Cycle 1
Health 2025-01-28 · Fire 2025-01-28
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Avon, IN
Avon Health & Rehabilitation Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies
4171 Forest Pointe Circle, Avon, IN
(317) 745-5184
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
137
Certified beds
Average residents
119
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
1984-09-10
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
0.42
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,162
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.88% · Performance 24.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.96% · Performance 8.25% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.13
Baseline 45.54% · Performance 50.88% · Measure score 3.13 · Achievement 3.13 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.37 hours · Performance 2.9 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 10.32% · Lower 95% interval 7.54% |
| Discharge to community | 60.34% |
50.57%
9.8 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 55.45% · Lower 95% interval 49.49% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 89 · Denominator 89 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge self-care score | 82.14% |
53.69%
28.5 pts better
|
Numerator 46 · Denominator 56 |
| Discharge mobility score | 80.36% |
50.94%
29.4 pts better
|
Numerator 45 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 2.25% |
2.29%
About the same
|
Numerator 2 · Denominator 89 · Adjusted rate 1.77% |
| Healthcare-associated infections requiring hospitalization | 8.25% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 4.83% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 4 · Denominator 168 |
| Staff flu vaccination coverage | 15.54% |
42%
26.5 pts worse
|
Numerator 30 · Denominator 193 |
| Discharge function score | 83.93% |
56.45%
27.5 pts better
|
Numerator 47 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 48.89% |
25.2%
23.7 pts better
|
Numerator 22 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.0% · Q3 0.9% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
24.6%
18.6 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.1% · Q3 5.9% · Q4 11.0% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.6%
2.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 4.1% · Q3 4.0% · Q4 3.2% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
23.5%
14.5 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.2% · Q3 9.0% · Q4 8.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
14.8%
0.3 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 16.7% · Q3 14.1% · Q4 11.9% · 4Q avg 14.5% · 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 | 7.0% |
13.3%
6.3 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 2.4% · Q3 9.6% · Q4 6.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
11.7%
6.9 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.8% · Q3 4.6% · Q4 7.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 11.3% |
24.2%
12.9 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.7% · Q3 9.7% · Q4 17.4% · 4Q avg 11.3% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.1%
3 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.2% · Q4 0.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
81.6%
15.5 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.5% · Q3 98.1% · Q4 96.1% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
10.5%
2.8 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 12.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
22.4%
2 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 19.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-20 · Fire 2023-11-20
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-22 · Fire 2022-08-22
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-08-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-28
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-28
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 2025-02-18
D · Potential for more than minimal harm
2025-01-28
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-28
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 2025-02-18
D · Potential for more than minimal harm
2023-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-20
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 2023-12-19
D · Potential for more than minimal harm
2023-08-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-07
E · Potential for more than minimal harm
2022-08-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
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 2022-09-16
D · Potential for more than minimal harm
2022-08-22
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 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-22
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Avon Healthcare Operations Company, LLC
Operational/Managerial Control · Organization
Friend, Jayna
Corporate Officer · Individual
Gimre, Jason
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Kalu, Chijioke
Operational/Managerial Control · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Majestic Care Of Avon
Avon, IN
2-star overall rating with 1-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Danville Regional Rehabilitation
Danville, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Countryside Meadows
Avon, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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