Indianapolis, IN

Community Nursing And Rehabilitation Center

2-star overall rating with 1-star inspections with Special Focus status with 24 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle

5600 E 16th St, Indianapolis, IN

(317) 356-0911

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

115

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

91 facilities

Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars

Changed ownership

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

0.59

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.12

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

1.89

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.61

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.98

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.54

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

0.58

CMS adjusted RN staffing hours

Adjusted total hours

3.54

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,531

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

3.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9805

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

Baseline 64.71% · Performance 68.63% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0.80

Baseline 2.87 hours · Performance 3.25 hours · Measure score 0.80 · Achievement 0.59 · Improvement 0.80

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 10 · 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 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	4.17%	8.2% 4 pts worse	Numerator 3 · Denominator 72
Staff flu vaccination coverage	4.35%	42% 37.6 pts worse	Numerator 3 · Denominator 69
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · 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 5 · 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	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	1.0%	3.8% 2.8 pts better	3.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	25.4%	24.6% 0.8 pts worse	11.4% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 16.3% · Q3 36.4% · Q4 26.7% · 4Q avg 25.4%
Percentage of long-stay residents who lose too much weight	3.2%	5.6% 2.4 pts better	5.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 4.2% · Q4 0.0% · 4Q avg 3.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.5%	23.5% 5 pts worse	19.6% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 34.0% · Q3 27.1% · Q4 23.8% · 4Q avg 28.5%
Percentage of long-stay residents who received an antipsychotic medication	13.1%	14.8% 1.7 pts better	16.7% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 16.7% · Q3 8.6% · Q4 6.7% · 4Q avg 13.1% · 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	5.2%	13.3% 8.1 pts better	16.3% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.4% · Q3 0.0% · Q4 10.6% · 4Q avg 5.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.0%	11.7% 6.7 pts better	14.9% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 10.2% · Q3 0.0% · Q4 5.1% · 4Q avg 5.0% · 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	0.0%	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	21.6%	24.2% 2.6 pts better	19.8% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 11.5% · Q3 24.9% · Q4 19.2% · 4Q avg 21.6%
Percentage of long-stay residents with pressure ulcers	5.9%	4.1% 1.8 pts worse	5.1% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.7% · Q3 4.6% · Q4 5.9% · 4Q avg 5.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.3%	81.6% 7.7 pts better	81.7% 7.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 88.2% · Q3 88.9% · Q4 89.2% · 4Q avg 89.3%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.5%	79.0% 7.5 pts better	79.7% 6.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.5%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-25 · Fire 2025-04-25

24 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-04-22 · Fire 2024-04-22

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-05-11 · Fire 2023-05-11

21 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-25

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-07-18

F · Potential for more than minimal harm 2025-04-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-19

E · Potential for more than minimal harm 2025-04-25

K222 · Egress Deficiencies

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 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-04-25

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-04-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-04-25

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-04-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-18

C · Minimal harm 2025-04-25

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2025-07-18

C · Minimal harm 2025-04-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-18

E · Potential for more than minimal harm 2024-04-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-19

E · Potential for more than minimal harm 2024-04-22

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-05-23

D · Potential for more than minimal harm 2024-04-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-06-19

E · Potential for more than minimal harm 2023-05-11

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 2023-06-02

E · Potential for more than minimal harm 2023-05-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-05-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-05-11

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-06-02

C · Minimal harm 2023-05-11

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-06-02

C · Minimal harm 2023-05-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-11

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 2026-01-09

D · Potential for more than minimal harm 2025-12-11

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 2026-01-09

D · Potential for more than minimal harm 2025-12-11

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 2026-01-09

D · Potential for more than minimal harm 2025-12-11

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 2026-01-09

D · Potential for more than minimal harm 2025-12-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2026-01-09

G · Actual harm 2025-11-13

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 2025-12-26

D · Potential for more than minimal harm 2025-07-14

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 2025-08-05

D · Potential for more than minimal harm 2025-07-14

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2025-08-05

F · Potential for more than minimal harm 2025-04-25

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 2025-07-02

E · Potential for more than minimal harm 2025-04-25

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 2025-05-31

E · Potential for more than minimal harm 2025-04-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-05-31

D · Potential for more than minimal harm 2025-04-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-31

D · Potential for more than minimal harm 2025-04-25

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 2025-07-02

E · Potential for more than minimal harm 2024-04-22

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-05-10

E · Potential for more than minimal harm 2024-04-22

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 2024-05-10

D · Potential for more than minimal harm 2024-04-22

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 2024-05-10

D · Potential for more than minimal harm 2024-04-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-22

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 2024-05-10

D · Potential for more than minimal harm 2024-04-22

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 2024-05-10

D · Potential for more than minimal harm 2024-04-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-05-10

F · Potential for more than minimal harm 2023-05-11

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-05-11

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-05-11

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 2023-06-02

E · Potential for more than minimal harm 2023-05-11

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 2023-06-02