Brownsburg Meadows

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's right to dignity when she was kissed by a facility bus driver for 1 of 3 residents reviewed for resident abuse (Resident B).

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to maintain a system for the reconciliation of controlled medications, resulting in diversion of at least 369 Oxycodone (a Schedule II narcotic medication) tablets from 4 of 4 hallways reviewed for diversion of narcotics (100, 200, 300, and 400 hallways). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past NoncomplianceFindings 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. [...]

Inspectors wroteBased 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).

Inspectors wroteA. Based on record review and interview, the facility failed to obtain resident weights as ordered for 2 of 2 residents reviewed for weights (Resident 74 and 107). B. Based on observations, interview and record review, the facility failed to ensure a newly admitted resident, (Resident C) had physician's orders in place and treatments rendered for a new surgical wound upon his admission for 1 of 5 residents reviewed for quality of care. C. Based on record review and interview the facility failed to ensure a resident's (Resident B) physician's ordered were followed to apply and remove a transdermal medication patch for 1 of 5 residents reviewed for quality of care.

Inspectors wroteBased on observations and interviews, the facility failed to date insulin and eye drops when opened and failed to remove expired tuberculin serum and insulin from the refrigerator for 3 of 6 medication carts and 2 of 4 medication rooms.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 1 residents (Resident 118) reviewed for transfers and discharges.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a newly admitted resident, (Resident C) had a baseline care plan in place to address his immediate medical needs for a new surgical wound upon his admission for 1 of 3 new admission records reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (Resident 87) received care plan revisions to implement new goals and/or approaches to address her diabetic management for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to prevent the potential for accidents when medications were left bedside with residents without self-administration assessments for 2 of 2 random observations (Residents 78 and 118), and when a nurse was observed leaving medications unattended on top of the medication cart during a medication pass observation which had the potential to affect 2 of 2 residents in the hallway when the medication was unattended.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the medical record reflected accurate documentation of a pressure injury for a resident for 1 of 25 residents reviewed for accurate documentation (Resident 16).

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage Peripherally Inserted Central Catheter (PICC) line dressing changes for a resident receiving intravenous (IV) antibiotics to treat extradural and subdural abscesses for 1 of 2 residents reviewed for PICC line dressing changes (Resident C).

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents' rooms and bathrooms were cleaned daily and the residents' shower rooms were kept clean and uncluttered for 3 of 4 shower rooms observed. This had the potential to affect 136 of 136 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to properly label medications with dates when they were opened and failed to dispose of expired insulin for 3 of 5 medication room observed and 3 of 6 medication carts observed.

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and wound cleanser were secure and not found in an unlocked memory care (MC) linen closet for 18 of 28 residents who resided in the MC unit. The facility failed to ensure medications were not found in resident's rooms without self-administration assessments for 4 of 4 residents reviewed for self-administration assessments (Resident 27, 68, 190, and 88).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, (Resident 70) who had recent medication adjustments and fluctuating blood pressures, received timely documentation from his Dialysis center after treatment sessions to ensure continuity of and to prevent the potential for complications related to post-Dialysis change of condition for 1 of 1 resident reviewed for Dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate hand hygiene while assisting residents with eating for 2 of 2 days of dining observations. (Resident 44, 89, 42, 76, 110, 84, 42, and 56).

Inspectors wroteBased on observation and interview, the facility failed to ensure all mechanical equipment was kept in safe operating condition for 1 of 1 observation of the laundry service area.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory equipment was stored properly to prevent the potential for cross contamination and infection for 3 of 11 residents reviewed for respiratory equipment/services and supplies (Residents 108, 334, and 184).

Inspectors wroteBased on record review and interview, the facility failed to include an indication for use of medications for 3 of 5 residents reviewed for unnecessary medications (Resident 108, 90, and 127).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene while assisting residents with eating for 4 of 5 residents requiring assistance with eating in the memory care area (Resident 20, 34, 47, and 65)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were in place for 2 of 22 residents reviewed for care plans (Resident 119 and 184).

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a resident who had a history of chronic venous ulcers and wound infections received interventions to prevent new areas from re-opening and becoming infected for 1 of 5 residents reviewed for nursing services (Resident C), and the facility failed to ensure a resident received a routine lab and complaints of acute pain noted on her Dialysis communication log were addressed for 1 of 5 residents reviewed for nursing services (Resident E).