Cycle 1
Health 2026-01-12 · Fire 2026-01-12
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Indianapolis, IN
Clearvista Lake Health Campus
2-star overall rating with 3-star inspections with 4 recent health deficiencies
8405 Clearvista Place, Indianapolis, IN
(317) 578-7500
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
54
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-02-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 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
0.60
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.07
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
1.63
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.60
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
0.46
CMS adjusted RN staffing hours
Adjusted total hours
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.79
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,421
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.16
Baseline 17.66% · Performance 19.97% · Measure score 3.16 · Achievement 3.16 · Improvement 0
Healthcare-associated infections
6.31
Baseline 5.56% · Performance 5.95% · Measure score 6.31 · Achievement 6.31 · Improvement 0
Total nurse turnover
1.73
Baseline 46.15% · Performance 56.60% · Measure score 1.73 · Achievement 1.73 · Improvement 0
Adjusted total nurse staffing
0.71
Baseline 2.73 hours · Performance 3.10 hours · Measure score 0.71 · Achievement 0 · Improvement 0.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 9.33% · Lower 95% interval 7.01% |
| Discharge to community | 63.49% |
50.57%
12.9 pts better
|
Better than the National Rate · Eligible stays 158 · Observed rate 56.33% · Lower 95% interval 54.86% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 73 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 35 · Denominator 55 |
| Discharge mobility score | 65.45% |
50.94%
14.5 pts better
|
Numerator 36 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 73 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 4.12% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 13.87% |
42%
28.1 pts worse
|
Numerator 19 · Denominator 137 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 35 · Denominator 55 |
| 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 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 27.66% |
25.2%
2.5 pts better
|
Numerator 13 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
93.6%
11.1 pts worse
|
93.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 81.2% · Q3 85.7% · Q4 90.6% · 4Q avg 82.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.8% |
95.4%
13.6 pts worse
|
95.5%
13.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.2% · Q3 7.1% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
24.6%
15.7 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 7.7% · Q4 23.3% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.6%
2.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
23.5%
12.6 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 8.0% · Q3 4.8% · Q4 13.0% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
14.8%
7.2 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · 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 | 13.6% |
13.3%
0.3 pts worse
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
11.7%
0.1 pts worse
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 12.5% · Q3 5.0% · Q4 14.3% · 4Q avg 11.8% · 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 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
24.2%
3.5 pts better
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 17.6% · Q3 16.0% · Q4 23.0% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.1%
0.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
81.6%
7.4 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 86.9% · Q3 88.5% · Q4 90.2% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.2% |
10.5%
14.7 pts worse
|
12.0%
13.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 24.4% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.1% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
79.0%
2.2 pts better
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
22.4%
1.4 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 22.0% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-12 · Fire 2024-11-12
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-22 · Fire 2023-08-22
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-08-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-12
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 2026-01-30
D · Potential for more than minimal harm
2026-01-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-30
D · Potential for more than minimal harm
2026-01-12
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 2026-01-30
D · Potential for more than minimal harm
2026-01-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-30
D · Potential for more than minimal harm
2024-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-11-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-11-12
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 2024-11-25
D · Potential for more than minimal harm
2024-11-12
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 2024-11-25
D · Potential for more than minimal harm
2024-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-11-12
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 2024-11-25
D · Potential for more than minimal harm
2024-06-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-21
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 2024-07-12
D · Potential for more than minimal harm
2024-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-20
D · Potential for more than minimal harm
2023-12-12
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 2023-12-29
G · Actual harm
2023-08-22
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-22
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 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-22
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 2023-09-22
D · Potential for more than minimal harm
2023-08-22
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 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-22
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Corporate Officer · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Mevzek, Stacy
Operational/Managerial Control · Individual
Reagan, Julie
Corporate Director · Individual
Rhs Partners Of Castleton LLC
Operational/Managerial Control · Organization
Sellers, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
Castleton Health Care Center
Indianapolis, IN
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 14 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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