Cycle 1
Health 2026-01-27 · Fire 2024-12-17
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Marion, IN
Wesleyan Health Care Center
3-star overall rating with 2-star inspections with $8,824 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
729 West 35th St, Marion, IN
(765) 674-3371
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
1992-06-01
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
0.56
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.25
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
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,099
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 19.15% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Healthcare-associated infections
0
Baseline 6.00% · Performance 8.48% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.65
Baseline 60.80% · Performance 52.83% · Measure score 2.65 · Achievement 2.65 · Improvement 1.72
Adjusted total nurse staffing
0
Baseline 3.43 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.74% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 14.46% · Lower 95% interval 7.41% |
| Discharge to community | 47.62% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 41.11% · Lower 95% interval 37.6% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 21 · Denominator 36 |
| Discharge mobility score | 69.44% |
50.94%
18.5 pts better
|
Numerator 25 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 7.46% |
2.29%
5.2 pts worse
|
Numerator 5 · Denominator 67 · Adjusted rate 5.97% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 11.86% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 5.93% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 135 |
| Staff flu vaccination coverage | 3.6% |
42%
38.4 pts worse
|
Numerator 5 · Denominator 139 |
| Discharge function score | 69.44% |
56.45%
13 pts better
|
Numerator 25 · Denominator 36 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 10 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.9% |
3.8%
0.1 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 5.4% · Q4 6.2% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
24.6%
13.2 pts better
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.7% · Q3 5.7% · Q4 28.7% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 11.4% |
5.6%
5.8 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 10.5% · Q3 12.6% · Q4 12.8% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
23.5%
13.2 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.1% · Q3 10.0% · Q4 11.7% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
14.8%
2.7 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 13.1% · Q3 12.5% · Q4 12.2% · 4Q avg 12.1% · 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 | 11.5% |
13.3%
1.8 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.5% · Q3 14.4% · Q4 6.8% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
11.7%
0.4 pts worse
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 12.5% · Q3 18.8% · Q4 6.0% · 4Q avg 12.1% · 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 0.8% · Q2 0.0% · Q3 1.7% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.2%
0.2 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
24.2%
1.5 pts better
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 18.9% · Q3 22.8% · Q4 25.7% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.1%
1.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 7.9% · Q4 7.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
81.6%
9.2 pts better
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 92.4% · Q3 93.3% · Q4 87.1% · 4Q avg 90.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
10.5%
2.8 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 9.1% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.1% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
79.0%
15.2 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.4%
2.3 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 25.5% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-17 · Fire 2023-12-04
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-12-04 · Fire 2022-10-24
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-12-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-12-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-12-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-07
F · Potential for more than minimal harm
2023-12-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-25
F · Potential for more than minimal harm
2023-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-12-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-12-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-25
F · Potential for more than minimal harm
2022-10-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-24
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-24
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 2023-01-20
E · Potential for more than minimal harm
2022-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-27
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 2026-02-13
D · Potential for more than minimal harm
2026-01-27
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 2026-02-13
D · Potential for more than minimal harm
2026-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-27
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 2026-02-13
D · Potential for more than minimal harm
2026-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-13
G · Actual harm
2024-12-17
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 2025-01-09
D · Potential for more than minimal harm
2024-12-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-17
F584 · Resident Rights Deficiencies
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 2025-01-09
D · Potential for more than minimal harm
2024-12-17
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 2025-01-09
D · Potential for more than minimal harm
2024-12-17
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
G · Actual harm
2024-05-06
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 2024-05-29
D · Potential for more than minimal harm
2024-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-29
F · Potential for more than minimal harm
2023-12-04
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-12-04
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-04
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 2023-12-22
D · Potential for more than minimal harm
2023-12-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-25
G · Actual harm
2023-08-11
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 2023-08-18
Penalties and ownership
What sits behind the stars
$8,824
2024-12-17
Fine
Fine · fine $8,824
Fine
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Baker, Brenda
Corporate Officer · Individual
Baker, Brenda
W-2 Managing Employee · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Warren, Seth
Corporate Officer · Individual
Warren, Seth
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Colonial Oaks Health Care Center
Marion, IN
5-star overall rating with 5-star inspections with 13 fire-safety deficiencies in the latest cycle
#2
Aperion Care Marion LLC
Marion, IN
1-star overall rating with 1-star inspections with abuse icon flag with $15,593 in total fines with 17 recent health deficiencies
#3
Miller's Merry Manor
Marion, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies
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