Cycle 1
Health 2025-02-14 · Fire 2025-02-14
17 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Indianapolis, IN
Envive Of Indianapolis
2-star overall rating with 1-star inspections with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
45 Beachway Dr, Indianapolis, IN
(317) 243-3721
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
184
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Envive Healthcare
Operator or chain grouping
Approved since
1968-07-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.48
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,884
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
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
6.50
Baseline 73.08% · Performance 39.33% · Measure score 6.50 · Achievement 5.96 · Improvement 6.50
Adjusted total nurse staffing
1.95
Baseline 3.07 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 1.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · 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 9 · 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 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · 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 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.73% |
8.2%
0.5 pts better
|
Numerator 11 · Denominator 126 |
| Staff flu vaccination coverage | 61.73% |
42%
19.7 pts better
|
Numerator 150 · Denominator 243 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
93.6%
6.7 pts worse
|
93.4%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.3% · Q2 89.8% · Q3 88.6% · Q4 84.0% · 4Q avg 86.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 56.9% |
95.4%
38.5 pts worse
|
95.5%
38.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 56.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.8%
3.3 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.3% |
24.6%
10.7 pts worse
|
11.4%
23.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 43.5% · Q3 22.7% · Q4 29.5% · 4Q avg 35.3% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.6%
2.4 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.3% · Q3 9.6% · Q4 10.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
23.5%
2.3 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 17.3% · Q3 25.0% · Q4 23.7% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
14.8%
10.8 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 26.0% · Q3 18.8% · Q4 30.0% · 4Q avg 25.6% · 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 | 14.5% |
13.3%
1.2 pts worse
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 7.2% · Q3 7.7% · Q4 20.4% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
11.7%
0.1 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 1.1% · Q3 6.1% · Q4 25.0% · 4Q avg 11.6% · 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 | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
24.2%
0.3 pts better
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 30.0% · Q3 16.1% · Q4 21.7% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.1%
0.7 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.4% · Q3 6.9% · Q4 3.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.5% |
81.6%
28.1 pts worse
|
81.7%
28.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.9% · Q2 59.3% · Q3 51.3% · Q4 38.9% · 4Q avg 53.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.7% |
10.5%
7.8 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 3.7% · Expected 15.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.5% |
79.0%
37.5 pts worse
|
79.7%
38.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
22.4%
6.9 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 18.5% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
18 health deficiencies
Top issue: Resident Rights (9 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-09-20 · Fire 2022-09-20
23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-02-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-02-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-31
E · Potential for more than minimal harm
2025-02-14
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 2025-04-10
E · Potential for more than minimal harm
2025-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-31
C · Minimal harm
2025-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-10
E · Potential for more than minimal harm
2024-12-06
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-01-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-01-11
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Not marked corrected
E · Potential for more than minimal harm
2024-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-11
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 2024-04-12
E · Potential for more than minimal harm
2024-01-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
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 2024-04-12
E · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-11
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 2024-03-27
E · Potential for more than minimal harm
2024-01-11
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-11
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 2024-04-12
D · Potential for more than minimal harm
2024-01-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-27
C · Minimal harm
2024-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-27
F · Potential for more than minimal harm
2022-09-20
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-01
F · Potential for more than minimal harm
2022-09-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-09-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-09-20
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 2022-12-15
E · Potential for more than minimal harm
2022-09-20
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 2022-12-15
E · Potential for more than minimal harm
2022-09-20
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-06-01
E · Potential for more than minimal harm
2022-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-09-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-09-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-19
G · Actual harm
2025-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-04
G · Actual harm
2025-06-03
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 2025-05-23
D · Potential for more than minimal harm
2025-02-19
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 2025-03-31
D · Potential for more than minimal harm
2025-02-19
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-14
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 2025-03-31
E · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
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 2025-03-31
D · Potential for more than minimal harm
2025-02-14
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 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-14
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 2025-03-31
D · Potential for more than minimal harm
2025-02-14
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 2025-03-31
E · Potential for more than minimal harm
2024-10-29
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 2024-11-19
D · Potential for more than minimal harm
2024-03-14
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 2024-03-29
E · Potential for more than minimal harm
2024-01-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-11
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-11
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 2024-02-19
E · Potential for more than minimal harm
2024-01-11
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 2024-02-19
E · Potential for more than minimal harm
2024-01-11
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-11
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 2024-02-19
E · Potential for more than minimal harm
2024-01-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-11
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 2024-02-19
D · Potential for more than minimal harm
2024-01-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-11
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 2024-02-19
D · Potential for more than minimal harm
2024-01-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-02-19
B · Minimal harm
2024-01-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-19
E · 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
D · Potential for more than minimal harm
2023-11-01
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 2023-12-01
D · Potential for more than minimal harm
2023-11-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-01
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 2023-12-01
D · Potential for more than minimal harm
2023-03-28
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 2023-04-21
K · Immediate jeopardy
2022-09-20
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 2022-10-21
G · Actual harm
2022-09-20
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 2022-10-21
G · Actual harm
2022-09-20
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2022-10-21
G · Actual harm
2022-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-21
G · Actual harm
2022-09-20
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 2022-10-21
F · Potential for more than minimal harm
2022-09-20
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-20
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 2022-11-17
E · Potential for more than minimal harm
2022-09-20
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 2022-10-21
E · Potential for more than minimal harm
2022-09-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-20
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 2022-10-21
D · Potential for more than minimal harm
2022-09-20
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 2022-10-21
D · Potential for more than minimal harm
2022-09-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-20
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 2022-10-21
D · Potential for more than minimal harm
2022-09-20
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 2022-10-21
D · Potential for more than minimal harm
2022-09-20
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 2022-10-21
D · Potential for more than minimal harm
2022-09-20
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-20
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 2022-10-21
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Beachway Property Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Daudelin, Douglas
Operational/Managerial Control · Individual
Envive Nursing Holdings, LLC
Operational/Managerial Control · Organization
Flueckiger, Russell
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Lt Care Acquisition Corp
Operational/Managerial Control · Organization
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Nbh Bank
5% Or Greater Mortgage Interest · Organization
Smith, Scott
Operational/Managerial Control · Individual
Smith, Scott
Corporate Officer · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Sprunger, Kyle
Corporate Officer · Individual
Sullivan, Jeremy
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Wheeler, Dane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Westside Retirement Village
Indianapolis, IN
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Westpark A Waters Community
Indianapolis, IN
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Washington Healthcare Center
Indianapolis, IN
4-star overall rating with 3-star inspections with $14,518 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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