Brownsburg Meadows
Inspection Findings
F-Tag F0602
F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
signature section where the QMA's signature would have been. The DNS called QMA 8 who indicated she had seen RN 6 administer a few flu vaccines and leave the unit, but RN 6 had not requested her keys to access the medication room where the drug buster was stored and had not asked her to witness a drug destruction. QMA 8 indicated she had not signed as having witnessed Resident B's medication being destroyed. The DNS indicated RN 6 had been observed on camera while in the facility but was not observed interacting with QMA 8 or seen destroying medications. The DNS indicated RN 6 did not explain why she had taken the card of Oxycodone from the 200 hallway to destroy versus having RN 7 who was working on the 200 hallway witness the destruction. 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 more residents found with discrepancies regarding their Oxycodone and around 348 tablets unaccounted for. The medication cards and narcotic sheets for discharged residents were missing. 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, 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)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brownsburg Meadows
2 E Tilden Brownsburg, IN 46112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
Federal health inspectors cited BROWNSBURG MEADOWS in BROWNSBURG, IN for a deficiency under regulatory tag F-F0755 during a complaint investigation conducted on 2025-10-16.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of BROWNSBURG MEADOWS.
Correction Status: Past Non-Compliance.
BROWNSBURG MEADOWS in BROWNSBURG, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BROWNSBURG, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROWNSBURG MEADOWS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.