Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hutsonwood At Brazil during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia was not accurately assessed in the MDS, as the assessment failed to document her upper extremity range of motion (ROM) limitation despite clear evidence from medical records, staff interviews, and care plans. Staff confirmed the resident could not use her right arm or hand, but the MDS Coordinator and DON acknowledged the impairment was not coded as required.
Three residents with cognitive impairment and upper or lower extremity limitations did not have proper assessment, documentation, or communication of interventions such as hand splints and tray tables. Staff were unaware or only informally notified of these devices, and there were no timely physician orders or care plan updates, contrary to facility policy.
A hospice nurse conducted a resident assessment and took vital signs in a dining area during meal service, violating the resident's privacy and dignity. The resident, who had severe cognitive impairment and was on hospice care, was assessed in the presence of other residents and staff. The facility's policy emphasizes the importance of privacy and dignity in care.
A resident with Alzheimer's and cognitive impairments was found without accessible call light devices, as observed in a hot room with reddened cheeks. The resident's call lights were out of reach, and a CNA confirmed the lack of accessibility. The DON noted that residents with mobility or cognitive issues could have soft touch call devices, which were later installed by the Administrator. The facility's policy requires call light accessibility and timely response.
A facility failed to implement a pharmacy recommendation for a gradual dose reduction of Zoloft for a resident with major depressive disorder and dementia. Despite agreement from the physician and psychologist, the order was not documented or executed until over a year later due to the DON's unexpected absence and lack of verification by the ADON.
A registered nurse in an LTC facility improperly handled medications by placing them in her bare hand and failed to prime insulin pens before administration, leading to a medication error rate over 5%. Additionally, the nurse did not instruct a resident to swish and spit after administering an inhaled corticosteroid, contrary to prescription directions.
The facility failed to properly label and dispose of insulin vials and pens, as observed on two medication carts. A multidose vial of insulin was found without an opening date, and two insulin pens were not discarded within 28 days as required. Interviews revealed staff confusion about the correct expiration period, despite facility policies aligning with FDA guidelines.
During a snack distribution, an Activity Assistant and a CNA were observed handling fudge round cream cookies with bare hands and distributing them to residents without using gloves or hand sanitizer. Interviews with staff confirmed that the facility's protocol required the use of gloves or packaging to handle food items. The Administrator acknowledged the issue and referred to the facility's existing food safety policy.
A facility failed to document insulin administration for a resident with multiple diagnoses, including diabetes. Physician orders required administering Lispro Insulin per a sliding scale and Basaglar KwikPen U-100 Insulin at bedtime. However, several doses were not documented in the EMAR for September and October. The resident was cognitively intact and had been administered insulin during the assessment period, but the care plan was not followed, and the facility's policy on medication administration was not adhered to.
The facility failed to ensure proper hand hygiene and disinfection of glucometers during resident care. An LPN and an RN were observed not following handwashing protocols, turning off faucets with bare hands. Additionally, they did not adhere to the manufacturer's guidelines for disinfecting glucometers, failing to keep the device wet for the required two minutes. The RN admitted to not knowing the necessary wet time for effective disinfection.
The facility failed to provide adequate wound care for two residents, leading to deficiencies in pressure ulcer management. One resident with a history of amputation complications had a dressing that was not changed as per physician orders, and the wound condition worsened. Another resident, with a history of stroke and COPD, was observed without prescribed heel boots and with an outdated dressing. Facility policies on dressing standards and skin condition management were not consistently followed, resulting in these deficiencies.
Inaccurate MDS Assessment for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident, who had a diagnosis of hemiplegia affecting the right dominant side, was observed sitting in a wheelchair with her right arm resting on a tray table. Documentation in the resident's record, including an admission observation and a physician's progress note, indicated impairment and weakness on the right side. The care plan also identified a self-care deficit related to right-sided hemiplegia. However, the admission MDS assessment did not reflect any functional limitation in range of motion (ROM) for the upper or lower extremities. Interviews with staff confirmed that the resident was unable to use her right arm or hand and relied on her left side for activities of daily living. The MDS Coordinator expressed uncertainty about whether the resident's hemiplegia should have been coded as an impairment in ROM, and the DON later acknowledged that the limitation should have been coded but was missed. The facility's policy, based on the CMS Resident Assessment Instrument (RAI) Manual, requires coding of functional ROM limitations that interfere with daily functions or place the resident at risk, which was not followed in this case.
