Indianapolis, IN

Hawthorne Healthcare Center

3-star overall rating with 2-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

7465 Madison Ave, Indianapolis, IN

(317) 788-3000

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Communicare Health

Operator or chain grouping

Approved since

2010-07-13

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

0.61

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.49

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.42

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.10

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.06

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.31

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

69%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

64%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,709

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

Performance score

1.17

Composite VBP score used to determine payment impact.

Payment multiplier

0.9804

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 67.00% · Performance 79.07% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0.23

Baseline 2.75 hours · Performance 2.97 hours · Measure score 0.23 · Achievement 0 · Improvement 0.23

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.19	1.02 0.2 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	4.17%	8.2% 4 pts worse	Numerator 3 · Denominator 72
Staff flu vaccination coverage	11.43%	42% 30.6 pts worse	Numerator 12 · Denominator 105
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · 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	93.2%	93.6% 0.4 pts worse	93.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 95.9% · Q3 96.1% · Q4 92.4% · 4Q avg 93.2%
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	0.9%	3.8% 2.9 pts better	3.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.7%	24.6% 17.9 pts better	11.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 7.1% · Q3 8.5% · Q4 1.8% · 4Q avg 6.7%
Percentage of long-stay residents who lose too much weight	10.7%	5.6% 5.1 pts worse	5.4% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 11.4% · Q3 6.5% · Q4 7.0% · 4Q avg 10.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.5%	23.5% 1 pts worse	19.6% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 23.9% · Q3 23.9% · Q4 22.4% · 4Q avg 24.5%
Percentage of long-stay residents who received an antipsychotic medication	16.9%	14.8% 2.1 pts worse	16.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 19.4% · Q3 10.0% · Q4 8.1% · 4Q avg 16.9% · 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	12.6%	13.3% 0.7 pts better	16.3% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 14.7% · 4Q avg 12.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.0%	11.7% 8.7 pts better	14.9% 11.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.7% · Q3 0.0% · Q4 3.4% · 4Q avg 3.0% · 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	0.5%	1.2% 0.7 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.0%	24.2% 0.2 pts better	19.8% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.4% · Q3 28.7% · Q4 28.8% · 4Q avg 24.0%
Percentage of long-stay residents with pressure ulcers	4.3%	4.1% 0.2 pts worse	5.1% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.8% · Q3 7.3% · Q4 4.7% · 4Q avg 4.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.9%	81.6% 20.7 pts worse	81.7% 20.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 51.5% · Q3 73.3% · Q4 77.8% · 4Q avg 60.9%
Percentage of short-stay residents who newly received an antipsychotic medication	4.3%	1.3% 3 pts worse	1.6% 2.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q3 8.7% · 4Q avg 4.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	64.7%	79.0% 14.3 pts worse	79.7% 15 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 64.7%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-05 · Fire 2025-12-05

3 health deficiencies

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

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-11-13 · Fire 2024-11-13

21 health deficiencies

Top issue: Resident Rights (5 deficiencies)

8 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 3 Health 2024-02-02 · Fire 2024-02-02

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-05

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2026-01-27

F · Potential for more than minimal harm 2025-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-02-06

F · Potential for more than minimal harm 2025-12-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2026-02-06

F · Potential for more than minimal harm 2025-12-05

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 2026-02-06

E · Potential for more than minimal harm 2025-12-05

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2026-02-06

E · Potential for more than minimal harm 2025-12-05

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2026-02-06

C · Minimal harm 2025-12-05

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2026-02-06

C · Minimal harm 2025-12-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2026-02-06

F · Potential for more than minimal harm 2024-11-13

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-11-13

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-11-13

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 2025-01-31

F · Potential for more than minimal harm 2024-02-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-15

F · Potential for more than minimal harm 2024-02-02

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-03-15

E · Potential for more than minimal harm 2024-02-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-02

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-02

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2024-03-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-05

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 2025-12-23

D · Potential for more than minimal harm 2025-12-05

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 2025-12-23

J · Immediate jeopardy 2025-04-23

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 2025-04-14

E · Potential for more than minimal harm 2024-11-13

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 2024-12-13

D · Potential for more than minimal harm 2024-11-13

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 2024-12-13

C · Minimal harm 2024-11-13

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-08-20

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-08-20

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-08-20

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 2024-08-28

E · Potential for more than minimal harm 2024-08-02

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 2024-08-27

D · Potential for more than minimal harm 2024-08-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-08-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-08-02

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-08-02

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 2024-08-27

D · Potential for more than minimal harm 2024-07-17

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-07-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-07-17

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-17

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-05

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2024-08-02

G · Actual harm 2024-06-17

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-06-17

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 2024-08-28

E · Potential for more than minimal harm 2024-06-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-06-17

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-03-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-04-05

E · Potential for more than minimal harm 2024-02-02

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 2024-02-26

D · Potential for more than minimal harm 2024-02-02

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-02-26

D · Potential for more than minimal harm 2024-02-02

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 2024-02-26

Penalties and ownership

What sits behind the stars

$0 2024-06-17

Payment Denial

Payment Denial · denial start 2024-08-27 · 1 days

1 day denial

Ownership

Adams County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 52 facilities 2012-07-01

Adams County Memorial Hospital

Operational/Managerial Control · Organization

0% 52 facilities 2012-07-01

Barbour, Jakob