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
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
2.78
Nurse aide staffing
Weekend hours
3.46
Weekend nurse staffing
RN turnover
36%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Nearby options
Other facilities in reach
#1
Greenwood Health And Living Community
Greenwood, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Greenwood Healthcare Center
Greenwood, IN
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
Indianapolis, IN
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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