.
Policy: It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.When the resident's physician discontinues a controlled substance, all unused medication will be destroyed by the Director of Nursing or ADNS and a witnessing licensed nurse or QMA.This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance.
The facility implemented a systemic plan that included monitoring delivery, storage and counting of narcotic medications, staff education regarding accurate narcotic counts and policy and procedures for medication destruction, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI).
This citation relates to Intake 2623477.3.1-28(e)(3)3.1-28(o)
155761 10/16/2025
Brownsburg Meadows 2 E Tilden Brownsburg, IN 46112
During an interview on 10/16/25 at 2:05 p.m., the ADNS indicated, the Regional Director of Clinical Services conducted a narcotic audit, specifically looking for discrepancies of Oxycodone, with a date range of 7/1/25 - 9/23/25.
Upon conclusion of the audit, there were at least 7 additional residents found with discrepancies regarding their Oxycodone and around 348 tablets unaccounted for.
The medication cards and narcotic sheets for discharged residents were missing. A list of the additional resident found with discrepancies and the exact count of Oxycodone tablets missing was not provided during the survey process. A Plan of Action document, dated 9/26/25, indicated there had been alleged diversion of narcotics by a licensed nurse.
The goal was to have no diversion of medications.
Preventative actions included a 100% audit of narcotic count sheets for all residents with routine and PRN narcotic medications.
Nurses were re-educated on medication destruction policy/procedure along with accurate counts for narcotics. A new form was initiated for adding/removal of narcotic cards.
The DNS or ADNS was to be involved in all narcotic destruction.
Preventative actions included audit of narcotic count sheets for all resident with routine and PRN narcotic medications utilizing pharmacy delivery manifests to be completed upon the following schedule: 5 times/week for 8 weeks, 3 times/week for 4 weeks, and weekly for 4 weeks.
Spot audits were to be completed monthly x 6 months and PRN thereafter, with results presented in QAPI meetings overseen by the Executive Director.On 10/16/25 at 4:15 p.m., the ADNS provided a Controlled Substances: Storage, Documentation, Inventory and Destruction policy, revised 10/25, and indicated the policy was the one currently being used by the facility.
The policy indicated, It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.1.
Facility will utilize the Shift Change Verification of Controlled Substances form to count all controlled substances for each medication cart in the facility. 2.
The incoming nurse or QMA will count all controlled substances being stored at the facility while the outgoing nurse or QMA watches the process.
Both staff members sign that the count sheets and verification have been completed with no discrepancies.Destruction: 1.
When the resident's physician discontinues a controlled substance, all unused medication will be destroyed by the Director of Nursing or ADNS and a witnessing licensed nurse or QMA. a.
Destruction will be documented on the residents' Controlled Substance Record. b.
Copies of the records will be scanned into the resident's EMR [electronic medical record] .
This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance.
The facility implemented a systemic plan that included monitoring delivery, storage and counting of narcotic medications, staff education regarding accurate narcotic counts and policy and procedures for medication destruction, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI).Cross reference F-F602.
This citation relates to Intake 2623477.3.1-25(e)(2)3.1-25(e)(3) 3.1-25(s)
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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.