Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hoosier Health & Living Community during CMS and state inspections, most recent first.
Unlabeled and undated food items were found in kitchen refrigerators, including open turkey, cooked bacon, and bread pudding without proper dating. Surveyors also observed the dishwasher rinse cycle repeatedly failing to reach the required 180°F, and review of the dish machine logs showed multiple low-temperature entries and incomplete documentation. The KM stated staff were supposed to hand wash dishes if the rinse temperature did not reach the required level.
Inaccurate MDS fall documentation was found for two residents. One resident had a fall while getting into a family member’s vehicle and sustained ankle bruising and swelling, but the quarterly MDS recorded only one fall with no injury. Another resident with dementia had several documented falls, including head injuries, a skin tear, broken teeth, and sutures, yet the quarterly MDS also recorded only one fall with no injury.
A resident with HTN, DM, stroke, dementia, bipolar disorder, and depression had multiple SBP readings at or above the ordered threshold, but PRN clonidine was not administered as ordered and the EMAR lacked documentation explaining the omissions. Another resident was observed with a silver dollar sized bruise and dry scab on the lower left arm after reporting she bumped it on a mechanical lift, but the skin impairment was not documented in the clinical record and staff were unaware of it.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing occurred when a resident with CAD, DM, HTN, CKD, total ADL dependence except eating, and mechanical lift transfers developed an unstageable sacral DTI with 100% slough. The wound was documented by the wound nurse and physician, later remained unstageable on follow-up, and the record lacked documentation that the resident had been away from the facility for an extended period during the month in question. Staff reported routine skin checks during care and wound monitoring by the wound nurse and floor nurses.
Failure to provide prescribed medication: A resident with moderate cognitive impairment and diagnoses including HTN, bipolar disorder, depression, stroke, and dementia did not receive ordered Farxiga 10 mg daily on multiple occasions. The EMAR documented missed doses as waiting on pharmacy delivery or drug/item unavailable, while an RN stated nurses and QMAs could order meds and that the facility used weekly packaged meds, faxed new orders to the pharmacy, and had EDK/local pharmacy options for urgent needs.
A resident with moderate cognitive impairment and diagnoses including dementia, anxiety, depression, and hypertension had hematuria, increased incontinence, increased urination, confusion, and night sweating. The facility received UA/C&S results showing 4+ bacteria, but treatment was not started until several days later when an order for Macrobid was finally received from the physician's office.
A resident with dementia, diabetes, and severe cognitive impairment was observed in bed with a floor mat beside the bed after prior falls. Staff stated the mat had been used for safety and comfort, but RN and DON review found it was not listed in the care plan, not documented in the EHR, and not included in physician orders.
Surveyors observed that nurse staffing information was not updated daily, with postings on the bulletin board showing an outdated date while other materials were current. The DON confirmed the posting should be updated daily by designated staff, but there was no facility policy guiding this process.
The facility failed to maintain safe water temperatures in 10 resident rooms, with temperatures exceeding the state regulation of 100 to 120 degrees Fahrenheit. Residents reported discomfort due to hot water, with temperatures measured as high as 126.5 degrees Fahrenheit. The Maintenance Director did not document individual sink temperatures, only the water heater gauge, which read 120 degrees Fahrenheit. The facility's policy stated water should range from 100 to 120 degrees Fahrenheit, but the Maintenance Director aimed for 120 to 125 degrees Fahrenheit.
A resident was observed with a bottle of cough syrup at his bedside, which he used without a physician's order or an assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which were not completed. The RN was unaware of the medication at the bedside, and it was removed after discovery.
A facility failed to maintain clean and safe oxygen therapy equipment and did not assess a resident during breathing treatments. A resident with COPD had a nebulizer machine with undated and exposed equipment. The facility's records lacked documentation of vital signs during treatments for two months, and staff confirmed that procedures for changing and labeling equipment were not followed.
