Inspection Report Summary
The most recent inspection on July 2, 2025, was a complaint investigation that found no deficiencies related to the allegations. Earlier inspections showed a mixed pattern, with some reports noting deficiencies in resident care, medication management, infection control, and Life Safety Code compliance. Prior issues included privacy and dignity concerns, medication labeling and storage problems, and fire safety code violations, but enforcement actions such as fines or license suspensions were not listed in the available reports. Several complaint investigations were unsubstantiated, though one substantiated complaint in early 2024 involved a transportation safety issue that was promptly corrected. The facility’s record shows some improvement in Life Safety Code compliance and complaint outcomes in recent months, though resident care and medication management issues have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
84 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462624.
Findings
No deficiencies related to the allegations in Complaint IN00462624 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00462624 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 84
Census Payor Type Total: 84
SNF/NF Census: 17
SNF Census: 67
Medicare Census: 23
Medicaid Census: 55
Other Payor Census: 6
Inspection Report
Follow-Up
Census: 78
Capacity: 117
Deficiencies: 0
May 22, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/15/25 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Brooke Knoll Village was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 76
Capacity: 117
Deficiencies: 1
Apr 15, 2025
Visit Reason
The visit was conducted as a Life Safety Code and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and an Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to provide an approved method to ensure the kitchen stove and flat grill were returned to their original positioning after maintenance or cleaning.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide an approved method for returning cooking appliances to their original positioning after maintenance or cleaning, violating NFPA 96 standards. | SS=E |
Report Facts
Certified beds: 117
Census: 76
Staff potentially affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Wilson | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Maintenance Director | Named in corrective action for deficiency related to stove positioning | |
| Life Safety Director | Interviewed regarding the deficiency and aware of the requirement | |
| Dietary Manager | Responsible for ongoing compliance observations and staff education |
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 10
Mar 27, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 24 to 27, 2025.
Findings
The facility was found deficient in multiple areas including resident rights violations related to privacy and dignity, failure to honor resident preferences for lab draw times, incomplete PASARR screening, inadequate discharge planning, medication safety issues, trauma-informed care deficiencies, delayed pharmacy recommendation follow-up, medication labeling and storage problems, and infection control lapses related to nasal spray administration and enhanced barrier precautions.
Severity Breakdown
SS=E: 5
SS=D: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Staff failed to knock and announce themselves before entering residents' rooms, violating residents' right to privacy and dignity. | SS=E |
| Facility failed to honor resident's preference for timing of routine lab draws, causing distress. | SS=D |
| Failed to initiate new PASARR screening after new mental health diagnosis was added. | SS=D |
| Failed to ensure comprehensive discharge plan was in place and implemented. | SS=D |
| Failed to prevent potential accidents related to medications left at bedside. | SS=D |
| Failed to provide trauma-informed care addressing triggers and personalized interventions for residents with PTSD. | SS=D |
| Failed to follow up timely with pharmacy recommendations for medication regimen changes. | SS=D |
| Failed to date medications when opened and label over-the-counter medications properly. | SS=E |
| Failed to use appropriate infection control measures during nasal spray administration. | SS=E |
| Failed to ensure consistent and effective infection control practices related to enhanced barrier precautions (EBP), including signage and PPE availability. | SS=E |
Report Facts
Survey dates: 4
Residents present: 79
Total licensed capacity: 79
Medicare residents: 17
Medicaid residents: 53
Other payor residents: 9
Pharmacy recommendation response time: 7
Medication cart inspections frequency: 2
Enhanced Barrier Precautions monitoring frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Wilson | HFA | Signed the report |
| CNA 12 | Mentioned in relation to resident lab draw timing and privacy issues | |
| CNA 14 | Mentioned in relation to privacy violations and enhanced barrier precautions | |
| LPN 13 | Licensed Practical Nurse | Observed administering nasal spray without gloves and medication pass |
| Social Service Director | SSD | Interviewed regarding trauma informed care and PASARR screening |
| Director of Nursing | DON | Interviewed regarding lab draw timing and pharmacy recommendation follow-up |
| Regional Nurse Consultant | RNC | Reviewed care plans and policies |
| Qualified Medication Aide 11 | QMA | Interviewed regarding resident lab draw timing |
| Unit Manager 10 | Interviewed regarding enhanced barrier precautions |
Inspection Report
Renewal
Deficiencies: 0
Mar 27, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on March 27, 2025.
Findings
Brooke Knoll Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Dec 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447176 and IN00447901 at Brooke Knoll Village.
