Inspection Reports for Brownsburg Health Care Center
1010 HORNADAY RD, IN, 46112
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2025, found deficiencies related to failure to protect a resident from verbal and physical abuse by staff, which the facility addressed before the survey by suspending involved employees and providing staff education. Earlier inspections showed a pattern of deficiencies involving resident care, including inadequate assistance with daily living activities, medication and wound treatment storage, respiratory equipment cleaning, and staffing levels, as well as issues with medication diversion and infection control. Several complaint investigations were unsubstantiated or found no deficiencies, though some substantiated complaints led to citations, particularly around abuse and narcotic medication management. Life Safety Code surveys noted issues with smoke barrier doors, fire alarm signal verification, and door signage, but corrective actions were implemented during those surveys. The inspection history shows ongoing challenges in care and safety practices, with some corrective actions taken, but deficiencies have recurred over time without a clear pattern of sustained improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
77 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Jun 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462259 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00462259 was substantiated with federal and state deficiencies cited related to abuse allegations involving Resident B. The facility self-reported the incident and corrective actions were implemented prior to the survey.
Findings
The facility failed to protect one resident's right to be free from verbal and physical abuse by staff. The incident involved two CNAs pulling on the resident's arms causing pain and other inappropriate care actions. The deficient practice was corrected prior to the survey date with suspension of involved CNAs and staff education.
Deficiencies (1)
Failure to protect resident from verbal and physical abuse by staff.
Report Facts
Census: 77
SNF beds: 2
SNF/NF beds: 75
Medicare residents: 3
Medicaid residents: 53
Other residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Aide | Named in abuse incident and suspended pending investigation |
| CNA 7 | Certified Nursing Aide | Named in abuse incident and suspended pending investigation |
| Executive Director | Executive Director | Responded to incident, suspended CNAs, and interviewed resident |
| Regional Director of Operations | Regional Director of Operations | Provided facility policy on Abuse Prevention and Prohibition |
| Hospice Case Manager | Hospice Case Manager | Interviewed regarding CNAs unfamiliarity with ALS care |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459068 and IN00460149 at Brownsburg Health Care Center.
Complaint Details
Investigation of Complaints IN00459068 and IN00460149 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00459068 and IN00460149 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 74
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 22
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00452678 and IN00455563 completed on April 30, 2025.
Complaint Details
The visit was related to investigations of complaints IN00452678 and IN00455563; compliance was found.
Findings
Brownsburg Health Care Center was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 4
Date: Apr 27, 2025
Visit Reason
This visit was for the investigation of complaints IN00452678, IN00455563, and IN00456607.
Complaint Details
Complaints IN00452678 and IN00455563 had federal/state deficiencies related to the allegations cited at F677, F689, F695, and F725. Complaint IN00456607 had no deficiencies related to the allegations.
Findings
The facility failed to ensure adequate assistance with activities of daily living (ADL) for dependent residents, proper medication and wound treatment storage, appropriate respiratory care equipment cleaning and storage, and sufficient nurse staffing levels to meet resident needs.
Deficiencies (4)
Failed to ensure residents dependent on staff for ADL assistance received those services for 8 of 15 residents reviewed.
Failed to ensure all medications and wound treatment solutions were secured in public hallways and resident rooms for 5 of 5 residents reviewed.
Failed to properly clean and store nebulizer and oxygen equipment for 4 of 4 residents reviewed for respiratory care.
Failed to ensure adequate staffing levels to provide ADL care, medication administration, and getting residents out of bed for 14 of 16 residents and 5 of 7 hallways observed.
Report Facts
Residents reviewed for ADL assistance: 15
Total residents: 78
Residents requiring assistance with feeding: 12
Residents requiring extensive to total assistance with toileting: 51
Staffing ratio: 15
Hours per resident day (HPRD): 3.48
Licensed nurse HPRD: 0.44
CNA/QMA HPRD: 2.45
Days with less than 7 CNAs on day shift: 22
Days with less than 6 CNAs on evening shift: 4
Days with less than 5 CNAs on night shift: 16
Days with less than 7 CNAs on day shift: 9
Days with less than 5 CNAs on night shift: 4
Days with less than 7 CNAs on day shift: 9
Days with less than 5 CNAs on night shift: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Frye | Administrator | Signed the report |
| QMA 4 | Qualified Medication Aide | Mentioned in relation to medication administration and staffing issues |
| RN 7 | Registered Nurse | Mentioned in relation to medication administration and staffing |
| CNA 8 | Certified Nursing Assistant | Mentioned in relation to resident care and staffing |
| CNA 15 | Certified Nursing Assistant | Mentioned in relation to staffing and resident care |
| CNA 16 | Certified Nursing Assistant | Mentioned in relation to staffing and resident care |
| RN 14 | Registered Nurse | Mentioned in relation to medication administration and staffing |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00450226, IN00450718, IN00450682, IN00451401, and IN00452254.