A resident with severe cognitive impairment was found to have bedrails installed without a proper assessment or physician's order, contrary to facility policy. Observations and staff interviews revealed that the required procedures for bedrail use were not followed, resulting in a deficiency.
The facility failed to follow physician's orders for two residents, leading to the administration of unnecessary medications. One resident received Digoxin despite a heart rate below the prescribed threshold, while another received Midodrine when their systolic blood pressure was above the specified limit. This indicates a failure to adhere to medication administration guidelines.
A facility failed to document a resident's skin condition accurately, as the resident's toenails were long, thick, and discolored, with no prior documentation of this impairment. Despite staff awareness of the condition, it was not recorded until a progress note was made. The resident, who was severely cognitively impaired and dependent on staff for care, initially had podiatry services declined by family but later consented. The facility's policy required weekly assessments and documentation, which was not followed.
Unlabeled Food Storage and Inadequate Dishwasher Sanitization
Penalty
Summary
The facility failed to store food safely when surveyors observed unlabeled and outdated food items in the kitchen refrigerators. During the kitchen tour, an open package of unsliced turkey was found in a plastic bag with no label showing when it was opened, a pan of cooked bacon was covered and dated 07/27, and two large pans of bread pudding were present without dates. The Kitchen Manager stated the turkey had been sliced for sandwiches and should have been labeled when opened, the bacon was used for sandwiches and to season green beans and was good for 10 days after cooking, and the bread pudding had been prepared the previous evening and should have been labeled. The facility also failed to ensure proper sanitization of dishware because the dishwasher rinse temperatures and monitoring logs did not consistently meet the required standard. When the dishwasher was observed, it had to be run multiple times before the rinse cycle reached 180 degrees Fahrenheit, and the Kitchen Manager stated it sometimes took a few cycles to reach the proper temperature. Review of the temperature logs showed multiple days with rinse temperatures below 180 degrees, including several entries in the current month and incomplete documentation in the June and July logs. The Kitchen Manager stated staff were supposed to hand wash dishes if the rinse temperature did not reach 180 degrees, and the Administrator stated there had been no outbreak of food borne illness in the facility.
Inaccurate MDS Fall Documentation
Penalty
Summary
The facility failed to complete MDS assessments accurately related to falls for 2 residents. One resident was observed sitting in a chair with a walker nearby and stated she had recently fallen near the outside entrance while getting into a family member’s vehicle for a doctor’s appointment, twisting her ankle. Facility staff confirmed the fall occurred while the resident was getting into the vehicle with family, that the family was educated to have staff assist with vehicle transfers, and that the resident had bruising and swelling to an ankle with x-rays negative for fracture. However, the resident’s quarterly MDS, completed after the fall, indicated only one fall with no injury since the last assessment, despite the documented post-fall event report showing the outside fall with ankle swelling and bruising. Another resident with dementia and severe cognitive impairment had multiple documented falls between the admission assessment and the quarterly MDS, including unwitnessed falls with a skin tear to the right elbow, no injury, head impact with swelling and a hematoma, a witnessed repeat head impact with a sluggish pupil, a fall with broken teeth and four sutures to the chin, and a witnessed fall with no injury. The quarterly MDS completed for this resident indicated only one fall with no injury since the prior assessment. The MDS coordinator stated the fall information was taken from the electronic record and that there should have been more falls documented on the quarterly MDS.
