6 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Brook, IN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3623 East State Rd 16, Brook, IN
(219) 275-2531
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
57
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.29
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.01
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
3.53
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.20
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
0.30
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
8,236
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.69% · Performance 21.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.99
Baseline 7.40% · Performance 7.54% · Measure score 0.99 · Achievement 0.99 · Improvement 0
Total nurse turnover
8.24
Baseline 44.64% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 6.90
Adjusted total nurse staffing
1.73
Baseline 3.91 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.9% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 20% · Lower 95% interval 9.72% |
| Discharge to community | 47.6% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 41.46% · Lower 95% interval 37.05% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 3.3% |
8.2%
4.9 pts worse
|
Numerator 3 · Denominator 91 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 101 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.8%
1.9 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.0% · Q4 3.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
24.6%
24.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.6%
0.9 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.4% · Q3 4.1% · Q4 2.2% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
23.5%
6.5 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.8% · Q3 16.3% · Q4 16.7% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
14.8%
4.8 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 10.0% · Q3 11.4% · Q4 11.1% · 4Q avg 10.0% · 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 · 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 | 20.9% |
13.3%
7.6 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 9.5% · Q4 31.2% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
11.7%
7.3 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 24.4% · Q3 18.6% · Q4 11.6% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.4%
1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.7% |
1.2%
10.5 pts worse
|
1.7%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.6% · Q3 13.7% · Q4 12.2% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
24.2%
4 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 31.2% · Q3 14.5% · Q4 18.4% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.1%
1.7 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.4% · Q3 5.0% · Q4 3.2% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
81.6%
18.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 13.0% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
22.4%
9.8 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-03-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-02
Fire Safety
Have an externally vented heating system.
Corrected 2025-03-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-01
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-16
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-16
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-16
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 2023-02-16
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-16
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-16
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-16
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-14
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-11-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-11
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-11
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 2024-02-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-02-01
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-01
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-01
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-01
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-01
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-01-05
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-01-05
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-01-05
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-05
Penalties and ownership
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Contracted Managing Employee · Individual
Contracted Managing Employee · Individual
W-2 Managing Employee · Individual
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