Cycle 1
Health 2025-06-23 · Fire 2025-06-23
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Danville, IN
Danville Regional Rehabilitation
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
255 Meadow Dr, Danville, IN
(317) 745-5451
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
110
Certified beds
Average residents
107
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1972-09-01
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
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
0.47
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,078
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0153
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.50
Baseline 16.55% · Performance 19.34% · Measure score 4.50 · Achievement 4.50 · Improvement 0
Healthcare-associated infections
8.06
Baseline 5.15% · Performance 5.43% · Measure score 8.06 · Achievement 8.06 · Improvement 0
Total nurse turnover
9.17
Baseline 22.22% · Performance 26.21% · Measure score 9.17 · Achievement 9.17 · Improvement 0
Adjusted total nurse staffing
2.34
Baseline 2.18 hours · Performance 3.20 hours · Measure score 2.34 · Achievement 0 · Improvement 2.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.89% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 222 · Observed rate 8.11% · Lower 95% interval 7.2% |
| Discharge to community | 64.08% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 223 · Observed rate 63.68% · Lower 95% interval 58.26% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 170 · Denominator 170 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 170 |
| Discharge self-care score | 55.71% |
53.69%
2 pts better
|
Numerator 78 · Denominator 140 |
| Discharge mobility score | 58.57% |
50.94%
7.6 pts better
|
Numerator 82 · Denominator 140 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 170 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.43% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 2.33% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 1.94% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 155 |
| Staff flu vaccination coverage | 60.45% |
42%
18.5 pts better
|
Numerator 107 · Denominator 177 |
| Discharge function score | 64.29% |
56.45%
7.8 pts better
|
Numerator 90 · Denominator 140 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 96.52% |
96.28%
0.2 pts better
|
Numerator 111 · Denominator 115 |
| Resident COVID-19 vaccinations up to date | 29.55% |
25.2%
4.4 pts better
|
Numerator 26 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 4.8% |
3.8%
1 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 5.3% · Q4 4.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 64.3% |
24.6%
39.7 pts worse
|
11.4%
52.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.4% · Q2 51.3% · Q3 64.9% · Q4 78.1% · 4Q avg 64.3% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.6%
1.8 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 2.9% · Q4 4.4% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
23.5%
9.9 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.3% · Q3 15.7% · Q4 13.0% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
14.8%
10.4 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 6.8% · Q4 4.9% · 4Q avg 4.4% · 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 | 9.0% |
13.3%
4.3 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 14.7% · Q3 4.8% · Q4 9.2% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
11.7%
2.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.6% · Q3 5.7% · Q4 16.2% · 4Q avg 8.9% · 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 | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · 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 27.2% · Q2 12.7% · Q3 25.3% · Q4 17.4% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.1%
1.5 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
81.6%
17.6 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 99.0% · Q4 98.5% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
10.5%
0.7 pts worse
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 9.8% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.4%
1.8 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 19.6% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-28 · Fire 2023-02-28
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-15
B · Minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-02-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-02-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-23
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 2025-07-16
D · Potential for more than minimal harm
2025-06-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-23
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 2025-07-16
D · Potential for more than minimal harm
2025-06-23
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 2025-07-16
D · Potential for more than minimal harm
2024-05-03
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 2024-05-31
D · Potential for more than minimal harm
2024-05-03
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 2024-05-31
E · Potential for more than minimal harm
2023-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-02-28
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 2023-03-30
E · Potential for more than minimal harm
2023-02-28
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 2023-03-30
E · Potential for more than minimal harm
2023-02-28
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 2023-03-30
D · Potential for more than minimal harm
2023-02-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-02-28
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 2023-03-30
D · Potential for more than minimal harm
2023-02-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-02-28
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 2023-03-30
D · Potential for more than minimal harm
2023-02-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-02-28
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 2023-03-30
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
Berry, Jenna
Operational/Managerial Control · Individual
Caine, Virginia
Corporate Officer · Individual
Drummer, Carl
Corporate Director · Individual
Fehribach, Gregory
Corporate Director · 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
Matthias, Stephanie
Operational/Managerial Control · Individual
Mukes-Gaither, Beverly
Corporate Director · Individual
Payne, Monica
Corporate Director · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Avon Health & Rehabilitation Center
Avon, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#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
Countryside Meadows
Avon, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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