Cycle 1
Health 2025-01-30 · Fire 2025-01-30
22 health deficiencies
Top issue: Environmental (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Forest Creek Village
2-star overall rating with 1-star inspections with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
525 E Thompson Rd, Indianapolis, IN
(317) 787-8253
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1984-10-01
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
0.44
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.27
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
2.87
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
2.85
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.15
Baseline 21.23% · Performance 20.43% · Measure score 2.15 · Achievement 2.15 · Improvement 1.40
Healthcare-associated infections
0
Baseline 6.28% · Performance 7.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 68.75% · Performance 67.71% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.81
Baseline 2.97 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 11.9% · Lower 95% interval 7.11% |
| Discharge to community | 47.2% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 39.02% · Lower 95% interval 30.11% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 29 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.7% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 21.13% |
42%
20.9 pts worse
|
Numerator 30 · Denominator 142 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
93.6%
1 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 98.8% · Q3 97.6% · Q4 100.0% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 25.8% |
95.4%
69.6 pts worse
|
95.5%
69.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 25.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.8%
2.6 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 45.1% |
24.6%
20.5 pts worse
|
11.4%
33.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 42.9% · Q3 40.0% · Q4 71.1% · 4Q avg 45.1% |
| 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 · Q1 4.0% · Q2 6.7% · Q3 2.8% · Q4 1.3% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
23.5%
11.2 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 32.4% · Q3 37.3% · Q4 43.6% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
14.8%
3.1 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.5% · Q3 10.2% · Q4 10.5% · 4Q avg 11.7% · 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 | 4.7% |
13.3%
8.6 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.0% · Q3 2.3% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
11.7%
3.7 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.0% · Q3 2.9% · Q4 6.8% · 4Q avg 8.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
24.2%
2.5 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 23.4% · Q3 25.2% · Q4 20.5% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.1%
1.5 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.9% · Q3 5.2% · Q4 4.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
81.6%
6 pts better
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 89.8% · Q3 91.5% · Q4 79.2% · 4Q avg 87.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
10.5%
3.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 8.7% · Expected 14.6% · 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 0.0% · Q3 2.4% · 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 | 68.9% |
79.0%
10.1 pts worse
|
79.7%
10.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.7% |
22.4%
10.7 pts better
|
23.9%
12.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 13.0% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-30
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 2025-02-24
E · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-24
C · Minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-24
F · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-15
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 2024-03-22
E · Potential for more than minimal harm
2024-02-15
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-15
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 2024-03-22
E · Potential for more than minimal harm
2024-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-22
F · Potential for more than minimal harm
2023-03-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-03-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-03-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-30
D · Potential for more than minimal harm
2026-01-16
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 2026-01-30
D · Potential for more than minimal harm
2026-01-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-12-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
E · Potential for more than minimal harm
2025-06-24
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 2025-07-07
D · Potential for more than minimal harm
2025-06-24
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 2025-07-07
D · Potential for more than minimal harm
2025-06-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-24
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 2025-07-07
D · Potential for more than minimal harm
2025-05-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
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 2025-06-27
D · Potential for more than minimal harm
2025-05-21
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 2025-06-27
D · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-03-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-14
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 2025-04-18
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-01-30
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 2025-02-14
D · Potential for more than minimal harm
2025-01-30
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 2025-02-14
D · Potential for more than minimal harm
2024-10-24
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-02-15
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 2024-03-07
D · Potential for more than minimal harm
2024-02-15
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 2024-03-07
D · Potential for more than minimal harm
2024-02-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-15
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 2024-03-07
D · Potential for more than minimal harm
2024-02-15
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 2024-03-07
D · Potential for more than minimal harm
2024-02-15
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 2024-03-07
C · Minimal harm
2024-02-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-07
D · Potential for more than minimal harm
2023-07-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
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
Dice, Mark
Contracted Managing Employee · Individual
Drummer, Carl
Corporate Director · 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
Patel, Neha
Contracted Managing Employee · Individual
Payne, Monica
Corporate Director · Individual
Smith, Danielle
Contracted Managing Employee · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
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#3
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