Cycle 1
Health 2025-03-28 · Fire 2025-03-28
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Greencastle, IN
Asbury Towers Health Care Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
102 W Poplar St, Greencastle, IN
(765) 653-5148
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-08-29
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
Hours and turnover
RN hours / resident day
1.66
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
4.63
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
7.28
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
6.51
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.25
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.70
CMS adjusted RN staffing hours
Adjusted total hours
7.44
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 5.72% |
| Discharge to community | 57.04% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 53.85% · Lower 95% interval 41.82% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.09% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 92 |
| Staff flu vaccination coverage | 10.53% |
42%
31.5 pts worse
|
Numerator 10 · Denominator 95 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.9% |
93.6%
23.7 pts worse
|
93.4%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 69.6% · 4Q avg 69.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
95.4%
0.4 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.8%
0.2 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.5% |
24.6%
5.1 pts better
|
11.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 15.0% · 4Q avg 19.5% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.6%
2.1 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.9% |
23.5%
10.4 pts worse
|
19.6%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.6% |
14.8%
20.8 pts worse
|
16.7%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.6% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
13.3%
2.2 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
11.7%
1.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · 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 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.2%
2.5 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
24.2%
5 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 14.7% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.1%
2.2 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.3% |
81.6%
15.3 pts worse
|
81.7%
15.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 61.9% · Q3 72.7% · Q4 75.0% · 4Q avg 66.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.3%
2.5 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.9% |
79.0%
17.1 pts worse
|
79.7%
17.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
28 fire-safety deficiencies
Top issue: Smoke (11 deficiencies)
Cycle 3
Health 2022-11-22 · Fire 2022-11-22
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-03-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-09
F · Potential for more than minimal harm
2024-02-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-02-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-09
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-02-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-02-09
K223 · Egress Deficiencies
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 2024-03-06
D · Potential for more than minimal harm
2024-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-05
C · Minimal harm
2024-02-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-20
C · Minimal harm
2024-02-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-04-20
C · Minimal harm
2024-02-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-04-20
C · Minimal harm
2024-02-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-20
C · Minimal harm
2024-02-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-20
C · Minimal harm
2024-02-09
K321 · Smoke Deficiencies
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 2024-03-21
C · Minimal harm
2024-02-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-20
F · Potential for more than minimal harm
2022-11-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-27
F · Potential for more than minimal harm
2022-11-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-13
F · Potential for more than minimal harm
2022-11-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-13
F · Potential for more than minimal harm
2022-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-02-28
C · Minimal harm
2022-11-22
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-06
C · Minimal harm
2022-11-22
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-01-06
C · Minimal harm
2022-11-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-01-26
C · Minimal harm
2022-11-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-02-09
F690 · Quality of Life and Care Deficiencies
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 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-22
E · Potential for more than minimal harm
2022-11-22
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-31
Penalties and ownership
What sits behind the stars
Ownership
Ahlbrand, Eric
Operational/Managerial Control · Individual
Asbury Towers Retirement Community Inc
Operational/Managerial Control · Organization
Beck, Kristy
Operational/Managerial Control · Individual
Case, Michelle
Operational/Managerial Control · Individual
Dickerson, Ashley
Operational/Managerial Control · Individual
Flatt, Martha
Operational/Managerial Control · Individual
Health Management Advisors Inc
Operational/Managerial Control · Organization
Homler, Justin
Operational/Managerial Control · Individual
Hoskins, Jessie
Operational/Managerial Control · Individual
Jarosinski, Stephen
Operational/Managerial Control · Individual
King, Darby
Operational/Managerial Control · Individual
Malott, Gregg
Operational/Managerial Control · Individual
Menora Finacial Corp
Operational/Managerial Control · Organization
Pulaski Memorial Hospital
Operational/Managerial Control · Organization
Roose, Jennifer
Operational/Managerial Control · Individual
Rose, Audra
Operational/Managerial Control · Individual
Savage, John
Operational/Managerial Control · Individual
Smith, Lisa
Operational/Managerial Control · Individual
Sterling Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Hickory Creek At Sunset
Greencastle, IN
2-star overall rating with 3-star inspections with 7 recent health deficiencies
#2
Mill Pond Health Campus
Greencastle, IN
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Waters Of Greencastle, The
Greencastle, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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