Brownsburg Meadows

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Oct 15, 2021

  Based on observation, interview, and record review, the facility failed to assess, notify of change of conditions, and ensure emergency medical attention was provided for 2 residents with significant head injuries after falls resulting in altered mental status, pain, change of conditions, and death for 2 of 3 residents reviewed for quality of care (Resident E and Resident B). The immediate jeopardy began on [DATE], when Resident E fell and sustained immediate injuries of a laceration and hematoma to his forehead, skin tears on his knees, and pain in his neck. Resident E was moved to his bed after the fall, and later transferred a second time to go outside for a visit and then back to his bed. The record lacked documentation of both a skin assessment and pain assessment after his fall. […]

• Actual harm, isolatedF689Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident was mechanically transferred using proper technique, resulting in harm when a resident had a fall resulting in an avulsion fracture at the tip of the distal fibula for 1 of 3 residents reviewed for falls with injury (Resident D). Findings include: A Facility Reported Incident (FRI), dated 8/30/25 at 4:39 p.m., indicated on 8/29/25 Resident D was being assisted with a transfer out of her wheelchair by Certified Nursing Assistant (CNA) 10 when the resident began to experience pain in her right foot. The resident was gently lowered to the floor. On 8/31/25 Resident D was diagnosed with a probable subacute nondisplaced demineralized medial cuneiform (bones between the toes and ankle) fracture. […]

• Actual harm, isolatedF684Feb 27, 2024

  Based on observation, interview, and record review, the facility failed to identify bruising timely and failed to accurately document a new skin area on her chest for 1 of 1 residents reviewed for hospice and end of life services (Resident 4). Findings include: On 2/19/24 at 11:50 a.m., Resident 4 was initially observed. There was a large irregularly shaped bruise on the middle of her left upper arm. It was dark purple and green, with a raised bump in the middle of the bruise. A second more faded bruise was observed on her upper left shoulder as well. Resident 4 indicated she did not know what happened, and it was a little tender as she touched the area. […]

• Actual harm, isolatedF689Oct 15, 2021

  Based on interview and record review, the facility failed to ensure Resident B had adequate staff present to prevent her from rolling off her bed, hitting her head, notifying the family at the time of the fall, notifying the physician with a change of condition resulting in altered mental status, pain, change of condition and death for 1 of 3 residents reviewed for accidents (Resident B). Finding includes: During an interview, on [DATE] at 9:50 a.m., Resident B's son and Power of Attorney (POA) indicated the facility did not call when his mother fell or when she died . He knew from the hospice nurse she fell about 4:00 a.m. and she was bleeding all over the place. Paramedics were called to stop the bleeding. Her head wound was on her upper left forehead, across to the middle. […]

• No harm, potential for more than minimal, patternF602Oct 16, 2025

  Based on interview, and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in 21 missing Oxycodone (a Schedule II narcotic medication) tablets, for 1 of 3 residents reviewed for misappropriation (Resident B). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance.Findings include:A Facility Reported Incident (FRI), dated 9/19/25 at 3:59 p.m., indicated a medication discrepancy was found with Resident B's pain medication from the pharmacy. The Executive Director (ED), Director of Nursing Services (DNS), Physician (MD), Power of Attorney (POA), pharmacy, police department, and Adult Protective Services (APS) were notified, and a consumer complaint was filed. […]