Failure to Follow PRN Medication Orders and Document a New Skin Impairment
Penalty
Summary
The facility failed to administer PRN clonidine for Resident 3 when the resident’s systolic blood pressure was at or above 160, as ordered. Resident 3’s record showed diagnoses including hypertension, diabetes, stroke, dementia, bipolar disorder, and depression, and an MDS assessment indicated moderate cognitive impairment. The physician ordered blood pressure checks twice daily and PRN clonidine 0.1 mg every 12 hours for SBP greater than 160, but the July 2025 EMAR showed multiple instances when the resident’s blood pressure met the ordered threshold and the medication was not given, including readings of 166/76, 167/67, 185/78, 170/68, 190/81, 176/71, 174/88, and 167/68. RN 4 stated that if a medication was held or not given, the EMAR had a button to document the reason, and the DON stated the facility lacked a policy for following physician’s orders and followed standard nursing practices. The facility also failed to identify and document a skin impairment for Resident 7. During interview and observation, the resident stated she had bumped her arm on the mechanical lift, and staff observed a silver dollar sized bruise with a dry L-shaped scab in the middle on the lower left arm on multiple occasions while the resident was in a short-sleeved shirt. Resident 7’s record showed she was cognitively intact, dependent on staff for all transfers, and had diagnoses including diabetes, anemia, hypertension, and depression, but the clinical record lacked documentation of the left lower arm skin impairment. Staff interviews indicated that a new bruise or skin tear should have been assessed, the physician notified, an event opened in the record, and treatment initiated if needed, but the DON and wound nurse were unaware of the impairment and the record did not reflect it.
Failure to Identify and Monitor a Sacral Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident 4, who was cognitively intact and had diagnoses including coronary artery disease, diabetes, hypertension, and stage 3 chronic kidney disease. The resident required staff assistance for all ADLs except eating, used a mechanical lift for transfers, and had a specialty mattress and chair cushion. A wound management note documented an unstageable deep tissue injury pressure ulcer on the sacrum measuring 1.7 cm by 0.7 cm by 0.1 cm with 100% slough, and a wound physician note described the same sacral wound with an estimated healing time of 2 to 4 months and treatment with calcium alginate and a foam border dressing. Subsequent wound documentation continued to describe the sacral wound as unstageable with 100% slough, including a later measurement of 1.5 cm by 0.7 cm by 0.1 cm. The wound was treated with non-contact, non-thermal, low frequency ultrasound instead of sharp debridement, and a later physician note stated the wound was healed. The clinical record lacked documentation that the resident had been absent from the facility for any services for an extended period during July. Staff interviews indicated the resident was incontinent of bowel and bladder, was turned and repositioned every two hours, and skin was observed during care, while the wound nurse stated floor nurses saw wounds at least twice a day during treatments and she visualized the wound when it was first identified as unstageable.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide physician-prescribed dapagliflozin propanediol (Farxiga) 10 mg by mouth once daily for one resident whose clinical record was reviewed. The resident’s annual MDS dated 08/03/25 indicated moderate cognitive impairment, and the resident’s diagnoses included hypertension, bipolar disorder, depression, stroke, and dementia. The medication order had a start date of 05/20/25. The EMAR showed the medication was documented as not administered on multiple dates, with reasons including “Waiting on delivery from pharmacy” and “Drug/Item Unavailable.” During interview, an RN stated nurses and QMAs were allowed to order medications for residents, that routine medications were received weekly in packaged rolls, and that new orders were faxed to the pharmacy with the family updated. The facility’s pharmaceutical services policy stated that pharmaceutical services were to be available to all residents and that routine and timely pharmacy service and emergency pharmacy service were to be provided.
Delayed UA Follow-Up and Antibiotic Start
Penalty
Summary
The facility failed to obtain a urinalysis and start treatment in a timely manner for one resident reviewed for laboratory services. The resident had a quarterly MDS dated 05/19/25 showing moderate cognitive impairment, with diagnoses including hypertension, non-Alzheimer's dementia, anxiety, depression, major depressive disorder, anxiety, and vascular dementia. On 06/25/25, the nurse received a call from the physician's office stating the resident's urine dipstick results had been received and that a urine sample should be sent to the lab for UA C&S; the nurse completed the paperwork and was waiting for the sample to send it to the lab. The record showed the resident had hematuria, increased frequency of bladder incontinence with increased urination, increased confusion, and night sweating on 06/26/25. UA results were received on 06/27/25 and showed 4+ bacteria, and the C&S was pending. The C&S results were received and faxed to the primary care physician on 06/28/25, but the facility was still awaiting a reply on 06/30/25. Later that day, the nurse received a call from the physician's office with a new order for Macrobid 100 mg twice daily for 7 days for a UTI, and the first dose was administered that evening.
