Cycle 1
Health 2024-12-06 · Fire 2024-12-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Southpointe Healthcare Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4904 War Admiral Drive, Indianapolis, IN
(317) 885-3333
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
2014-08-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
122 facilities
Chain averages 3 overall / 2 health / 2 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
0.60
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.31
Baseline 20.68% · Performance 20.36% · Measure score 2.31 · Achievement 2.31 · Improvement 0.38
Healthcare-associated infections
0
Baseline 7.29% · Performance 9.22% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.68
Performance 48.62% · Measure score 3.68 · Achievement 3.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.11
Baseline 2.91 hours · Performance 3.09 hours · Measure score 0.11 · Achievement 0 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.75% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 168 · Observed rate 16.67% · Lower 95% interval 9.43% |
| Discharge to community | 57.99% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 50.33% · Lower 95% interval 48.45% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.24% |
95.27%
4 pts better
|
Numerator 131 · Denominator 132 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 132 |
| Discharge self-care score | 64.13% |
53.69%
10.4 pts better
|
Numerator 59 · Denominator 92 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 48 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 132 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.22% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 12.39% · Lower 95% interval 5.81% |
| Staff COVID-19 vaccination coverage | 2.03% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 148 |
| Staff flu vaccination coverage | 20.5% |
42%
21.5 pts worse
|
Numerator 33 · Denominator 161 |
| Discharge function score | 66.3% |
56.45%
9.8 pts better
|
Numerator 61 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 12.68% |
25.2%
12.5 pts worse
|
Numerator 9 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.1 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.6%
5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.4%
0.7 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.8%
1.1 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.0% · Q3 4.3% · Q4 5.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.0% |
24.6%
16.4 pts worse
|
11.4%
29.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.8% · Q2 41.1% · Q3 37.7% · Q4 34.8% · 4Q avg 41.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
5.6%
2.6 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 8.8% · Q3 6.8% · Q4 7.7% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
23.5%
1.3 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 30.5% · Q3 19.7% · Q4 16.7% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
14.8%
7.1 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.8% · Q3 3.8% · Q4 3.8% · 4Q avg 7.7% · 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 | 11.7% |
13.3%
1.6 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.7% · 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 9.7% · Q2 3.5% · Q3 5.1% · Q4 7.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
24.2%
9 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 27.1% · Q3 42.7% · Q4 35.9% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.1%
0.2 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 2.4% · Q3 1.1% · Q4 3.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.3% |
81.6%
8.3 pts worse
|
81.7%
8.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 71.2% · Q3 91.4% · Q4 87.2% · 4Q avg 73.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
10.5%
7.2 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 3.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
79.0%
2.3 pts worse
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
22.4%
2.6 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 20.3% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-20 · Fire 2022-12-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-06
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 2025-01-22
E · Potential for more than minimal harm
2024-12-06
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-01-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-02-09
E · Potential for more than minimal harm
2024-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-06
C · Minimal harm
2022-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-12
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 2025-03-03
D · Potential for more than minimal harm
2024-12-06
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 2025-01-02
D · Potential for more than minimal harm
2024-12-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-05-22
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 2024-06-10
D · Potential for more than minimal harm
2024-01-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-24
D · Potential for more than minimal harm
2022-12-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-27
C · Minimal harm
2022-12-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-12-27
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Hancock Regional Hospital
5% Or Greater Indirect Ownership Interest · Organization
Kelley, Sara
Operational/Managerial Control · Individual
Long, Steven
Operational/Managerial Control · Individual
Odenthal, Richard
Operational/Managerial Control · Individual
Sweeny, Brendan
Operational/Managerial Control · Individual
War Admiral Mgt Co LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Rosegate Village
Indianapolis, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Hawthorne Healthcare Center
Indianapolis, IN
3-star overall rating with 2-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Southport
Indianapolis, IN
2-star overall rating with 1-star inspections with $53,762 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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