Findings
No deficiencies related to the allegations in complaints IN00447176 and IN00447901 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447176 - No deficiencies related to the allegations are cited. Complaint IN00447901 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 65
Census Bed Type - SNF: 14
Census Bed Type - Total: 79
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 53
Census Payor Type - Other: 8
Census Payor Type - Total: 79
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
May 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433641 and IN00433687.
Findings
No deficiencies related to the allegations in complaints IN00433641 and IN00433687 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00433641 and Complaint IN00433687 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 66
Census Bed Type: 14
Total Census: 80
Census Payor Type: 18
Census Payor Type: 51
Census Payor Type: 11
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Mar 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427498 and IN00428895. Complaint IN00427498 had no deficiencies related to the allegations, while Complaint IN00428895 resulted in federal/state deficiencies being cited.
Findings
The facility failed to ensure a resident's wheelchair wheels were properly engaged in the facility van's wheelchair-locks, resulting in the resident tipping over and hitting her head during transport. The incident was investigated, and the facility took corrective actions including removing the van from service, inspecting the vehicle, and educating transportation drivers on proper securement procedures. The deficiency was cited as past noncompliance and corrected prior to the survey.
Complaint Details
Complaint IN00428895 was substantiated with federal/state deficiencies cited. Complaint IN00427498 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's wheelchair wheels were engaged into the facility van wheelchair-locks properly, causing the resident to tip over and hit her head during transport. | SS=D |
Report Facts
Census Bed Type Total: 85
SNF/NF Census: 71
SNF Census: 14
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 49
Census Payor Type Other: 22
Inspection Report
Life Safety
Census: 79
Capacity: 117
Deficiencies: 0
Feb 19, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
Brooke Knoll Village was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and smoke detectors in all resident sleeping rooms and corridors.
Report Facts
Certified beds: 117
Census: 79
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 10
Jan 25, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00416462.
Findings
The facility was found deficient in multiple areas including call light accessibility, accuracy of assessments, PASARR coordination, ADL care, podiatry services, accident hazards, feeding tube management, respiratory care, trauma-informed care, medication labeling and storage, and food safety. Complaint allegations were not substantiated.
Complaint Details
Complaint IN00416462 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=E: 3
SS=D: 6
SS=A: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure call lights were placed within reach for 4 of 4 residents observed. | SS=E |
| Failed to accurately code the MDS for PASARR level II services for 1 of 2 residents reviewed. | SS=D |
| Failed to submit new Level of Care screen after new mental health diagnosis and medication for 1 of 2 residents reviewed. | SS=A |
| Failed to ensure a resident's toenails were cut to prevent discomfort for 1 of 1 resident reviewed. | SS=D |
| Failed to maintain bedrails and secure medications for 1 of 5 residents reviewed for accidents. | SS=D |
| Failed to date feeding and water bags for 1 of 2 residents reviewed for feeding tubes. | SS=D |
| Failed to exchange oxygen equipment timely for 1 of 4 residents receiving oxygen therapy. | SS=D |
| Failed to provide culturally appropriate and person-centered services for a resident who spoke a different language. | SS=D |
| Failed to ensure expired medications were replaced and refrigerated medications stored properly for 5 of 6 residents reviewed. | SS=E |
| Failed to ensure hand washing was completed according to policy for 2 of 4 residents during meal assistance. | SS=D |
Report Facts
Census: 88
SNF Beds: 9
SNF/NF Beds: 79
Medicare Census: 9
Medicaid Census: 61
Other Payor Census: 18
Deficiency Count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Davison | Administrator | Signed report and plan of correction |
| CNA 21 | Certified Nursing Aide | Mentioned in culturally competent care and feeding assistance findings |
| CNA 14 | Certified Nursing Aide | Mentioned in culturally competent care and beard trimming findings |
| LPN 20 | Licensed Practical Nurse | Mentioned in medication storage and administration findings |
| Infection Preventionist | Provided policies and interviewed regarding multiple findings | |
| Physical Therapist 23 | Physical Therapist | Spoke resident's language and provided cultural insight |
| Physical Therapist 24 | Physical Therapist | Spoke resident's language and provided cultural insight |
| Corporate Dietary Consultant | Observed meal preparation and interviewed regarding food service |
Inspection Report
Renewal
Deficiencies: 0
Jan 25, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on January 25, 2024.
Findings
Brooke Knoll Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
May 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408662 regarding alleged deficiencies related to the accuracy of a resident's Minimum Data Set (MDS) assessment for bed mobility.
