Cycle 1
Health 2025-05-09 · Fire 2025-05-09
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Indianapolis, IN
Hoosier Village
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
9875 Cherryleaf Dr, Indianapolis, IN
(317) 873-3349
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
24
Certified beds
Average residents
13
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bhi Senior Living
Operator or chain grouping
Approved since
1992-12-01
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 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
1.68
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.72
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
5.15
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
3.40
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.96
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.38
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.58
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
95%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,901
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9913
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.43
Baseline 19.00% · Performance 18.45% · Measure score 6.43 · Achievement 6.43 · Improvement 2.31
Healthcare-associated infections
1.2
Baseline 6.01% · Performance 7.48% · Measure score 1.2 · Achievement 1.2 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 7.14% · Lower 95% interval 6.98% |
| Discharge to community | 55.4% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 51.92% · Lower 95% interval 46.35% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 24 · Denominator 45 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 30 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 2.66% |
| Healthcare-associated infections requiring hospitalization | 7.48% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 4.61% |
| Staff COVID-19 vaccination coverage | 2.5% |
8.2%
5.7 pts worse
|
Numerator 5 · Denominator 200 |
| Staff flu vaccination coverage | 3.3% |
42%
38.7 pts worse
|
Numerator 7 · Denominator 212 |
| Discharge function score | 75.56% |
56.45%
19.1 pts better
|
Numerator 34 · Denominator 45 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 10 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
81.6%
9.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 96.9% · Q3 98.1% · Q4 78.6% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
10.5%
5.9 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
79.0%
5.6 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
22.4%
0.8 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 18.4% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-22 · Fire 2024-03-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-06
E · Potential for more than minimal harm
2024-03-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-05-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-12
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-05-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-08
C · Minimal harm
2023-05-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-08
C · Minimal harm
2023-05-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-06
D · Potential for more than minimal harm
2024-03-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-22
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 2024-04-30
D · Potential for more than minimal harm
2024-03-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-22
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 2024-04-30
E · Potential for more than minimal harm
2023-05-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-05-12
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 2023-07-05
D · Potential for more than minimal harm
2023-05-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-12
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 2023-07-05
D · Potential for more than minimal harm
2023-05-12
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 2023-07-05
D · Potential for more than minimal harm
2023-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
Ownership
Bhi Senior Living, Inc.
Operational/Managerial Control · Organization
Burton, Laura
W-2 Managing Employee · Individual
Dattilo, John
Corporate Officer · Individual
Kantz, Mindy
W-2 Managing Employee · Individual
Kennerk, Harry
Corporate Director · Individual
Seigel, Jane
Corporate Director · Individual
Weideman Ii, Roger
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Zionsville Meadows
Zionsville, IN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#2
St Augustine Home For The Aged
Indianapolis, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Marquette
Indianapolis, IN
5-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out