Cycle 1
Health 2025-12-16 · Fire 2025-12-16
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Avon, IN
Countryside Meadows
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
762 N Dan Jones Rd, Avon, IN
(317) 495-7200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
171
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
2011-07-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.08
Weekend nurse staffing
RN turnover
35%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.8%
About the same
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 65.9% |
24.6%
41.3 pts worse
|
11.4%
54.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.6%
1.9 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
23.5%
2.6 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
14.8%
2.6 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
13.3%
7.7 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
11.7%
7 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
24.2%
5.8 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.1%
1.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
81.6%
17.3 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
10.5%
0.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
79.0%
19.2 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
22.4%
2.4 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-07 · Fire 2024-10-07
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-31 · Fire 2023-08-31
14 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-01-29
E · Potential for more than minimal harm
2025-12-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-29
C · Minimal harm
2025-12-16
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2026-01-28
C · Minimal harm
2025-12-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2026-01-29
C · Minimal harm
2025-12-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2026-01-29
C · Minimal harm
2025-12-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-29
E · Potential for more than minimal harm
2024-10-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-13
C · Minimal harm
2024-10-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-13
E · Potential for more than minimal harm
2023-08-31
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 2023-09-18
E · Potential for more than minimal harm
2023-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
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 2026-01-14
D · Potential for more than minimal harm
2025-12-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-16
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 2026-01-14
D · Potential for more than minimal harm
2025-12-16
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 2026-01-14
G · Actual harm
2025-11-10
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 2025-11-19
D · Potential for more than minimal harm
2025-09-29
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 2025-11-19
E · Potential for more than minimal harm
2024-10-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-07
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 2024-10-24
D · Potential for more than minimal harm
2024-10-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-07
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 2024-10-24
D · Potential for more than minimal harm
2024-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-07
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 2024-10-24
D · Potential for more than minimal harm
2024-10-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-24
G · Actual harm
2024-08-01
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 2024-08-22
D · Potential for more than minimal harm
2024-08-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-01
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 2024-08-22
D · Potential for more than minimal harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-01
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 2024-08-22
D · Potential for more than minimal harm
2024-06-18
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 2024-07-02
D · Potential for more than minimal harm
2024-01-19
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 2024-02-16
D · Potential for more than minimal harm
2024-01-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-19
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-08-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-23
E · Potential for more than minimal harm
2023-08-31
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 2023-09-23
E · Potential for more than minimal harm
2023-08-31
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 2023-09-23
D · Potential for more than minimal harm
2023-08-31
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-23
D · Potential for more than minimal harm
2023-08-31
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 2023-09-23
D · Potential for more than minimal harm
2023-08-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-23
D · Potential for more than minimal harm
2023-08-31
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 2023-09-23
D · Potential for more than minimal harm
2023-08-31
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 2023-09-23
D · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-23
D · Potential for more than minimal harm
2023-06-19
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 2023-06-30
D · Potential for more than minimal harm
2023-05-25
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-05-26
Penalties and ownership
What sits behind the stars
Ownership
The Health And Hospital Corporation Of Marion County
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Corporate Officer · Individual
Caine, Virginia
Corporate Officer · Individual
Drummer, Carl
Corporate Director · Individual
Elliott, Tiffany
Operational/Managerial Control · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Officer · Individual
Horn, Brenda
Corporate Director · Individual
Lazard, Robert
Corporate Director · Individual
Mantravadi, Geeta
Corporate Director · Individual
Mcglothlin, Tara
Operational/Managerial Control · Individual
Payne, Monica
Corporate Director · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Brooke Knoll Village
Avon, IN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of Avon
Avon, IN
2-star overall rating with 1-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Plainfield Health Care Center
Plainfield, IN
2-star overall rating with 1-star inspections with Special Focus status with $31,852 in total fines with 20 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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