Cycle 1
Health 2025-04-28 · Fire 2025-04-28
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Greenwood, IN
Aspen Trace Health & Living Community
5-star overall rating with 5-star inspections with 2 recent health deficiencies
3154 South State Road 135, Greenwood, IN
(317) 535-3344
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
100
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
2014-06-12
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
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,826
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.75% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.40
Baseline 6.46% · Performance 7.42% · Measure score 1.40 · Achievement 1.40 · Improvement 0
Total nurse turnover
1.31
Baseline 61.05% · Performance 58.33% · Measure score 1.31 · Achievement 1.31 · Improvement 0.25
Adjusted total nurse staffing
1.38
Baseline 2.74 hours · Performance 3.31 hours · Measure score 1.38 · Achievement 0.82 · Improvement 1.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 319 · Observed rate 12.85% · Lower 95% interval 9.3% |
| Discharge to community | 60.57% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 316 · Observed rate 56.33% · Lower 95% interval 54.61% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.16% |
95.27%
1.9 pts better
|
Numerator 171 · Denominator 176 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 176 |
| Discharge self-care score | 76.22% |
53.69%
22.5 pts better
|
Numerator 109 · Denominator 143 |
| Discharge mobility score | 56.64% |
50.94%
5.7 pts better
|
Numerator 81 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 1.7% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 176 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 7.02% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 4.19% |
8.2%
4 pts worse
|
Numerator 8 · Denominator 191 |
| Staff flu vaccination coverage | 54.27% |
42%
12.3 pts better
|
Numerator 89 · Denominator 164 |
| Discharge function score | 71.33% |
56.45%
14.9 pts better
|
Numerator 102 · Denominator 143 |
| Transfer of health information to provider | 94.87% |
95.95%
1.1 pts worse
|
Numerator 37 · Denominator 39 |
| Transfer of health information to patient | 99.09% |
96.28%
2.8 pts better
|
Numerator 109 · Denominator 110 |
| Resident COVID-19 vaccinations up to date | 19.05% |
25.2%
6.1 pts worse
|
Numerator 16 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
93.6%
0.5 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 90.3% · Q3 94.7% · Q4 95.9% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.4%
0.9 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.8%
2.5 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.9% · Q3 6.7% · Q4 8.1% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 30.9% |
24.6%
6.3 pts worse
|
11.4%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 20.0% · Q3 31.9% · Q4 41.4% · 4Q avg 30.9% |
| Percentage of long-stay residents who lose too much weight | 16.1% |
5.6%
10.5 pts worse
|
5.4%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 23.2% · Q3 11.6% · Q4 13.4% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.3% |
23.5%
15.8 pts worse
|
19.6%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 37.7% · Q3 39.1% · Q4 43.3% · 4Q avg 39.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
14.8%
8 pts worse
|
16.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 28.8% · Q3 23.3% · Q4 17.0% · 4Q avg 22.8% · 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 | 8.3% |
13.3%
5 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 0.0% · Q3 7.4% · Q4 7.3% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
11.7%
7.5 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 3.0% · Q3 1.5% · Q4 3.0% · 4Q avg 4.2% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
24.2%
3.8 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 34.0% · Q3 23.6% · Q4 26.2% · 4Q avg 28.0% |
| 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 5.1% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
81.6%
13.3 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 94.6% · Q3 98.3% · Q4 94.9% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
10.5%
1.3 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.4% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
79.0%
12.9 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
22.4%
0.5 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 19.6% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-17 · Fire 2024-06-17
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-26
E · Potential for more than minimal harm
2023-07-14
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-28
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 2025-05-14
E · Potential for more than minimal harm
2023-07-14
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 2023-07-28
D · Potential for more than minimal harm
2023-07-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Balla, Matthew
Operational/Managerial Control · Individual
Cardon And Associates Inc
Operational/Managerial Control · Organization
Cardon Management Company LLC
Operational/Managerial Control · Organization
Cattell, Zachary
Operational/Managerial Control · Individual
Fauth, Kendra
Operational/Managerial Control · Individual
Friend, Jayna
Operational/Managerial Control · Individual
Friend, Jayna
Corporate Officer · Individual
Gormal, Gregg
Operational/Managerial Control · Individual
Hafidh, Saad
Operational/Managerial Control · Individual
Haug, Amy
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Ingram, Stephanie
Operational/Managerial Control · Individual
Lopossa, Lynn
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Mcclelland, Thomas
Operational/Managerial Control · Individual
Mcintosh, Eric
Operational/Managerial Control · Individual
Moore Operating Group Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Greenwood Healthcare Center
Greenwood, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Greenwood Village South
Greenwood, IN
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
Greenwood Health And Living Community
Greenwood, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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