25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
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
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
Staffing
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
0.61
Licensed practical nurse staffing
Aide hours / resident day
2.73
Nurse aide staffing
Weekend hours
3.68
Weekend nurse staffing
RN turnover
78%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-13
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-13
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-10
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-10-10
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-10
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-08-31
Fire Safety
Develop a communication plan.
Corrected 2023-08-31
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-08-31
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-31
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-31
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-31
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-31
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-31
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-31
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-08-31
Inspection history
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-16
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-16
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
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-17
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-17
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-17
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
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-17
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-17
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
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
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
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-17
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-09-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-21
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
Health
Assess the resident when there is a significant change in condition
Corrected 2024-09-16
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
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-16
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
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-16
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
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
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
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-31
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-31
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
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-31
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-03
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
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-26
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-26
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-07-26
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
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-26
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
Payment Denial · denial start 2024-12-20 · 2 days
2 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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