Cycle 1
Health 2025-03-27 · Fire 2025-03-27
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Avon, IN
Brooke Knoll Village
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1108 Kingwood Drive, Avon, IN
(317) 271-7052
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
86
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Hcf Management Indiana
Operator or chain grouping
Approved since
2014-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 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
0.58
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.18
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
0.34
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,601
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.7
Baseline 20.42% · Performance 20.64% · Measure score 1.7 · Achievement 1.7 · Improvement 0
Healthcare-associated infections
2.24
Baseline 6.14% · Performance 7.17% · Measure score 2.24 · Achievement 2.24 · Improvement 0
Total nurse turnover
2.41
Baseline 57.61% · Performance 53.85% · Measure score 2.41 · Achievement 2.41 · Improvement 0.65
Adjusted total nurse staffing
1.58
Baseline 2.39 hours · Performance 3.10 hours · Measure score 1.58 · Achievement 0 · Improvement 1.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 10.23% · Lower 95% interval 7.22% |
| Discharge to community | 68.57% |
50.57%
18 pts better
|
Better than the National Rate · Eligible stays 135 · Observed rate 63.7% · Lower 95% interval 60.93% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 107 · Denominator 107 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 107 |
| Discharge self-care score | 63.08% |
53.69%
9.4 pts better
|
Numerator 41 · Denominator 65 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 39 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 3.74% |
2.29%
1.5 pts worse
|
Numerator 4 · Denominator 107 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 7.17% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 117 · Observed rate 6.84% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 52.8% |
42%
10.8 pts better
|
Numerator 66 · Denominator 125 |
| Discharge function score | 63.08% |
56.45%
6.6 pts better
|
Numerator 41 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 1.89% |
25.2%
23.3 pts worse
|
Numerator 1 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.6%
5.6 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
95.4%
1 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.8%
2.3 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 54.7% |
24.6%
30.1 pts worse
|
11.4%
43.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 53.3% · Q3 42.2% · Q4 52.5% · 4Q avg 54.7% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.6%
3.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 6.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
23.5%
9.9 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 13.1% · Q3 10.6% · Q4 17.9% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
14.8%
9.4 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.1% · Q3 5.5% · Q4 4.3% · 4Q avg 5.4% · 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 | 23.1% |
13.3%
9.8 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 32.0% · Q3 25.3% · Q4 20.7% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
11.7%
3.9 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 15.3% · Q3 13.1% · Q4 15.4% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.4%
0.6 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.2%
3.1 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.7% · Q3 6.3% · Q4 3.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
24.2%
2.2 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 34.4% · Q3 17.9% · Q4 14.5% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.1%
0.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.8% · Q3 3.4% · Q4 3.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
81.6%
15.5 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.0% · Q3 100.0% · Q4 94.1% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
10.5%
0.2 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
79.0%
15.1 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
22.4%
5.4 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 17.8% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
5 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-16
F · Potential for more than minimal harm
2022-10-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-13
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 2025-09-02
E · Potential for more than minimal harm
2025-03-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-27
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 2025-04-18
E · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-18
D · Potential for more than minimal harm
2024-03-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-25
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 2024-01-26
D · Potential for more than minimal harm
2024-01-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-25
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 2024-01-26
D · Potential for more than minimal harm
2024-01-25
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-25
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 2024-01-26
E · Potential for more than minimal harm
2022-10-06
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 2022-10-07
E · Potential for more than minimal harm
2022-10-06
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 2022-10-07
E · Potential for more than minimal harm
2022-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-10-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-10-06
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 2022-10-07
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hafidh, Saad
Operational/Managerial Control · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Magnolia Health Management Xxx, LLC
Operational/Managerial Control · Organization
Reagan, Julie
Corporate Director · Individual
Reed, Stuart
Operational/Managerial Control · Individual
Sellers, Daniel
Corporate Officer · Individual
Wilson, Jessica
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Westside Retirement Village
Indianapolis, IN
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Countryside Meadows
Avon, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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