Findings
The facility failed to accurately code a resident's MDS assessment for bed mobility for 1 of 3 residents reviewed, specifically Resident C, who was incorrectly coded as totally dependent when she could use side rails to assist mobility. The facility initiated education and audits to ensure accurate coding and compliance.
Complaint Details
Complaint IN00408662 was investigated and deficiencies related to the allegations were substantiated and cited at F641 regarding MDS accuracy for bed mobility coding.
Severity Breakdown
SS=A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to accurately code a resident's Minimum Data Set (MDS) assessment for bed mobility for 1 of 3 residents reviewed. | SS=A |
Report Facts
Census: 67
SNF/NF beds: 59
SNF beds: 8
Medicare residents: 10
Medicaid residents: 51
Other payor residents: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Mille | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Apr 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403650.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00403650 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 76
Census Bed Type - SNF/NF: 64
Census Bed Type - SNF: 12
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Feb 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400112.
Findings
The complaint IN00400112 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00400112 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 78
Census Payor Type Total: 78
SNF/NF Beds: 66
SNF Beds: 12
Medicare Residents: 9
Medicaid Residents: 59
Other Residents: 10
Inspection Report
Follow-Up
Census: 77
Capacity: 117
Deficiencies: 0
Jan 17, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/17/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Brooke Knoll Village was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 117
Census: 77
Inspection Report
Life Safety
Census: 74
Capacity: 117
Deficiencies: 3
Nov 17, 2022
Visit Reason
The visit was conducted as a Life Safety Code and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements, including deficiencies related to door latches on a kitchen door, missing exit signage in the kitchen, and failure to conduct quarterly fire drills for one of four quarters in 2022.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 door from the kitchen to the service hall was provided with door latches that required only one operation to open. | SS=E |
| Failed to install exit signage in 1 of 1 kitchen in the facility in accordance with LSC 7.10. | SS=E |
| Failed to conduct quarterly fire drills for 1 of 4 quarters in 2022. | SS=F |
Report Facts
Certified beds: 117
Census: 74
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Davison | Administrator | Named in relation to findings and exit conference |
| Director of Corporate Maintenance | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Renewal
Census: 81
Capacity: 81
Deficiencies: 6
Oct 6, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from September 29 to October 6, 2022.
Findings
The facility was found deficient in several areas including failure to provide timely Notice of Medicare Noncoverage to a resident, inaccurate coding of mental health diagnoses in assessments, incomplete baseline care plans, unsecured medications left in residents' rooms, improper food storage and sanitation practices in the kitchen, and inadequate infection control practices related to glucometer cleaning and linen handling.
Severity Breakdown
SS=D: 3
SS=A: 1
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a resident received appropriate and timely Notice of Medicare Noncoverage. | SS=D |
| Failure to ensure accurate coding of mental health diagnoses in Minimum Data Set assessments. | SS=A |
| Failure to ensure a complete baseline care plan was implemented within 48 hours of admission. | SS=D |
| Failure to ensure medications were not left unsecured in residents' rooms and unauthorized staff were not present with unsecured medications. | SS=E |
| Failure to ensure proper food safety practices including presence of thermometers, labeling and dating of food, sanitizer concentration, and staff wearing beard covers. | SS=E |
| Failure to ensure proper infection prevention and control including cleaning of glucometers and appropriate handling of soiled and clean linens. | SS=E |
Report Facts
Census SNF/NF: 66
Census SNF: 15
Total Census: 81
Medicare Census: 13
Medicaid Census: 55
Other Payor Census: 13
Medication counts left unsecured: 5
Sanitizer concentration: 0
Sanitizer concentration after refill: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Miller | Laboratory Director or Provider/Supplier Representative | Signed the report on 10/31/2022 |
| LPN 19 | Licensed Practical Nurse | Named in medication administration and glucometer cleaning deficiencies |
| Business Office Manager | Interviewed regarding Notice of Medicare Noncoverage process | |
| Clinical Consultant | Provided multiple interviews and policies related to care planning, medication administration, and infection control | |
| Social Service Director | Interviewed regarding mental health diagnoses and MDS coding | |
| Dietary Manager | Interviewed regarding food safety and sanitation practices | |
| District Manager of Dietary Services | Interviewed regarding sanitizer concentration and kitchen observations |
Inspection Report
Renewal
Deficiencies: 0
Oct 6, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey.
Findings
Brooke Knoll Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
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