4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Greentown, IN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
705 N Meridian St, Greentown, IN
(765) 628-3377
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
84
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Exceptional Living Centers
Operator or chain grouping
Approved since
1994-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
RN hours / resident day
0.52
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9957
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.29
Baseline 21.35% · Performance 18.05% · Measure score 7.29 · Achievement 7.29 · Improvement 7.13
Healthcare-associated infections
6.74
Baseline 8.49% · Performance 5.96% · Measure score 6.74 · Achievement 6.28 · Improvement 6.74
Total nurse turnover
2.69
Baseline 60.66% · Performance 52.70% · Measure score 2.69 · Achievement 2.69 · Improvement 1.72
Adjusted total nurse staffing
0.39
Baseline 2.85 hours · Performance 3.11 hours · Measure score 0.39 · Achievement 0 · Improvement 0.39
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 8.47% · Lower 95% interval 6.77% |
| Discharge to community | 63.56% |
50.57%
13 pts better
|
Better than the National Rate · Eligible stays 94 · Observed rate 64.89% · Lower 95% interval 52.81% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 71 · Denominator 71 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 71 |
| Discharge self-care score | 71.67% |
53.69%
18 pts better
|
Numerator 43 · Denominator 60 |
| Discharge mobility score | 65% |
50.94%
14.1 pts better
|
Numerator 39 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 2.82% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 71 · Adjusted rate 3.38% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 1.61% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 6.56% |
42%
35.4 pts worse
|
Numerator 8 · Denominator 122 |
| Discharge function score | 73.33% |
56.45%
16.9 pts better
|
Numerator 44 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 2 · Denominator 36 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.6
1.4 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.5
1.9 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.3 · Expected 1.6 · 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 | 5.6% |
3.8%
1.8 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.6% · Q3 4.6% · Q4 5.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.7% |
24.6%
9.9 pts better
|
11.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.6% · Q3 10.0% · Q4 13.0% · 4Q avg 14.7% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
5.6%
4.1 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
23.5%
6.7 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 31.9% · Q3 26.4% · Q4 29.4% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
14.8%
2.9 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 11.9% · Q3 10.4% · Q4 9.5% · 4Q avg 11.9% · 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 | 8.1% |
13.3%
5.2 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 7.3% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
11.7%
7.6 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 10.9% · Q3 2.0% · Q4 2.0% · 4Q avg 4.1% · 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 | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.6% |
24.2%
6.4 pts worse
|
19.8%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 33.3% · Q3 26.2% · Q4 22.5% · 4Q avg 30.6% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.1%
1.9 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.2% · Q3 1.5% · Q4 1.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
81.6%
17.8 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
10.5%
9.5 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.3% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 1.7% · 4Q avg 0.9% · 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 | 25.7% |
22.4%
3.3 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 23.0% · Expected 21.3% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-02-14
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-02-14
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-12-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-02
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 2024-12-02
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-12-02
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-02
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-03
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-03
Inspection history
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-15
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 2026-01-15
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-26
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-26
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-08-26
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-26
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-26
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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