Cycle 1
Health 2025-01-03 · Fire 2025-01-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Anderson, IN
Countryside Manor Health & Living Community
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
205 Marine Dr, Anderson, IN
(765) 649-4558
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
82
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
1985-04-03
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
0.54
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,553
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.53
Baseline 18.71% · Performance 19.80% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Healthcare-associated infections
3.81
Baseline 5.78% · Performance 6.70% · Measure score 3.81 · Achievement 3.81 · Improvement 0
Total nurse turnover
5.42
Baseline 59.70% · Performance 41.54% · Measure score 5.42 · Achievement 5.42 · Improvement 4.71
Adjusted total nurse staffing
0.24
Baseline 2.90 hours · Performance 3.11 hours · Measure score 0.24 · Achievement 0 · Improvement 0.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 13.59% · Lower 95% interval 7.64% |
| Discharge to community | 56.82% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 47.71% · Lower 95% interval 48.32% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 92.31% |
95.27%
3 pts worse
|
Numerator 60 · Denominator 65 |
| Falls with major injury | 3.08% |
0.77%
2.3 pts worse
|
Numerator 2 · Denominator 65 |
| Discharge self-care score | 64% |
53.69%
10.3 pts better
|
Numerator 32 · Denominator 50 |
| Discharge mobility score | 66% |
50.94%
15.1 pts better
|
Numerator 33 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 4.62% |
2.29%
2.3 pts worse
|
Numerator 3 · Denominator 65 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 7.04% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 37.68% |
42%
4.3 pts worse
|
Numerator 52 · Denominator 138 |
| Discharge function score | 78% |
56.45%
21.5 pts better
|
Numerator 39 · Denominator 50 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 3 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
93.6%
0.9 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 92.7% · Q3 85.7% · Q4 98.5% · 4Q avg 92.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
95.4%
0.2 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.8%
4.7 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 12.7% · Q3 9.5% · Q4 5.9% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
24.6%
16.4 pts better
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.4% · Q3 9.1% · Q4 12.9% · 4Q avg 8.2% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.6%
3.9 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 11.5% · Q3 11.7% · Q4 6.3% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
23.5%
2.4 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 23.1% · Q3 28.3% · Q4 29.7% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
14.8%
7.1 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.5% · Q3 9.8% · Q4 9.3% · 4Q avg 7.7% · 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 | 17.0% |
13.3%
3.7 pts worse
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q3 16.4% · Q4 21.2% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
11.7%
5.7 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 16.3% · Q3 12.5% · Q4 23.2% · 4Q avg 17.4% · 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 | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
24.2%
0.4 pts better
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 22.0% · Q3 20.4% · Q4 33.2% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.1%
0.1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 7.8% · Q3 4.0% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.9% |
81.6%
14.7 pts worse
|
81.7%
14.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.4% · Q2 59.0% · Q3 71.1% · Q4 74.6% · 4Q avg 66.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
10.5%
6.2 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 18.8% · Expected 12.5% · 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 1.2% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
79.0%
9.4 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
22.4%
4.5 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 20.8% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-04 · Fire 2023-12-04
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-10-04 · Fire 2022-10-04
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-08
C · Minimal harm
2025-01-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-02-05
F · Potential for more than minimal harm
2023-12-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-04
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 2024-02-02
E · Potential for more than minimal harm
2023-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-15
E · Potential for more than minimal harm
2023-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-15
C · Minimal harm
2023-12-04
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-02-02
F · Potential for more than minimal harm
2022-10-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-01-17
F · Potential for more than minimal harm
2022-10-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-10-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-10-04
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 2022-12-07
E · Potential for more than minimal harm
2022-10-04
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-10-04
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 2022-12-07
E · Potential for more than minimal harm
2022-10-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-10-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-10-04
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-10-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-10-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-10-04
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-12-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-11
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 2025-05-23
D · Potential for more than minimal harm
2025-01-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-20
D · Potential for more than minimal harm
2025-01-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-09-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-06-24
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 2024-07-09
D · Potential for more than minimal harm
2024-06-24
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 2024-07-09
E · Potential for more than minimal harm
2023-12-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-12-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-12-04
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-12-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-04
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 2023-12-21
D · Potential for more than minimal harm
2023-12-04
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 2023-12-21
D · Potential for more than minimal harm
2022-10-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-10-04
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 2022-10-26
D · Potential for more than minimal harm
2022-10-04
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 2022-10-26
D · Potential for more than minimal harm
2022-10-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-10-04
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-10-26
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Balla, Matthew
Operational/Managerial Control · Individual
Cardon And Associates Inc
Operational/Managerial Control · Organization
Cardon Management Company LLC
Operational/Managerial Control · Organization
Cattell, Zachary
Operational/Managerial Control · Individual
Estep, Kenneth
Operational/Managerial Control · Individual
Fauth, Kendra
Operational/Managerial Control · Individual
Friend, Jayna
Operational/Managerial Control · Individual
Friend, Jayna
Corporate Officer · Individual
German American Bank
5% Or Greater Security Interest · Organization
Gormal, Gregg
Operational/Managerial Control · Individual
Hashmi, Syed
Operational/Managerial Control · Individual
Haug, Amy
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Ingram, Stephanie
Operational/Managerial Control · Individual
Lopossa, Lynn
Operational/Managerial Control · Individual
Mcclelland, Thomas
Operational/Managerial Control · Individual
Mcintosh, Eric
Operational/Managerial Control · Individual
Moore Operating Group Inc
Operational/Managerial Control · Organization
Trennepohl, Whitney
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Envive Of Anderson
Anderson, IN
3-star overall rating with 3-star inspections with $8,390 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Beaumont Rehabilitation And Healthcare Center
Anderson, IN
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Edgewater Woods
Anderson, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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