Failure to Assess, Document, and Communicate Range of Motion Interventions
Penalty
Summary
The facility failed to ensure that limitations in range of motion (ROM) were properly assessed, treated, and that required interventions were effectively communicated to staff for three residents with ROM limitations. For one resident with severe cognitive impairment and upper extremity weakness, hand splints intended to prevent contractures were brought in at admission but not used until several days later. Staff were initially unaware of the splints, and there was a lack of timely physician orders, care plan documentation, and communication between therapy and nursing regarding the use of the splints. The care plan did not reflect the resident's functional limitation in ROM or the presence of hand splints, and therapy notes did not indicate communication of splint use to nursing staff. Another resident with severe cognitive impairment and right-sided hemiplegia was observed using a right-sided tray table for arm support. However, there was no physician order for the tray table, and the care plan did not document its use. Staff interviews revealed that the tray table intervention was communicated informally through verbal reports rather than through formal documentation or assignment sheets. The Director of Nursing was unaware of the tray table's use and could not find documentation or therapy notes supporting its implementation. A third resident with moderate cognitive impairment and left-sided hemiplegia was observed with a left-sided tray table, but again, there was no physician order or care plan documentation for the device. Staff were unsure when the tray table was introduced and relied on verbal communication for such interventions. The facility's policy required that assistive devices be based on comprehensive assessment and included in the plan of care, with staff training and monitoring, but these procedures were not followed for the residents in question.
Privacy Violation During Resident Assessment
Penalty
Summary
The facility failed to ensure that a contracted hospice nurse completed a resident assessment and vital signs in privacy for a resident during meal service. The incident occurred when the hospice nurse entered the dining area of the memory care unit and conducted an assessment on a resident sitting in a Broda chair at a table waiting for lunch. The nurse obtained various vital signs, including a temporal temperature, blood pressure, pulse oximeter reading, heart rate, and arm circumference, while other residents, a licensed practical nurse, and a certified nurse's aide were present. The hospice nurse also leaned in to ask the resident questions about her well-being. The resident involved had diagnoses of unspecified dementia and major depressive disorder and was receiving hospice services. The resident's quarterly Minimum Data Set assessment indicated severe cognitive impairment. Interviews with the LPN, Director of Nursing, and the Administrator confirmed that the hospice nurse should not have conducted the assessment during meal service, as it violated the resident's right to privacy and dignity. The facility's policy on resident rights emphasized the importance of personal privacy and dignity in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, identified as Resident 7, who was observed in a Broda chair facing the window with the left side of his face in direct sunlight. The room was hot, and the resident's cheeks were reddened. Two button-press call lights were observed on the beds, not within reach of the resident. A Certified Nursing Assistant (CNA) confirmed the room was hot and that the resident appeared to be leaning to get out of the sunlight. The CNA acknowledged that the resident did not have his call light and provided him with a button-press call light before leaving the room. Further observations revealed that the resident, who had diagnoses including Alzheimer's disease, cognitive communication deficit, and dementia, was resting in bed with two button-press call lights in a recliner at the foot of the bed, again not within reach. The Director of Nursing (DON) indicated that residents with mobility issues or cognitive impairments could have soft touch call devices. The Administrator later installed soft touch call devices for the resident, acknowledging that he was unaware the resident did not have one previously. The facility's policy on call lights emphasized ensuring accessibility and timely response, with special accommodations identified in the resident's person-centered plan of care.
Failure to Implement Pharmacy Recommendation for Dose Reduction
Penalty
Summary
The facility failed to address a pharmacy recommendation for a gradual dose reduction of Zoloft for a resident diagnosed with major depressive disorder and dementia with behavioral disturbance. The recommendation was initially made in October of the previous year, suggesting a reduction from 50 mg to 25 mg daily. Although the physician and psychologist agreed to the reduction, the order was not documented or implemented until December of the following year. This oversight was due to a series of events, including the Director of Nursing (DON) leaving the facility unexpectedly due to a car accident, which resulted in a six-month absence. During the DON's absence, the Assistant Director of Nursing (ADON) and corporate nursing support were responsible for managing unfinished tasks. However, the ADON did not verify the completion of the pharmacy recommendation in the resident's electronic medical record, leading to the oversight. The facility's policy on medication orders requires documentation of changes, but this was not adhered to in this case, resulting in the failure to implement the recommended dose reduction in a timely manner.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper handling and administration of medications, resulting in a medication error rate exceeding 5 percent for two residents. During a medication administration observation, a registered nurse placed medications for two residents into her bare hand before transferring them to a medication cup, which is against the facility's policy. Additionally, the nurse did not prime the insulin pens according to the manufacturer's guidelines before administering insulin to both residents. This failure to prime the insulin pens could lead to incorrect dosing. Furthermore, the nurse administered an inhaled corticosteroid to one of the residents without instructing them to swish and spit with water afterward, as required by the medication prescription label directions. The facility's policies on medication administration and insulin pen use were not followed, contributing to the medication errors observed during the survey.
Improper Labeling and Disposal of Insulin Products
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of insulin vials and pens, as observed during a survey. On two medication carts, a multidose vial of Amaolg insulin prescribed for a resident was found without an opening date, and two Lantus insulin pens for another resident were dated as opened but not discarded within the required 28 days. Additionally, a Basaglar insulin pen for a third resident lacked an opening date, although the prescription label indicated it was opened. These observations indicate non-compliance with the FDA guidelines and the facility's own policy, which require insulin products to be discarded 28 days after opening. Interviews with facility staff revealed a lack of understanding of the correct expiration period for insulin products. An LPN incorrectly stated that insulin vials and pens are good for 30 days once opened, while the DON confirmed the correct expiration period of 28 days. The facility's policy documents, provided by the DON, also specify that insulin pens should be disposed of after 28 days or according to the manufacturer's recommendation. The failure to adhere to these guidelines and policies resulted in the observed deficiencies.
