Cycle 1
Health 2024-09-13 · Fire 2024-09-13
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Indianapolis, IN
Castleton Health Care Center
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
7630 E 86th St, Indianapolis, IN
(317) 845-0032
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-01-23
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
0.36
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
2.54
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
0
Performance 73.08% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.73 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 27 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 73.1% |
93.6%
20.5 pts worse
|
93.4%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.1% · Q2 63.6% · Q3 66.7% · Q4 84.5% · 4Q avg 73.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 58.1% |
95.4%
37.3 pts worse
|
95.5%
37.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 58.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.8%
3.3 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.7% |
24.6%
36.1 pts worse
|
11.4%
49.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 67.3% · Q3 57.9% · Q4 66.0% · 4Q avg 60.7% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.6%
2 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 5.7% · Q4 5.9% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
23.5%
1.2 pts better
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 17.0% · Q3 20.8% · Q4 26.4% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
14.8%
4.2 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 6.7% · Q3 13.9% · Q4 6.5% · 4Q avg 10.6% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.4% |
13.3%
0.1 pts worse
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 9.3% · Q4 19.0% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
11.7%
2.4 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.3% · Q3 4.0% · Q4 8.2% · 4Q avg 9.3% · 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 | 0.9% |
1.2%
0.3 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
24.2%
5.9 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 27.7% · Q3 24.7% · Q4 31.8% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.1%
2.9 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.3% · Q3 8.1% · Q4 5.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.4% |
81.6%
31.2 pts worse
|
81.7%
31.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 43.5% · Q3 32.2% · Q4 60.2% · 4Q avg 50.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
10.5%
4.1 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 21.7% · Expected 16.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.1% |
79.0%
55.9 pts worse
|
79.7%
56.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.4%
1.5 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 30.4% · Expected 30.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-29 · Fire 2023-09-29
13 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-22 · Fire 2022-04-22
24 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-09-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-13
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 2024-10-14
E · Potential for more than minimal harm
2024-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-14
F · Potential for more than minimal harm
2023-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-09-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-09-29
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 2023-11-16
E · Potential for more than minimal harm
2023-09-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-16
F · Potential for more than minimal harm
2022-04-22
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 2022-06-13
F · Potential for more than minimal harm
2022-04-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-13
F · Potential for more than minimal harm
2022-04-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-13
F · Potential for more than minimal harm
2022-04-22
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 2022-06-13
F · Potential for more than minimal harm
2022-04-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-13
E · Potential for more than minimal harm
2022-04-22
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-06-13
D · Potential for more than minimal harm
2022-04-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-13
D · Potential for more than minimal harm
2022-04-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-13
D · Potential for more than minimal harm
2022-04-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-13
C · Minimal harm
2022-04-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-06-13
C · Minimal harm
2022-04-22
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-06-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-09
D · Potential for more than minimal harm
2025-11-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-09
E · Potential for more than minimal harm
2025-09-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-09
D · Potential for more than minimal harm
2025-09-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-21
D · Potential for more than minimal harm
2025-09-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-09
D · Potential for more than minimal harm
2025-09-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-21
E · Potential for more than minimal harm
2025-08-05
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 2025-08-07
D · Potential for more than minimal harm
2025-08-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-08-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-08-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-18
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-18
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 2025-07-30
D · Potential for more than minimal harm
2025-06-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-09-13
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 2024-09-23
F · Potential for more than minimal harm
2024-09-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-13
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-02-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-22
G · Actual harm
2023-09-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-09-29
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 2023-10-24
D · Potential for more than minimal harm
2023-09-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-29
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 2023-10-24
D · Potential for more than minimal harm
2023-09-29
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 2023-10-24
D · Potential for more than minimal harm
2023-09-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-29
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 2023-10-24
D · Potential for more than minimal harm
2023-09-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-29
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 2023-10-24
C · Minimal harm
2023-09-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-24
C · Minimal harm
2023-09-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-03-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-04-21
G · Actual harm
2022-04-22
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 2022-05-20
G · Actual harm
2022-04-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
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 2022-05-20
D · Potential for more than minimal harm
2022-04-22
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 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-04-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-13
D · Potential for more than minimal harm
2022-04-22
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 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-22
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 2022-05-20
D · Potential for more than minimal harm
2022-04-22
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 2022-05-20
D · Potential for more than minimal harm
2022-04-22
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-04-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-05-20
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Castleton Care Center, LLC
Operational/Managerial Control · Organization
Engels, Erin
Corporate Director · Individual
Engels, Erin
5% Or Greater Mortgage Interest · Individual
Fenoughty, Deanna
Operational/Managerial Control · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Pike, James
Operational/Managerial Control · Individual
Starkey, Tyler
Corporate Director · Individual
Waite, John
Corporate Director · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Clearvista Lake Health Campus
Indianapolis, IN
2-star overall rating with 3-star inspections with 4 recent health deficiencies
#2
Waters Of Castleton Skilled Nursing Facility, The
Indianapolis, IN
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Allisonville Meadows
Fishers, IN
3-star overall rating with 2-star inspections with $11,190 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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