Resident record did not reflect floor mat intervention
Penalty
Summary
The facility failed to ensure one resident’s record accurately reflected current nursing measures or interventions. Resident 68, who had dementia, diabetes, severe cognitive impairment, and required extensive staff assistance with transfers, was observed multiple times in bed with the bed in a low position and a floor mat placed on the floor beside the bed. A CNA stated the mat had been used because the resident had fallen and that it had been in place since the resident was readmitted from a psychiatric hospital. During record review, RN 4 stated the floor mat was not listed on the resident’s care plan, and if the mat was in place it should have been included. The resident’s electronic record lacked documentation for the use of a floor mat, and the physician’s orders also did not include an order for it. The resident’s fall care plan included other interventions, such as keeping the room clear of obstacles, but did not document the floor mat as an intervention. The DON stated the mat was considered a nursing measure and comfort measure, while the SSD stated a floor mat could be used if a resident was fidgety or restless; however, the resident’s record did not document that she was frequently restless or preferred to spend time lying on the floor.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, as observed on two separate occasions. On both observations, the bulletin board by the Unit Manager's office on the 300 Hall displayed a nurse staffing posting that was outdated, showing a date from several months prior, while the activity calendar was current for April. During interviews, the DON confirmed that the nurse staffing information should be updated daily by herself, the Assistant DON, or the scheduler, but acknowledged that there was no facility policy in place for this process and that they simply followed the regulation.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in 10 out of 18 resident rooms observed, with temperatures exceeding the state regulation of 100 to 120 degrees Fahrenheit. During interviews and observations, residents reported that the water in their bathrooms was too hot to keep their hands under without discomfort. The water temperatures in these rooms were measured using a probe thermometer and found to be as high as 126.5 degrees Fahrenheit. Despite the high temperatures, residents indicated they had not been burned by the water. The Maintenance Director admitted to conducting random checks of water temperatures but did not document the actual temperatures from individual sinks, only recording the temperature from the water heater gauge, which read 120 degrees Fahrenheit. The facility's policy on water temperature inspection, last reviewed in March 2022, stated that hot water in resident areas should range from 100 to 120 degrees Fahrenheit. However, the Maintenance Director mentioned attempting to maintain water temperatures between 120 to 125 degrees Fahrenheit, which is above the policy's stated range.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident who self-administered medications was appropriately assessed for self-administration. During multiple observations, Resident 18 was seen with a bottle of severe cold and cough syrup on his over-the-bed table, which he indicated he used when he had something caught in his throat. However, there was no assessment or physician's order in the resident's clinical record to authorize self-administration of medications, nor was there an order for the cough syrup itself. The facility's policy requires that the interdisciplinary team assess a resident's cognitive, physical, and visual abilities before allowing self-administration of medications, and a physician's order must be obtained and recorded. RN 7, during an interview, was unaware that Resident 18 had cough syrup at his bedside and confirmed that the resident did not have an order to self-administer medications. The cough syrup was subsequently removed from the resident's room. The facility's failure to follow its policy resulted in a deficiency related to the self-administration of medications.
