Brownsburg Health Care Center

In the surveyor’s words

From the most serious findings on record at Brownsburg Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 13, 2026

  Based on observations, interviews, and record reviews, the facility failed to prevent physical abuse between two dementia residents resulting in Resident D obtaining a laceration to the upper lip, nasal fracture, fractures to the 6th, 7th, and 8th ribs, and subsequent change in condition related to weakness from her hospitalization where she is no longer able to walk independently and requires staff assistance to be transported in a wheelchair (Residents D and E) for 1 of 6 residents reviewed for abuse. […]

• Actual harm, isolatedF697Jun 30, 2021

  Based on observation, interview, and record review, the facility failed ensure residents were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. On 6/29/21 at 10:30 a.m., the medical record was reviewed for Resident B. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) annual assessment, dated 4/16/21, indicated Resident B had a Brief Interview for Mental Status (BIM) score of 4 out of 15, which indicated severe cognitive impairment. Resident B had resided on the Memory Care. A Fall Risk Screen, dated 3/1/21, indicated Resident B scored 10, with a score of 10 or greater considered high risk for falls. A care plan, revised on 5/7/21, indicated Resident B was a high risk for falls. […]

• No harm, potential for more than minimal, widespreadF725Jan 13, 2026

  Based on observation, interview, and record reviews, the facility failed to provide RN coverage per the facility assessment, failed to ensure adequate staffing on the memory care (dementia) unit, and failed to ensure adequate staffing to answer call lights and provide showers. This deficient practice had the potential to affect 78 of 78 residents residing in the facility. Findings include:1. Upon the survey entrance on 1/5/26 at 10:00 a.m., the Executive Director (ED) provided a copy of the Facility Assessment. Per the assessment, the facility required a minimum PPD (how many hours are spent with a patient per day) for Registered Nurses (RN) of 0.54 hours daily. A copy of the schedules requested were provided by the Executive Director (ED) on 1/5/26 at 10:33 a.m. […]

• No harm, potential for more than minimal, widespreadF867Jan 13, 2026

  Based on interview and record review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic quality and safety issues. This failure resulted in the facility's inability to prevent recurrence of known problems and contributed to harm-level and Immediate Jeopardy deficiencies. This deficient practice had the potential to affect 78 of 78 residents who resided in the facility. Findings include:During interview on 1/12/26 at 11:21 a.m., the Regional Director of Operation (RDO) and the Regional Nurse Consultant, (RNC) indicated the faculty had failed to effectively incorporate a QAPI program to help mitigate deficiencies that were identified during the survey period. […]

• No harm, potential for more than minimal, widespreadF851Sep 15, 2023

  Based on interview and record review, the facility failed to ensure mandatory staffing information for the payroll-based journal (PBJ) was submitted by the required deadline for 1 of 1 quarters reviewed for PBJ submission. Findings include: The facilities Certification and Survey Provider Enhanced Reports, (CASPER) was reviewed. The report indicated 1-star staffing had been triggered for the 2nd quarter of 2023. During an interview on 9/12/23 at 11:43 a.m., the Regional Director of Operations (RDO) indicated, PBJ data was submitted out of the company's home office in Florida. Unfortunately, an administrative error had been made when the individual home-office staff responsible for the data submission missed the deadline by one day. […]