Unsanitary Snack Distribution Observed
Penalty
Summary
The facility failed to ensure snacks were served in a sanitary manner during a random snack distribution observation. On the memory care unit, an Activity Assistant was observed removing fudge round cream cookies from their plastic packaging with bare hands and handing them to seven different residents without using gloves or hand sanitizer. Similarly, a Certified Nurse's Assistant (CNA) was seen in the nutrition room removing a cookie from its packaging with bare hands and giving it to a male resident, then touching the resident's shoulder without using gloves or hand sanitizer. Interviews with staff members, including a CNA and a Qualified Medication Aide (QMA), revealed that the facility's protocol was to use gloves or the plastic packaging to handle food items, indicating that staff should not touch food with bare hands. The Administrator confirmed that staff should not handle food with bare hands and mentioned plans to address the issue. The facility's policy on Food Safety and Sanitation, dated 8/14/2019, was provided, which emphasized handling all foods safely.
Failure to Document Insulin Administration
Penalty
Summary
The facility failed to document insulin administration for a resident, identified as Resident 23, who was reviewed for medication administration. The resident was admitted with multiple diagnoses, including COPD, type 2 diabetes mellitus with diabetic neuropathy, and GERD. Physician orders for the resident included administering Lispro Insulin per a sliding scale and Basaglar KwikPen U-100 Insulin at bedtime. However, a review of the electronic medication administration record (EMAR) revealed that several doses of Lispro sliding scale insulin, Lispro insulin, and Protonix were not documented as administered in September and October. The resident's annual Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and had been administered insulin during the assessment period. Despite this, the care plan, which included administering medication as ordered, was not followed as evidenced by the missing documentation. The facility's policy on medication administration required signing the MAR after administering medication, which was not adhered to in this case.
Improper Hand Hygiene and Glucometer Disinfection
Penalty
Summary
The facility failed to ensure proper hand hygiene and handling of medical equipment during resident care, specifically during medication administration. On two separate occasions, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were observed not following proper handwashing procedures. Both nurses turned off the faucet with their bare hands after washing, which is against the facility's hand hygiene policy that requires using a paper towel to turn off the faucet. This improper handwashing practice was observed during routine handwashing observations. Additionally, the facility did not adhere to the manufacturer's guidelines for disinfecting glucometers used for measuring blood sugar levels. During medication administration, both the LPN and RN were observed cleaning the glucometer with a Sani wipe but failed to keep the device wet for the required two minutes as per the manufacturer's instructions. The nurses set the glucometer aside on a paper towel without ensuring the necessary contact time for effective disinfection. The RN admitted to not knowing the required wet time for the disinfectant to be effective, indicating a lack of awareness or training regarding the proper cleaning procedures for medical devices.
Deficiencies in Wound Care and Pressure Ulcer Management
Penalty
Summary
The facility failed to provide adequate wound care for two residents, leading to deficiencies in pressure ulcer management. Resident S, who had a history of complications from an amputation and other significant health issues, was observed with a dressing on the left foot that had not been changed over the weekend, contrary to the physician's orders for regular dressing changes. The treatment administration record showed missing documentation for several scheduled dressing changes, and the wound condition worsened over time. The Director of Nursing Services was unaware of the facility's policy regarding dating dressings, and the Licensed Practical Nurse confirmed that dressings were usually changed during the day shift. Resident C, who had a history of stroke and chronic obstructive pulmonary disease, was observed without the prescribed off-loading heel boots and with a dressing on the left heel that had not been changed since four days prior. The resident's care plan lacked documentation for the use of heel boots, and the dressing was not changed as per the physician's order. Interviews with nursing staff revealed inconsistencies in the application and dating of dressings, and the Certified Nurse Aide acknowledged the absence of pressure-relieving boots, which were not found in the resident's room. The facility's policies on treatment dressing standards and skin condition management were not adhered to, as evidenced by the lack of proper documentation and failure to follow physician orders for wound care. The Administrator provided the relevant policies, which emphasized the importance of dating dressings and elevating heels to prevent skin impairment, but these practices were not consistently implemented, leading to the identified deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brazil
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cloverleaf Of Knightsville | 1.1 mi | — | 6 | 0 |
| Signature Healthcare Of Terre Haute | 14 mi | — | 18 | 0 |
| Majestic Care Of Deming Park | 14.5 mi | — | 4 | 2 |
| Hickory Creek At Sunset | 15.1 mi | — | 7 | 0 |
| Asbury Towers Health Care Center | 15.5 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.