Cycle 1
Health 2025-07-29 · Fire 2025-07-29
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Greenwood, IN
Greenwood Village South
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
295 Village Lane, Greenwood, IN
(317) 859-4444
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
137
Certified beds
Average residents
123
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
1969-08-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
0.42
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.46
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,839
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9954
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.20
Baseline 14.84% · Performance 18.56% · Measure score 6.20 · Achievement 6.20 · Improvement 0
Healthcare-associated infections
1.89
Baseline 5.74% · Performance 7.27% · Measure score 1.89 · Achievement 1.89 · Improvement 0
Total nurse turnover
5.20
Baseline 53.62% · Performance 42.45% · Measure score 5.20 · Achievement 5.20 · Improvement 3.38
Adjusted total nurse staffing
3.70
Baseline 3.77 hours · Performance 4.13 hours · Measure score 3.70 · Achievement 3.70 · Improvement 1.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 258 · Observed rate 14.34% · Lower 95% interval 10.11% |
| Discharge to community | 64.26% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 58.16% · Lower 95% interval 56.15% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 136 · Denominator 136 |
| Falls with major injury | 0.74% |
0.77%
About the same
|
Numerator 1 · Denominator 136 |
| Discharge self-care score | 64.08% |
53.69%
10.4 pts better
|
Numerator 66 · Denominator 103 |
| Discharge mobility score | 52.43% |
50.94%
1.5 pts better
|
Numerator 54 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 2.21% |
2.29%
0.1 pts better
|
Numerator 3 · Denominator 136 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 7.14% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 0.94% |
8.2%
7.3 pts worse
|
Numerator 2 · Denominator 212 |
| Staff flu vaccination coverage | 23.51% |
42%
18.5 pts worse
|
Numerator 75 · Denominator 319 |
| Discharge function score | 63.11% |
56.45%
6.7 pts better
|
Numerator 65 · Denominator 103 |
| Transfer of health information to provider | 97.18% |
95.95%
1.2 pts better
|
Numerator 69 · Denominator 71 |
| Transfer of health information to patient | 93.1% |
96.28%
3.2 pts worse
|
Numerator 27 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 27.14% |
25.2%
1.9 pts better
|
Numerator 19 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
93.6%
4.7 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.0% · Q3 99.0% · Q4 99.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
95.4%
0.9 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.8%
2.8 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
24.6%
21.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 2.9% · Q4 2.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
5.6%
4.5 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.7% · Q3 8.1% · Q4 9.0% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
23.5%
12.1 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.6% · Q3 11.6% · Q4 8.9% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
14.8%
0.8 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 13.8% · Q3 14.7% · Q4 17.3% · 4Q avg 15.6% · 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 | 36.4% |
13.3%
23.1 pts worse
|
16.3%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 53.3% · 4Q avg 36.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.8% |
11.7%
23.1 pts worse
|
14.9%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 26.4% · Q3 41.1% · Q4 32.4% · 4Q avg 34.8% · 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 | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 1.9% · Q4 1.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
24.2%
3.1 pts better
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 20.8% · Q3 11.1% · Q4 20.3% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.1%
4.1 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
81.6%
17.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
10.5%
0.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.1% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.4% |
79.0%
13.4 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| 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 19.1% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-13 · Fire 2024-08-13
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-08-15 · Fire 2023-08-15
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-29
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 2025-10-03
F · Potential for more than minimal harm
2025-07-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-07-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-07-29
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-07-29
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 2025-09-26
E · Potential for more than minimal harm
2025-07-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-07-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-07-29
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-10-03
F · Potential for more than minimal harm
2024-08-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-12
F · Potential for more than minimal harm
2023-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-08-15
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 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
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 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-15
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-12
E · Potential for more than minimal harm
2023-08-15
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 2023-09-08
D · Potential for more than minimal harm
2023-08-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-08
C · Minimal harm
2023-08-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-08
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Callon, George
Operational/Managerial Control · Individual
Callon, George
Corporate Director · Individual
Colvin, Jeffrey
Operational/Managerial Control · Individual
Colvin, Jeffrey
Corporate Director · Individual
Cripps, Jerry
Operational/Managerial Control · Individual
Cripps, Jerry
Corporate Director · Individual
Crowder, Diane
Operational/Managerial Control · Individual
Crowder, Diane
Corporate Director · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Officer · Individual
Gibson, Linda
Operational/Managerial Control · Individual
Gibson, Linda
Corporate Director · Individual
Gipson, Crystal
Operational/Managerial Control · Individual
Gipson, Crystal
Corporate Director · Individual
Greathouse, Karen
Operational/Managerial Control · Individual
Greathouse, Karen
Corporate Director · Individual
Hestand, David
Operational/Managerial Control · Individual
Hestand, David
Corporate Director · Individual
Hoover, Kevin
Operational/Managerial Control · Individual
Hoover, Kevin
Corporate Officer · Individual
Johnson Memorial Hospital
Operational/Managerial Control · Organization
Johnson, Ellen
Operational/Managerial Control · Individual
Johnson, Ellen
Corporate Director · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Morrison, Dennis
Operational/Managerial Control · Individual
Morrison, Dennis
Corporate Director · Individual
Morrow, Jordan
Operational/Managerial Control · Individual
Morrow, Jordan
Corporate Director · Individual
Neese, Kevin
Operational/Managerial Control · Individual
Pfaff, Paul
Operational/Managerial Control · Individual
Pfaff, Paul
Corporate Director · Individual
Powell, Stephen
Operational/Managerial Control · Individual
Powell, Stephen
Corporate Director · Individual
Seegers, Pamela
Operational/Managerial Control · Individual
Tapp, Michael
Operational/Managerial Control · Individual
Tapp, Michael
Corporate Director · Individual
Ulrey, Alexa
Operational/Managerial Control · Individual
Ulrey, Alexa
Corporate Director · Individual
Wagner, Daniel
Operational/Managerial Control · Individual
Wagner, Daniel
Corporate Director · Individual
Westminster Village Greenwood, Inc
Operational/Managerial Control · Organization
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Greenwood, IN
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#2
Greenwood Healthcare Center
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
University Heights Health And Living Community
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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