Indianapolis, IN

Evergreen Crossing And The Lofts

1-star overall rating with 1-star inspections with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

5404 Georgetown Road, Indianapolis, IN

(317) 291-5404

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 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

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Communicare Health

Operator or chain grouping

Approved since

2014-12-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

122 facilities

Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.60

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.17

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.08

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

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.25

CMS adjusted total nurse staffing hours

Case-mix index

1.51

Higher values indicate more complex resident acuity

RN turnover

54%

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

8,172

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9846

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.51

Baseline 21.09% · Performance 18.88% · Measure score 5.51 · Achievement 5.51 · Improvement 4.96

Healthcare-associated infections

2.26

Baseline 7.03% · Performance 7.16% · Measure score 2.26 · Achievement 2.26 · Improvement 0

Total nurse turnover

2.30

Baseline 53.06% · Performance 54.29% · Measure score 2.30 · Achievement 2.30 · Improvement 0

Adjusted total nurse staffing

0.97

Baseline 2.63 hours · Performance 3.09 hours · Measure score 0.97 · Achievement 0 · Improvement 0.97

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.14%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 72 · Observed rate 16.67% · Lower 95% interval 8.61%
Discharge to community	52.49%	50.57% 1.9 pts better	No Different than the National Rate · Eligible stays 66 · Observed rate 40.91% · Lower 95% interval 36.37%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 34 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	40%	53.69% 13.7 pts worse	Numerator 8 · Denominator 20
Discharge mobility score	35%	50.94% 15.9 pts worse	Numerator 7 · Denominator 20
Pressure ulcers or injuries, new or worsened	2.94%	2.29% 0.6 pts worse	Numerator 1 · Denominator 34 · Adjusted rate 2.37%
Healthcare-associated infections requiring hospitalization	7.16%	7.12% About the same	No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.43%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 108
Staff flu vaccination coverage	2.99%	42% 39 pts worse	Numerator 4 · Denominator 134
Discharge function score	35%	56.45% 21.5 pts worse	Numerator 7 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	73.3%	93.6% 20.3 pts worse	93.4% 20.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.6% · Q2 78.5% · Q3 81.9% · Q4 82.1% · 4Q avg 73.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.0%	95.4% 4.4 pts worse	95.5% 4.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.3%	3.8% 3.5 pts better	3.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	49.2%	24.6% 24.6 pts worse	11.4% 37.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 59.2% · Q2 60.3% · Q3 41.3% · Q4 36.8% · 4Q avg 49.2%
Percentage of long-stay residents who lose too much weight	8.1%	5.6% 2.5 pts worse	5.4% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.6% · Q3 14.6% · Q4 6.0% · 4Q avg 8.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.2%	23.5% 12.3 pts better	19.6% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.5% · Q3 13.4% · Q4 18.1% · 4Q avg 11.2%
Percentage of long-stay residents who received an antipsychotic medication	8.8%	14.8% 6 pts better	16.7% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.0% · Q3 7.3% · Q4 11.5% · 4Q avg 8.8% · 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	5.5%	13.3% 7.8 pts better	16.3% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 9.3% · Q3 3.9% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.3%	11.7% 6.4 pts better	14.9% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.0% · Q3 5.1% · Q4 3.8% · 4Q avg 5.3% · 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 1.2% · 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	29.5%	24.2% 5.3 pts worse	19.8% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 35.4% · Q3 25.9% · Q4 28.6% · 4Q avg 29.5%
Percentage of long-stay residents with pressure ulcers	6.2%	4.1% 2.1 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.9% · Q3 3.3% · Q4 4.2% · 4Q avg 6.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	25.7%	81.6% 55.9 pts worse	81.7% 56 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 28.8% · Q3 34.2% · Q4 24.2% · 4Q avg 25.7%
Percentage of short-stay residents who had an outpatient emergency department visit	24.0%	10.5% 13.5 pts worse	12.0% 12 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 28.0% · Expected 13.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.3% 0.6 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	42.1%	79.0% 36.9 pts worse	79.7% 37.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 42.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.1%	22.4% 6.7 pts worse	23.9% 5.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 36.0% · Expected 29.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-28 · Fire 2025-02-28

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-12-15 · Fire 2023-12-15

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-07-31 · Fire 2023-07-31

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-28

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-18

F · Potential for more than minimal harm 2025-02-28

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-04-15

F · Potential for more than minimal harm 2025-02-28

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 2025-04-09

E · Potential for more than minimal harm 2025-02-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-04-09

E · Potential for more than minimal harm 2025-02-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-02

E · Potential for more than minimal harm 2025-02-28

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-04-07

F · Potential for more than minimal harm 2023-12-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-25

F · Potential for more than minimal harm 2023-07-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-08

F · Potential for more than minimal harm 2023-07-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-09-08

F · Potential for more than minimal harm 2023-07-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-31

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 2026-02-06

D · Potential for more than minimal harm 2025-12-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2026-02-06

G · Actual harm 2025-11-14

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Not marked corrected

D · Potential for more than minimal harm 2025-11-14

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.

Not marked corrected

E · Potential for more than minimal harm 2025-08-11

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-09-30

E · Potential for more than minimal harm 2025-08-11

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 2025-09-30

E · Potential for more than minimal harm 2025-08-11

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-09-30

E · Potential for more than minimal harm 2025-08-11

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-11

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 2025-09-30