Failure to Maintain Safe Respiratory Care for a Resident
Penalty
Summary
The facility failed to maintain oxygen therapy equipment in a clean and safe manner and did not properly assess a resident during breathing treatments. Resident 69, who has Chronic Obstructive Pulmonary Disease (COPD), was observed with a nebulizer machine on her nightstand, with the face mask and tubing exposed to air and not dated. There was no plastic bag or other equipment visible, and a small amount of fluid was present in the reservoir. The resident confirmed that staff did not use a bag for her equipment. The Assistant Director of Nursing (ADON) indicated that oxygen tubing was supposed to be changed weekly and dated, but the equipment for Resident 69 was not labeled or stored properly. The clinical records for September and October 2024 lacked a physician's order to change the breathing treatment equipment and did not document the required vital signs during treatments. The facility's policies, which were last reviewed in 2011, stated that tubing must be changed weekly and labeled, and that nursing staff should monitor the effectiveness of nebulizer treatments by assessing lung sounds, respiratory rate, and heart rate. However, these procedures were not followed, as evidenced by the absence of documentation for the entire months of September and October 2024. Interviews with staff confirmed that vital signs should be taken during medication administration, but this was not done for Resident 69.
Failure to Assess and Obtain Physician's Order for Bedrail Use
Penalty
Summary
The facility failed to properly assess a resident for the use of bedrails, as observed in the case of a resident who was severely cognitively impaired with diagnoses including unspecified dementia, hypertension, and anxiety. The resident was observed multiple times with half bedrails on both sides of her bed, yet the clinical record lacked a physician's order or an assessment for the bedrails prior to their installation. The Assistant Director of Nursing (ADON) confirmed that an order and assessment should have been completed before the bedrails were placed. Interviews with facility staff, including a Certified Nurse Aide (CNA) and the Maintenance Director, revealed that the process for installing bedrails involved obtaining a physician's order, which was not followed in this case. The Maintenance Director was unaware of when the bedrails were installed for the resident, indicating a lapse in communication and procedure adherence. The facility's policy on the use of bedrails, which requires a proper assessment and physician's order, was not followed, leading to this deficiency.
Failure to Follow Medication Hold Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration for two residents, leading to the administration of unnecessary drugs. Resident 18, who was cognitively intact and diagnosed with conditions including atrial fibrillation, was prescribed Digoxin with a specific instruction to withhold the medication if the heart rate was below 60. Despite this, the resident received Digoxin on multiple occasions when their heart rate was below the specified threshold, indicating a failure to follow the hold parameters set by the physician. Similarly, Resident 5, who was moderately cognitively impaired and had diagnoses including diabetes and hypertension, was prescribed Midodrine with instructions to hold the medication if the systolic blood pressure exceeded 105. The resident received the medication numerous times when their systolic blood pressure was above the specified limit. This repeated administration of Midodrine against the physician's orders further highlights the facility's failure to comply with medication administration guidelines, as confirmed by the Qualified Medication Aide's interview and the facility's policy.
Failure to Document Resident's Skin Condition
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's skin condition, specifically regarding the toenails and skin of Resident 80. Observations revealed that the resident's toenails were long, thick, yellow, and curved, with a black discoloration under the third toenail on the right foot. Despite these conditions, there was no prior documentation of this skin impairment in the resident's clinical record before a progress note dated 10/29/24. Interviews with staff, including CNAs and an LPN, indicated that the condition of the resident's toe was known but not documented, and there was uncertainty about when the impairment was first noticed or reported. Resident 80, who was severely cognitively impaired with diagnoses including stroke, hemiplegia, hypertension, and aphasia, required substantial assistance for daily activities and was dependent on staff for care. The resident's family initially declined podiatry services upon admission in July 2024, but later consented after being informed of the need. The facility's policy required weekly head-to-toe assessments and documentation of findings, which was not adhered to in this case, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brownstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covered Bridge Health Campus | 8.4 mi | ★★★★★ | 8 | 0 |
| Lutheran Community Home | 9.6 mi | ★★★★★ | 15 | 0 |
| Seymour Crossing | 10.9 mi | ★★★★★ | 10 | 0 |
| Hampton Oaks Health Campus | 17.5 mi | ★★★★★ | 1 | 0 |
| Lake Pointe Village | 17.6 mi | ★★★★★ | 3 | 0 |
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