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
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)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Brownsburg Meadows
2 E Tilden Brownsburg, IN 46112
SUMMARY STATEMENT OF DEFICIENCIES
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.