Complaint Details
Complaints IN00450226, IN00450718, IN00450682, IN00451401, and IN00452254 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The Brownsburg Health Care Center was found to be in compliance with relevant federal and state regulations regarding the complaints investigated.
Report Facts
Census Bed Type: 75
Census Bed Type: 2
Total Census: 77
Census Payor Type: 9
Census Payor Type: 47
Census Payor Type: 21
Total Capacity: 77
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448317.
Complaint Details
Complaint IN00448317 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 6
Medicaid Census: 46
Other Payor Census: 30
Inspection Report
Life Safety
Census: 80
Capacity: 160
Deficiencies: 4
Date: Dec 3, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to properly mark non-exit doors, lack of approved method to secure cooking appliances, resident room doors not closing and latching properly, and smoke barrier doors not closing fully. Corrective actions were implemented during the survey.
Deficiencies (4)
Failed to ensure 1 of 1 door to the outside was not mistaken as an exit; door lacked 'NO EXIT' signage.
Failed to provide an approved method to ensure cooking appliances were returned to approved design location after maintenance.
Failed to ensure 1 of 83 resident room doors would close completely and latch into the door frame.
Failed to ensure 2 of 7 sets of smoke barrier doors would restrict smoke movement by closing fully and latching properly.
Report Facts
Certified beds: 160
Census: 80
Resident room doors: 83
Barrier doors: 7
Affected residents: 40
Affected residents: 18
Affected residents: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Spall | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Maintenance Director | Interviewed and acknowledged deficiencies related to door and cooking appliance issues. | |
| Administrator | Interviewed and present during observations and exit conference. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey.
Findings
Brownsburg Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446492 at Brownsburg Health Care Center.
Complaint Details
Complaint IN00446492 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00446492 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 77
SNF beds: 1
SNF/NF beds: 76
Medicare residents: 1
Medicaid residents: 46
Other payor residents: 30
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 9
Date: Oct 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00445712.
Complaint Details
Complaint IN00445712 was investigated and federal/state deficiencies related to the allegations were cited at F684.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, comprehensive care planning, coordination with hospice, tube feeding management, pain management, dementia care programming, pharmacy services, infection prevention and control, and hand hygiene compliance.
Deficiencies (9)
Failed to code pressure ulcers correctly on the Minimum Data Set (MDS) assessment for residents.
Failed to ensure comprehensive resident centered care plans for residents with indwelling urinary catheters.
Failed to coordinate treatments and services with hospice after new skin impairment areas were discovered.
Failed to ensure all tube feedings were completed according to physician's orders.
Failed to ensure timely interventions to assess and treat pain for a newly admitted resident, resulting in discharge against medical advice.
Failed to ensure specialized dementia care programming was implemented to provide meaningful, engaging and diverse activities for residents with dementia.
Failed to ensure alternative or additional emergency pharmaceutical services were available to obtain an authorization code for emergency medication kit.
Failed to ensure staff provided lunches according to policy for residents on enhanced barrier precautions, including hand hygiene compliance.
Failed to ensure the Infection Preventionist role was filled for 6 of 12 months and failed to ensure all new residents were screened for tuberculosis.
Report Facts
Census: 78
Survey dates: 6
Tube feeding calories: 1780
Weight loss: 7.6
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Spall | HFA | Signed the report |
| Grant Wallace | LPN, Dementia Care Unit Director | Designated as director of Dementia Care Unit and responsible for dementia care programming |
| Takia Bradberry | Infection Preventionist | Completed IP certification and serves as facility Infection Preventionist |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00445712.
Complaint Details
Investigation of Complaint IN00445712 was completed and found in compliance.
Findings
Brownsburg Health Care Center was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00445712.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
This visit was conducted to investigate complaints IN00440163, IN00441058, IN00441709, and IN00442003 at Brownsburg Health Care Center.
Complaint Details
Complaints IN00440163, IN00441058, IN00441709, and IN00442003 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 81
Census Bed Type - SNF: 4
Census Bed Type - Total: 85
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 28
Census Payor Type - Total: 85
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 1
Date: May 23, 2024
Visit Reason
This visit was for the investigation of complaints IN00421255, IN00427538, and IN00431889.
Complaint Details
Complaint IN00427538 was substantiated with federal/state deficiencies cited at F602 related to narcotic medication diversion. Complaints IN00421255 and IN00431889 had no deficiencies related to the allegations.
