Greenwood, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
937 Fry Rd, Greenwood, IN
(317) 881-3535
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
111
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
1991-12-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 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
RN hours / resident day
0.41
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
6,917
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.91
Baseline 20.02% · Performance 19.62% · Measure score 3.91 · Achievement 3.91 · Improvement 0.83
Healthcare-associated infections
5.28
Baseline 8.85% · Performance 6.62% · Measure score 5.28 · Achievement 4.05 · Improvement 5.28
Total nurse turnover
3.35
Baseline 50.00% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 13.73% · Lower 95% interval 7.83% |
| Discharge to community | 52.49% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 46.23% · Lower 95% interval 42.32% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 82 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 45.31% |
53.69%
8.4 pts worse
|
Numerator 29 · Denominator 64 |
| Discharge mobility score | 42.19% |
50.94%
8.8 pts worse
|
Numerator 27 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 83 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 5.56% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 1.01% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 99 |
| Staff flu vaccination coverage | 56.12% |
42%
14.1 pts better
|
Numerator 55 · Denominator 98 |
| Discharge function score | 60.94% |
56.45%
4.5 pts better
|
Numerator 39 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 7.89% |
25.2%
17.3 pts worse
|
Numerator 3 · Denominator 38 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
93.6%
0.9 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 93.1% · Q3 91.2% · Q4 90.2% · 4Q avg 92.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
95.4%
2.9 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.8%
1.4 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.1% · Q3 2.5% · Q4 2.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
24.6%
22.6 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.3% · Q3 0.0% · Q4 1.3% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.6%
3.3 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 9.9% · Q3 12.8% · Q4 10.4% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
23.5%
3.2 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 28.9% · Q3 24.4% · Q4 28.6% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
14.8%
1 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 14.3% · Q3 16.9% · Q4 16.4% · 4Q avg 15.8% · 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 | 3.4% |
13.3%
9.9 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 13.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
11.7%
8.4 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.2% · Q3 1.3% · Q4 2.7% · 4Q avg 3.3% · 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 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
24.2%
3.3 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 22.5% · Q3 16.2% · Q4 18.3% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.1%
1.7 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 8.4% · Q4 7.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
81.6%
9.8 pts worse
|
81.7%
9.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 69.0% · Q3 71.3% · Q4 76.2% · 4Q avg 71.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
10.5%
6.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.4% · Expected 11.5% · 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 1.5% · Q2 1.3% · Q3 0.0% · 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 | 69.9% |
79.0%
9.1 pts worse
|
79.7%
9.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
22.4%
0.7 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 20.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Resident Assessment and Care Planning (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
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 2025-07-11
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-11
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 2025-07-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-11
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-18
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-18
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-18
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-18
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-06-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-18
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-18
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-21
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-21
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-21
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-07-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-21
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-17
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-17
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 2025-06-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-17
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-29
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 2024-05-29
Health
Post nurse staffing information every day.
Corrected 2024-05-29
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-04
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-08-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Nearby options
Indianapolis, IN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Greenwood, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Greenwood, IN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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