Cycle 1
Health 2025-09-23 · Fire 2025-09-23
25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Robin Run Health Center
1-star overall rating with 1-star inspections with 25 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
6370 Robin Run W, Indianapolis, IN
(317) 293-5500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Boncrest Resource Group
Operator or chain grouping
Approved since
1993-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 4 staffing / 3 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
0.74
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,774
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.12
Baseline 19.85% · Performance 20.91% · Measure score 1.12 · Achievement 1.12 · Improvement 0
Healthcare-associated infections
0
Baseline 5.83% · Performance 7.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 62.96% · Performance 74.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.11
Baseline 4.51 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 8.16% · Lower 95% interval 7.33% |
| Discharge to community | 58.49% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 53.76% · Lower 95% interval 47.26% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 10 · Denominator 22 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 8 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 41 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 7.69% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 31.82% |
56.45%
24.6 pts worse
|
Numerator 7 · Denominator 22 |
| Transfer of health information to provider | 93.1% |
95.95%
2.9 pts worse
|
Numerator 27 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
93.6%
11.6 pts worse
|
93.4%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 85.4% · Q3 95.2% · Q4 76.7% · 4Q avg 82.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
95.4%
1.3 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 13.7% |
3.8%
9.9 pts worse
|
3.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 18.8% · Q3 14.3% · Q4 9.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
24.6%
19.9 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.4% · Q3 0.0% · Q4 10.5% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 5.9% · Q4 9.7% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
23.5%
9.1 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 24.3% · Q3 11.4% · Q4 9.7% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
14.8%
0.6 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 29.2% · Q3 4.0% · Q4 12.0% · 4Q avg 15.4% · 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 | 36.1% |
13.3%
22.8 pts worse
|
16.3%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
11.7%
4.2 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 11.4% · Q3 27.3% · Q4 16.1% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
24.2%
2.2 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 27.3% · Q3 20.0% · Q4 18.9% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.1%
0.5 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.4% · Q3 5.7% · Q4 3.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.0% |
81.6%
15.6 pts worse
|
81.7%
15.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.5% · Q2 67.6% · Q3 73.5% · Q4 62.8% · 4Q avg 66.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
10.5%
2.9 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.3% |
79.0%
22.7 pts worse
|
79.7%
23.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
22.4%
2.5 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 25.6% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-23 · Fire 2024-08-23
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-12 · Fire 2023-06-12
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-09-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-09-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-09-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-09-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-13
F · Potential for more than minimal harm
2024-08-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-08-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
C · Minimal harm
2024-08-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-10-10
C · Minimal harm
2024-08-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-06-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-12
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 2023-08-31
F · Potential for more than minimal harm
2023-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
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 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-31
C · Minimal harm
2023-06-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-08-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-12-23
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 2026-02-16
D · Potential for more than minimal harm
2025-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-16
F · Potential for more than minimal harm
2025-12-01
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 2025-12-19
F · Potential for more than minimal harm
2025-09-23
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 2025-11-17
E · Potential for more than minimal harm
2025-09-23
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 2025-11-17
E · Potential for more than minimal harm
2025-09-23
F585 · Resident Rights Deficiencies
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 2025-11-17
E · Potential for more than minimal harm
2025-09-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-17
E · Potential for more than minimal harm
2025-09-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-11-17
E · Potential for more than minimal harm
2025-09-23
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 2025-11-17
E · Potential for more than minimal harm
2025-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-23
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 2025-11-17
D · Potential for more than minimal harm
2025-09-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-23
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 2025-11-17
D · Potential for more than minimal harm
2025-09-23
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 2025-11-17
D · Potential for more than minimal harm
2025-09-23
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 2025-11-17
D · Potential for more than minimal harm
2025-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-23
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 2025-11-17
E · Potential for more than minimal harm
2025-08-18
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-08-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-04-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-21
D · Potential for more than minimal harm
2024-12-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-22
G · Actual harm
2024-11-15
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 2024-12-20
E · Potential for more than minimal harm
2024-08-23
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-23
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 2024-09-16
D · Potential for more than minimal harm
2024-08-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-23
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 2024-09-16
D · Potential for more than minimal harm
2024-08-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-23
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 2024-09-16
D · Potential for more than minimal harm
2024-08-23
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 2024-09-16
E · Potential for more than minimal harm
2024-04-29
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 2024-05-31
D · Potential for more than minimal harm
2024-04-29
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 2024-05-31
D · Potential for more than minimal harm
2024-04-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-29
F585 · Resident Rights Deficiencies
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 2024-05-31
D · Potential for more than minimal harm
2024-04-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-29
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 2024-05-31
D · Potential for more than minimal harm
2024-04-29
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 2024-05-31
C · Minimal harm
2024-04-29
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-06-12
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 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
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 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
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 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
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 2023-07-26
Penalties and ownership
What sits behind the stars
$0
2024-11-15
Payment Denial
Payment Denial · denial start 2024-12-20 · 2 days
2 day denial
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Carroll, Paula
Operational/Managerial Control · Individual
Indianapolis Healthcare Investors LLC
5% Or Greater Mortgage Interest · Organization
Indianapolis Senior Care LLC
Operational/Managerial Control · Organization
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Mustaklem, Marwan
Operational/Managerial Control · Individual
Oakdale Seniors Alliance LLC
Operational/Managerial Control · Organization
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