Findings
The facility failed to ensure residents' narcotic medications were protected from diversion, resulting in at least 56 missing narcotic medication tablets. The investigation found that LPN 14 diverted narcotics from the automated drug unit and medication carts. Corrective actions included staff education, securing narcotics in blister cards or locked medication carts, and implementing stricter narcotic dispensing and counting procedures.
Deficiencies (1)
Failed to ensure residents' narcotic medications were protected from diversion resulting in at least 56 missing narcotic medication tablets.
Report Facts
Missing narcotic medication tablets: 56
Residents affected: 5
Census: 74
Total capacity: 74
Nurse shifts worked: 9
Compensation tablets for Resident C: 18
Compensation tablets for Resident D: 27
Compensation tablets for Resident P: 2
Compensation tablets for Resident Q: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 14 | Licensed Practical Nurse | Named in narcotic medication diversion finding. |
| RN 11 | Registered Nurse | Provided information about staff education on drug diversion. |
| RN 12 | Registered Nurse | Provided observations about Resident D during inspection. |
| DON | Director of Nursing | Led investigation, provided policy information, and described corrective actions. |
Inspection Report
Life Safety
Census: 62
Capacity: 160
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/03/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Brownsburg Health Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system and battery operated smoke detectors in all resident sleeping rooms.
Report Facts
Facility capacity: 160
Census: 62
Inspection Report
Life Safety
Census: 64
Capacity: 160
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure of one set of smoke barrier doors to restrict smoke movement for at least 20 minutes and failure to verify transmission of fire alarm signals during 5 of 12 fire drills conducted between 6:00 a.m. and 9:00 p.m. in the last 4 quarters.
Deficiencies (2)
Failed to ensure 1 of 7 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to holes in the door from previous self-closing device installation.
Failed to ensure 5 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters.
Report Facts
Certified beds: 160
Census: 64
Fire drills missing verification: 5
Total fire drills reviewed: 12
Smoke barrier doors inspected: 7
Residents affected: 18
Staff affected: 4
Visitors affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Brushaber | Administrator | Signed report and participated in exit conference |
| Maintenance Director | Interviewed and involved in findings and corrective actions | |
| Regional Maintenance Director | Interviewed and involved in findings and corrective actions | |
| Director of Nursing | Participated in exit conference and discussion of findings |
Inspection Report
Annual Inspection
Census: 68
Capacity: 68
Deficiencies: 7
Date: Sep 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 10 to 15, 2023.
Findings
The facility was found deficient in multiple areas including quality of care related to wound treatment, accident hazard prevention, pharmacy services and medication accountability, infection control practices, payroll-based journal submission, medication storage, and personnel background checks.
Deficiencies (7)
Failed to ensure a resident with non-pressure wounds received treatments upon admission and lacked proper wound assessments and follow-up.
Failed to implement post-fall interventions and complete smoking assessment after significant change for residents.
Failed to ensure narcotic and non-narcotic drugs were properly received, administered, and accounted for with controlled substance accountability sheets.
Failed to destroy expired and outdated tuberculin serum and influenza vaccinations in medication room.
Failed to submit mandatory payroll-based journal staffing information by required deadline.
Failed to ensure infection prevention and control practices including proper cleaning of glucometers between resident uses.
Failed to complete criminal background check for an employee prior to employment.
Report Facts
Census: 68
Total Capacity: 68
Medication doses destroyed: 30
Medication doses destroyed: 14
Medication doses destroyed: 29
Medication doses destroyed: 27
Medication doses destroyed: 27
Employee work days: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA 7 | Dietary Aide | Employee without completed Indiana State Police criminal background check who worked 17 days |
| LPN 19 | Licensed Practical Nurse | Named in medication accountability issues and suspension related to narcotic discrepancies |
| ADON | Assistant Director of Nursing | Named in medication accountability issues with forged signatures |
| QMA 14 | Qualified Medication Aide | Observed failing to properly clean glucometer between resident uses |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 15, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Brownsburg Health Care Center was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00397167.
Complaint Details
Investigation of Complaint IN00397167 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00397167 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 55
Medicare residents: 5
Medicaid residents: 32
Other residents: 18
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Nov 21, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390893.
Complaint Details
Complaint IN00390893 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00390893 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 49
Census SNF/NF beds: 47
Census SNF beds: 2
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 29
Census Payor Type Other: 18
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 18, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/18/22 was completed on 08/01/22.
Findings
Brownsburg Health Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 17, 2022.
Findings
Brownsburg Health Care Center was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
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