7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Anderson, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
1235 W Cross St, Anderson, IN
(765) 203-2409
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
94
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-03-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.49
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.73
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
0.17
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
1,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0144
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.76
Baseline 18.28% · Performance 18.76% · Measure score 5.76 · Achievement 5.76 · Improvement 0
Healthcare-associated infections
6.97
Baseline 7.00% · Performance 5.75% · Measure score 6.97 · Achievement 6.97 · Improvement 5.74
Total nurse turnover
6.76
Baseline 53.70% · Performance 36.05% · Measure score 6.76 · Achievement 6.76 · Improvement 5.62
Adjusted total nurse staffing
4.19
Baseline 3.97 hours · Performance 4.27 hours · Measure score 4.19 · Achievement 4.19 · Improvement 1.14
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 9.02% · Lower 95% interval 7.09% |
| Discharge to community | 59.36% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 114 · Observed rate 57.89% · Lower 95% interval 50.83% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.05% |
95.27%
1.2 pts worse
|
Numerator 79 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 42 · Denominator 69 |
| Discharge mobility score | 53.62% |
50.94%
2.7 pts better
|
Numerator 37 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 84 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.75% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 2.53% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 5.05% |
8.2%
3.1 pts worse
|
Numerator 5 · Denominator 99 |
| Staff flu vaccination coverage | 41.91% |
42%
0.1 pts worse
|
Numerator 57 · Denominator 136 |
| Discharge function score | 59.42% |
56.45%
3 pts better
|
Numerator 41 · Denominator 69 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 88.24% |
96.28%
8 pts worse
|
Numerator 45 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 29.55% |
25.2%
4.4 pts better
|
Numerator 13 · Denominator 44 |
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 1.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
93.6%
4.1 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 96.3% · Q4 96.3% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.8%
1.1 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 3.7% · Q4 1.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
24.6%
24.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 9.8% |
5.6%
4.2 pts worse
|
5.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 15.4% · Q3 4.4% · Q4 11.4% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
23.5%
0.1 pts better
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 23.1% · Q3 32.6% · Q4 21.7% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
14.8%
7.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.7% · Q3 6.7% · Q4 10.0% · 4Q avg 7.3% · 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 | 37.8% |
13.3%
24.5 pts worse
|
16.3%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.3% · Q2 57.1% · 4Q avg 37.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.9% |
11.7%
13.2 pts worse
|
14.9%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 37.0% · Q3 14.3% · Q4 17.9% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.4%
1.3 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 1.5% · Q4 3.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 0.0% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
24.2%
2.7 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 21.1% · Q3 22.7% · Q4 17.8% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.1%
1.6 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.5% · Q3 1.8% · Q4 3.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
81.6%
15.3 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.1% · Q3 97.1% · Q4 92.9% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
10.5%
8.2 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 16.5% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.8% · Q3 3.1% · Q4 1.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
79.0%
14 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.4%
1.6 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 21.5% · Expected 21.4% · Used in QM five-star |
Survey summary
Top issue: Nursing and Physician Services (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-18
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-04-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-04-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-15
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-04-18
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 2025-04-18
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-04-18
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-04-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-18
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-20
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 2024-05-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-20
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-06-26
Fire Safety
Develop a communication plan.
Corrected 2023-06-26
Fire Safety
Establish methods for sharing information.
Corrected 2023-06-26
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-06-26
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-26
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-26
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-26
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-26
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-06-26
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-26
Fire Safety
Meet other general requirements.
Corrected 2023-06-26
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-26
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-06-26
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-26
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-26
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-26
Inspection history
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2026-01-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-28
Health
Post nurse staffing information every day.
Corrected 2025-03-28
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-03
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-03
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 2024-05-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-02
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-02
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-26
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 2023-05-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-26
Penalties and ownership
Payment Denial · denial start 2025-06-24 · 56 days
56 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
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Nearby options
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Anderson, IN
3-star overall rating with 3-star inspections with $8,390 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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