Cycle 1
Health 2025-12-22 · Fire 2025-12-22
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Pendleton, IN
Rawlins House Health & Living Community
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
300 J H Walker Dr, Pendleton, IN
(765) 778-7501
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
110
Certified beds
Average residents
106
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
1990-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.85
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.58
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
0.97
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0000
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.09
Baseline 18.65% · Performance 17.22% · Measure score 9.09 · Achievement 9.09 · Improvement 8.32
Healthcare-associated infections
2.99
Baseline 7.24% · Performance 6.94% · Measure score 2.99 · Achievement 2.99 · Improvement 0.84
Total nurse turnover
5.09
Baseline 38.16% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 0
Adjusted total nurse staffing
1.47
Baseline 2.74 hours · Performance 3.34 hours · Measure score 1.47 · Achievement 0.91 · Improvement 1.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 10.11% · Lower 95% interval 8.08% |
| Discharge to community | 58.15% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 178 · Observed rate 56.18% · Lower 95% interval 51.88% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 73.39% |
95.27%
21.9 pts worse
|
Numerator 80 · Denominator 109 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 109 |
| Discharge self-care score | 71.74% |
53.69%
18 pts better
|
Numerator 66 · Denominator 92 |
| Discharge mobility score | 72.83% |
50.94%
21.9 pts better
|
Numerator 67 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 109 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 5.88% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 1.43% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 140 |
| Staff flu vaccination coverage | 93.27% |
42%
51.3 pts better
|
Numerator 194 · Denominator 208 |
| Discharge function score | 81.52% |
56.45%
25.1 pts better
|
Numerator 75 · Denominator 92 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 87.84% |
96.28%
8.4 pts worse
|
Numerator 65 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 12 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
95.4%
2.5 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.8%
0.6 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.5% · Q3 2.4% · Q4 2.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
24.6%
18 pts better
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.1% · Q3 9.0% · Q4 2.6% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.6%
3.1 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 2.5% · Q4 3.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
23.5%
About the same
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 22.9% · Q3 20.3% · Q4 25.3% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
14.8%
5.9 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 18.7% · Q3 24.3% · Q4 21.7% · 4Q avg 20.7% · 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 | 5.9% |
13.3%
7.4 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.9% · Q3 6.9% · Q4 7.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
11.7%
5.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.5% · Q3 3.9% · Q4 13.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.4%
0.6 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.2%
1.7 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.0% · Q3 1.2% · Q4 1.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
24.2%
1.9 pts better
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 17.5% · Q3 25.4% · Q4 27.7% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.1%
2.3 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 2.1% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
81.6%
7.1 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 86.5% · Q3 84.7% · Q4 91.1% · 4Q avg 88.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
10.5%
5.1 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.2% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
79.0%
6.6 pts better
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
22.4%
1.4 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 21.6% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2024-09-11
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-31 · Fire 2023-07-31
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-22
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 2026-01-27
E · Potential for more than minimal harm
2025-12-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-27
F · Potential for more than minimal harm
2024-09-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-09-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-11
K222 · Egress Deficiencies
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 2024-10-01
E · Potential for more than minimal harm
2024-09-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-01
C · Minimal harm
2024-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-01
E · Potential for more than minimal harm
2023-07-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-31
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 2023-09-18
E · Potential for more than minimal harm
2023-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-18
C · Minimal harm
2023-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-12-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2026-01-13
E · Potential for more than minimal harm
2024-09-11
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-09-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-11
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 2024-09-30
D · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
D · Potential for more than minimal harm
2023-07-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-31
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 2023-08-16
D · Potential for more than minimal harm
2023-07-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Balla, Matthew
Operational/Managerial Control · Individual
Cardon And Associates Inc
Operational/Managerial Control · Organization
Cardon Management Company LLC
Operational/Managerial Control · Organization
Cattell, Zachary
Operational/Managerial Control · Individual
Covey, Charles
Operational/Managerial Control · Individual
Fauth, Kendra
Operational/Managerial Control · Individual
Friend, Jayna
Corporate Officer · Individual
Gormal, Gregg
Operational/Managerial Control · Individual
Hashmi, Syed
Operational/Managerial Control · Individual
Haug, Amy
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Ingram, Stephanie
Operational/Managerial Control · Individual
Lopossa, Lynn
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Security Interest · Organization
Mcclelland, Thomas
Operational/Managerial Control · Individual
Mccoskey, Catherine
Operational/Managerial Control · Individual
Mcintosh, Eric
Operational/Managerial Control · Individual
Moore Operating Group Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Countryside Manor Health & Living Community
Anderson, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Beaumont Rehabilitation And Healthcare Center
Anderson, IN
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Envive Of Anderson
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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