Cycle 1
Health 2026-01-09 · Fire 2026-01-09
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Avilla, IN
Ascension Living Sacred Heart Village
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
515 N Main St, Avilla, IN
(260) 897-2841
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
78
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1994-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,633
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.74
Baseline 64.89% · Performance 44.32% · Measure score 4.74 · Achievement 4.74 · Improvement 4.64
Adjusted total nurse staffing
1.70
Baseline 3.33 hours · Performance 3.56 hours · Measure score 1.70 · Achievement 1.70 · Improvement 0.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.34% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 20.51% · Lower 95% interval 8.74% |
| Discharge to community | 46.16% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 37.93% · Lower 95% interval 30.78% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 80% |
95.27%
15.3 pts worse
|
Numerator 16 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.09% |
8.2%
1.1 pts worse
|
Numerator 9 · Denominator 127 |
| Staff flu vaccination coverage | 88.51% |
42%
46.5 pts better
|
Numerator 131 · Denominator 148 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| 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 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| 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 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
93.6%
5.1 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 87.1% · Q3 88.4% · Q4 94.8% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.4%
1.9 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.8%
1.4 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 1.4% · Q4 3.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
24.6%
23.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.6%
1.3 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.6% · Q3 8.2% · Q4 4.3% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
23.5%
1.6 pts worse
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 25.8% · Q3 30.2% · Q4 19.7% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
14.8%
1.9 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.0% · Q3 12.5% · Q4 15.6% · 4Q avg 12.9% · 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 | 27.3% |
13.3%
14 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 20.7% · Q3 42.4% · Q4 18.7% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
11.7%
15.3 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 27.8% · Q3 30.5% · Q4 24.3% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.4%
0.7 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.3% |
24.2%
9.9 pts better
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 15.7% · Q3 23.9% · Q4 10.1% · 4Q avg 14.3% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.1%
1.3 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.9% · Q3 4.2% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.1% |
81.6%
0.5 pts better
|
81.7%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 71.8% · Q2 80.8% · Q3 80.8% · Q4 93.6% · 4Q avg 82.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
10.5%
6.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 5.0% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.7% |
79.0%
3.7 pts better
|
79.7%
3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
22.4%
2.3 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 30.0% · Expected 29.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-19 · Fire 2024-12-19
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2024-01-08 · Fire 2024-01-08
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
F · Potential for more than minimal harm
2026-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Not marked corrected
E · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-12-19
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-12-19
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-12-19
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-01-08
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 2024-03-01
E · Potential for more than minimal harm
2024-01-08
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-08
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
C · Minimal harm
2024-01-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-03-01
E · Potential for more than minimal harm
2023-08-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-09
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 2026-01-27
E · Potential for more than minimal harm
2026-01-09
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 2026-01-27
E · Potential for more than minimal harm
2026-01-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-01-27
D · Potential for more than minimal harm
2026-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-27
D · Potential for more than minimal harm
2026-01-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-27
F · Potential for more than minimal harm
2024-12-19
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 2025-01-16
D · Potential for more than minimal harm
2024-12-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-19
F688 · Quality of Life and Care Deficiencies
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 2025-01-16
D · Potential for more than minimal harm
2024-12-19
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 2025-01-16
E · Potential for more than minimal harm
2024-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-08
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 2024-01-26
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Breedlove, Ryan
Operational/Managerial Control · Individual
Eidam, Joellen
Corporate Officer · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Gronefeld, Kellie
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Musgrave, Lisa
Operational/Managerial Control · Individual
Presence Life Connections
Operational/Managerial Control · Organization
Prokupek, Craig
Contracted Managing Employee · Individual
Shadbolt, Erin
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Smoot, Kenneth
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Kendallville Manor
Kendallville, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lutheran Life Villages
Kendallville, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Orchard Pointe Health Campus
Kendallville, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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