Cycle 1
Health 2025-04-25 · Fire 2025-04-25
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brownsburg, IN
Brownsburg Meadows
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2 E Tilden, Brownsburg, IN
(317) 852-8585
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
147
Certified beds
Average residents
136
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
2007-02-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
91 facilities
Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
690
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.33
Composite VBP score used to determine payment impact.
Payment multiplier
1.0196
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.54% · Performance 16.12% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.57
Baseline 6.59% · Performance 5.27% · Measure score 8.57 · Achievement 8.57 · Improvement 7.76
Total nurse turnover
6.32
Baseline 46.08% · Performance 37.84% · Measure score 6.32 · Achievement 6.32 · Improvement 3.38
Adjusted total nurse staffing
1.24
Baseline 3.34 hours · Performance 3.43 hours · Measure score 1.24 · Achievement 1.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 227 · Observed rate 9.25% · Lower 95% interval 7.07% |
| Discharge to community | 61.56% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 211 · Observed rate 54.98% · Lower 95% interval 54.13% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.03% |
95.27%
4.2 pts worse
|
Numerator 132 · Denominator 145 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 145 |
| Discharge self-care score | 42.61% |
53.69%
11.1 pts worse
|
Numerator 49 · Denominator 115 |
| Discharge mobility score | 38.26% |
50.94%
12.7 pts worse
|
Numerator 44 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 145 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.27% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 2.88% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 2.07% |
8.2%
6.1 pts worse
|
Numerator 4 · Denominator 193 |
| Staff flu vaccination coverage | 74.84% |
42%
32.8 pts better
|
Numerator 235 · Denominator 314 |
| Discharge function score | 46.09% |
56.45%
10.4 pts worse
|
Numerator 53 · Denominator 115 |
| Transfer of health information to provider | 91.18% |
95.95%
4.8 pts worse
|
Numerator 31 · Denominator 34 |
| Transfer of health information to patient | 92.41% |
96.28%
3.9 pts worse
|
Numerator 73 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 33.78% |
25.2%
8.6 pts better
|
Numerator 25 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
93.6%
4.6 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 89.5% · Q3 91.4% · Q4 89.9% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.4%
1.3 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.8%
2.2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.6% · Q3 1.9% · Q4 0.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.4% |
24.6%
10.8 pts worse
|
11.4%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 19.0% · Q3 46.9% · Q4 53.3% · 4Q avg 35.4% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.6%
1.9 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.2% · Q3 3.3% · Q4 3.2% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
23.5%
5.8 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.4% · Q3 17.4% · Q4 15.6% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
14.8%
5.1 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.0% · Q3 11.9% · Q4 12.2% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.1% |
13.3%
7.2 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.0% · Q3 1.9% · Q4 3.8% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
11.7%
6.6 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.5% · Q3 2.3% · Q4 6.4% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
24.2%
2.7 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 21.7% · Q3 21.9% · Q4 20.3% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.1%
1.2 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.8% · Q3 1.8% · Q4 1.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.7% |
81.6%
22.9 pts worse
|
81.7%
23 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.3% · Q2 55.1% · Q3 51.1% · Q4 53.7% · 4Q avg 58.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
10.5%
1 pts worse
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.3% |
79.0%
27.7 pts worse
|
79.7%
28.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
22.4%
0.3 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 22.5% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-27 · Fire 2024-02-27
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-04 · Fire 2023-04-04
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-04-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-12
E · Potential for more than minimal harm
2024-02-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-04-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-09
E · Potential for more than minimal harm
2023-04-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
E · Potential for more than minimal harm
2025-10-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
G · Actual harm
2025-09-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-19
E · Potential for more than minimal harm
2025-04-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-25
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-01-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-07-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-02-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-20
D · Potential for more than minimal harm
2023-06-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-04-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-04-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-04-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-04-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-24
Penalties and ownership
What sits behind the stars
Ownership
The Health And Hospital Corporation Of Marion County
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Corporate Officer · Individual
Brooks, Jocelyn
Operational/Managerial Control · Individual
Caine, Virginia
Corporate Officer · Individual
Carter, Timothy
Operational/Managerial Control · Individual
Dice, Mark
Contracted Managing Employee · Individual
Drummer, Carl
Corporate Director · Individual
Durham, Robert
Operational/Managerial Control · Individual
Fehribach, Gregory
Corporate Director · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Director · Individual
Lazard, Robert
Corporate Director · Individual
Mantravadi, Geeta
Corporate Director · Individual
Mukes-Gaither, Beverly
Corporate Director · Individual
Payne, Monica
Corporate Director · Individual
Stordy, David
Contracted Managing Employee · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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Brownsburg Health Care Center
Brownsburg, IN
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with 22 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Brooke Knoll Village
Avon, IN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Wellbrooke Of Avon
Indianapolis, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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