Cycle 1
Health 2025-05-30 · Fire 2025-05-30
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.
Newburgh, IN
Cypress Grove Rehabilitation Center
4-star overall rating with 3-star inspections with 4 recent health deficiencies
4255 Medwell Dr, Newburgh, IN
(812) 853-2993
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
90
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1986-01-10
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
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
0.53
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,321
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.17
Performance 20.42% · Measure score 2.17 · Achievement 2.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7
Baseline 6.67% · Performance 5.74% · Measure score 7 · Achievement 7 · Improvement 5.05
Total nurse turnover
5.33
Baseline 42.19% · Performance 41.89% · Measure score 5.33 · Achievement 5.33 · Improvement 0
Adjusted total nurse staffing
0.13
Baseline 2.83 hours · Performance 3.02 hours · Measure score 0.13 · Achievement 0 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 7.82% |
| Discharge to community | 46.32% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 36.36% · Lower 95% interval 31.18% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 13 · Denominator 28 |
| Discharge mobility score | 32.14% |
50.94%
18.8 pts worse
|
Numerator 9 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 4.14% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 2.86% |
| Staff COVID-19 vaccination coverage | 1.85% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 108 |
| Staff flu vaccination coverage | 25.47% |
42%
16.5 pts worse
|
Numerator 27 · Denominator 106 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 71.43% |
25.2%
46.2 pts better
|
Numerator 15 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.6 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
93.6%
2.1 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 93.9% · Q3 96.9% · Q4 98.6% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.4%
3.3 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 96.5% |
24.6%
71.9 pts worse
|
11.4%
85.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 93.3% · Q3 100.0% · Q4 98.4% · 4Q avg 96.5% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.6%
4.2 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.0% · Q4 1.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
23.5%
About the same
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 23.5% · Q3 23.5% · Q4 20.8% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
14.8%
8.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 2.9% · Q3 2.8% · Q4 8.6% · 4Q avg 6.2% · 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 | 8.3% |
13.3%
5 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.2% · Q3 4.0% · Q4 10.4% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
11.7%
9.8 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.9% · 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 | 21.9% |
24.2%
2.3 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 28.5% · Q3 18.9% · Q4 23.2% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.1%
1.4 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.6% · Q3 3.0% · Q4 5.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
81.6%
12.6 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 95.4% · Q3 96.8% · Q4 92.8% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
10.5%
10.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.3%
0.9 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
79.0%
18.3 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.4% |
22.4%
13 pts worse
|
23.9%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.4% · Observed 32.1% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-21 · Fire 2023-02-21
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-02-21
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-05-30
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 2025-06-25
D · Potential for more than minimal harm
2025-05-30
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 2025-06-25
D · Potential for more than minimal harm
2025-05-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-25
E · Potential for more than minimal harm
2024-05-17
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 2024-06-17
D · Potential for more than minimal harm
2024-05-17
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 2024-06-17
D · Potential for more than minimal harm
2024-05-17
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-17
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 2024-06-17
D · Potential for more than minimal harm
2024-05-17
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 2024-06-17
D · Potential for more than minimal harm
2024-05-17
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 2024-06-17
E · Potential for more than minimal harm
2023-11-29
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 2023-12-18
E · Potential for more than minimal harm
2023-11-01
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 2023-12-01
D · Potential for more than minimal harm
2023-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-02-21
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 2023-03-21
E · Potential for more than minimal harm
2023-02-21
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 2023-03-21
C · Minimal harm
2023-02-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-21
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
Burns, Brandon
Operational/Managerial Control · Individual
Caine, Virginia
Corporate Officer · Individual
Drummer, Carl
Corporate Director · Individual
Fehribach, Gregory
Corporate Director · Individual
Hadra, Jeanie
Operational/Managerial Control · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Officer · Individual
Kelsey, Donna
Contracted Managing Employee · Individual
Lazard, Robert
Corporate Director · Individual
Mantravadi, Geeta
Corporate Director · Individual
Mukes-Gaither, Beverly
Corporate Director · Individual
Payne, Monica
Corporate Director · Individual
Snyder, Brandie
Operational/Managerial Control · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Brickyard Healthcare - Woodlands Care Center
Newburgh, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Hamilton Pointe Health And Rehab
Newburgh, IN
2-star overall rating with 1-star inspections with 15 recent health deficiencies
#3
Newburgh Health and Rehab
Newburgh, IN
1-star overall rating with 1-star inspections with 11 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
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