Cycle 1
Health 2025-03-19 · Fire 2025-03-19
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jasper, IN
Brookside Village Inc
5-star overall rating with 5-star inspections
1111 Church Ave, Jasper, IN
(812) 634-7750
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
27
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
2002-07-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 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
1.06
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,227
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.58
Baseline 17.98% · Performance 19.31% · Measure score 4.58 · Achievement 4.58 · Improvement 0
Healthcare-associated infections
6.33
Baseline 5.46% · Performance 5.94% · Measure score 6.33 · Achievement 6.33 · Improvement 0
Total nurse turnover
0.17
Baseline 79.41% · Performance 75.76% · Measure score 0.17 · Achievement 0 · Improvement 0.17
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 11.4% · Lower 95% interval 7.76% |
| Discharge to community | 57.88% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 57.41% · Lower 95% interval 48.8% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 84.87% |
95.27%
10.4 pts worse
|
Numerator 101 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 41.75% |
53.69%
11.9 pts worse
|
Numerator 43 · Denominator 103 |
| Discharge mobility score | 51.46% |
50.94%
0.5 pts better
|
Numerator 53 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 119 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 2.44% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.28% |
56.45%
0.8 pts better
|
Numerator 59 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 78 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 28.79% |
25.2%
3.6 pts better
|
Numerator 19 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
24.6%
15.1 pts better
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.6%
2.7 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.9% |
23.5%
20.6 pts better
|
19.6%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.8%
14.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
11.7%
2.6 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
24.2%
11.3 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.1%
1.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
81.6%
14.4 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 97.6% · Q3 94.5% · Q4 95.1% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
10.5%
1.6 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.3%
2.6 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.9% · Q3 2.4% · Q4 5.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
79.0%
18.6 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
22.4%
9 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 10.6% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-26 · Fire 2024-02-26
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-15 · Fire 2022-08-15
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-18
F · Potential for more than minimal harm
2024-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
C · Minimal harm
2024-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-12
F · Potential for more than minimal harm
2022-08-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-13
C · Minimal harm
2022-08-15
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-10-13
C · Minimal harm
2022-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-02-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-11
D · Potential for more than minimal harm
2023-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-30
Penalties and ownership
What sits behind the stars
Ownership
Cardon Operating Group Inc
5% Or Greater Direct Ownership Interest · Organization
Moore Operating Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Broughton, Wendy
Operational/Managerial Control · Individual
Cardon And Associates Inc
Operational/Managerial Control · Organization
Grannan, Britt
Operational/Managerial Control · Individual
Moore, Stephen
Corporate Officer · Individual
Rodgers, Kent
W-2 Managing Employee · Individual
Nearby options
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#2
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#3
Timbers Of Jasper The
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