8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Brownstown, IN
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
621 S Sugar St, Brownstown, IN
(812) 358-2504
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
97
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
1997-03-01
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
RN hours / resident day
0.43
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.24
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
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
8,344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.99
Baseline 18.50% · Performance 19.58% · Measure score 3.99 · Achievement 3.99 · Improvement 0
Healthcare-associated infections
0
Baseline 6.03% · Performance 7.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.14
Baseline 46.39% · Performance 42.68% · Measure score 5.14 · Achievement 5.14 · Improvement 1.22
Adjusted total nurse staffing
1.69
Baseline 3.70 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 5.41% |
| Discharge to community | 59.31% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 59.15% · Lower 95% interval 49.88% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 68.75% |
53.69%
15.1 pts better
|
Numerator 22 · Denominator 32 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 20 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 128 |
| Staff flu vaccination coverage | 65.91% |
42%
23.9 pts better
|
Numerator 145 · Denominator 220 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 18 · Denominator 32 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 5 · Denominator 20 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
95.4%
2.2 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| 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 3.9% · Q2 1.3% · Q3 1.3% · Q4 1.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 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 who lose too much weight | 10.0% |
5.6%
4.4 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 13.7% · Q3 11.1% · Q4 2.8% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
23.5%
5.6 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 19.2% · Q3 18.1% · Q4 18.1% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
14.8%
1.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.1% · Q3 14.5% · Q4 10.9% · 4Q avg 13.0% · 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 | 16.9% |
13.3%
3.6 pts worse
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 19.1% · Q3 13.2% · Q4 10.3% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
11.7%
2.4 pts worse
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 22.6% · Q3 10.8% · Q4 6.0% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 1.3% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
24.2%
2.7 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 29.8% · Q3 28.9% · Q4 25.6% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.1%
0.4 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.1% · Q3 3.3% · Q4 3.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
81.6%
14.2 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 95.5% · Q3 97.1% · Q4 96.8% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
10.5%
0.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
79.0%
12.3 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
22.4%
3.8 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 13.6% · Expected 17.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
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 2025-10-01
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-10-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-13
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-06
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-06
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-06
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-29
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-08-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-29
Health
Post nurse staffing information every day.
Corrected 2025-05-05
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-15
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
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 2024-11-15
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-15
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 2023-09-19
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-19
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-09-19
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-02-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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