Cycle 1
Health 2025-01-15 · Fire 2025-01-15
21 health deficiencies
Top issue: Resident Rights (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Westside Retirement Village
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
8616 W 10th St, Indianapolis, IN
(317) 209-2800
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
132
Certified beds
Average residents
94
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1997-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 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
0.40
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.31
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
1.37
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
0.16
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,299
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.75
Baseline 20.64% · Performance 18.77% · Measure score 5.75 · Achievement 5.75 · Improvement 4.69
Healthcare-associated infections
6.36
Baseline 4.51% · Performance 5.93% · Measure score 6.36 · Achievement 6.36 · Improvement 0
Total nurse turnover
3.35
Baseline 59.77% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 2.30
Adjusted total nurse staffing
0.74
Baseline 3.16 hours · Performance 3.29 hours · Measure score 0.74 · Achievement 0.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 12.06% · Lower 95% interval 7.87% |
| Discharge to community | 63.64% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 98 · Observed rate 53.06% · Lower 95% interval 51.73% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 64 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 21 · Denominator 42 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 21 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 65 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 2.99% · Lower 95% interval 3.21% |
| Staff COVID-19 vaccination coverage | 5.84% |
8.2%
2.4 pts worse
|
Numerator 9 · Denominator 154 |
| Staff flu vaccination coverage | 18.66% |
42%
23.3 pts worse
|
Numerator 39 · Denominator 209 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 30 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 6 · Denominator 20 |
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 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
93.6%
4.3 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 96.2% · Q4 96.2% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
95.4%
3.6 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.8%
0.4 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.4% · Q3 7.5% · Q4 3.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.3% |
24.6%
16.7 pts worse
|
11.4%
29.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.1% · Q2 43.2% · Q3 40.6% · Q4 27.0% · 4Q avg 41.3% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.6%
3.1 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 7.0% · Q3 4.5% · Q4 11.4% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
23.5%
0.9 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 23.3% · Q3 28.2% · Q4 23.3% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
14.8%
1.6 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 18.0% · Q3 12.5% · Q4 8.2% · 4Q avg 13.2% · 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 | 21.0% |
13.3%
7.7 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.2% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
11.7%
1.2 pts worse
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.0% · Q3 19.4% · Q4 23.2% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
24.2%
2.7 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 18.2% · Q3 20.6% · Q4 17.0% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.1%
1.3 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.2% · Q3 3.6% · Q4 3.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
81.6%
7 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 96.4% · Q3 84.9% · Q4 84.3% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
10.5%
4.4 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 12.5% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
79.0%
14.2 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.2% |
22.4%
12.2 pts better
|
23.9%
13.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 8.3% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-04 · Fire 2023-12-04
33 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-03
C · Minimal harm
2025-01-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-03
C · Minimal harm
2025-01-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-03
C · Minimal harm
2025-01-15
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-03-03
F · Potential for more than minimal harm
2023-12-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-19
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 2024-01-19
E · Potential for more than minimal harm
2023-12-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-19
F · Potential for more than minimal harm
2022-09-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-23
E · Potential for more than minimal harm
2022-09-01
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-10-23
E · Potential for more than minimal harm
2022-09-01
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-10-23
E · Potential for more than minimal harm
2022-09-01
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2022-10-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-05-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
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 2025-06-27
E · Potential for more than minimal harm
2025-01-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-15
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 2025-02-17
E · Potential for more than minimal harm
2025-01-15
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 2025-02-17
E · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-15
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 2025-02-17
D · Potential for more than minimal harm
2025-01-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-17
E · Potential for more than minimal harm
2024-11-07
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-08-16
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 2024-09-13
D · Potential for more than minimal harm
2024-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-06-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-04-17
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 2024-05-15
D · Potential for more than minimal harm
2024-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-12-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-12-04
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 2024-01-04
F · Potential for more than minimal harm
2023-12-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-04
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 2024-01-04
E · Potential for more than minimal harm
2023-12-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-04
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 2024-01-04
E · Potential for more than minimal harm
2023-12-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-04
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 2024-01-04
E · Potential for more than minimal harm
2023-12-04
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-04
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 2024-01-04
E · Potential for more than minimal harm
2023-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
E · 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 2024-01-04
D · Potential for more than minimal harm
2023-12-04
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 2024-01-04
D · Potential for more than minimal harm
2023-12-04
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 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-04
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 2024-01-04
D · Potential for more than minimal harm
2023-12-04
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 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-04
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 2024-01-04
G · Actual harm
2023-10-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-12
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 2023-11-03
D · Potential for more than minimal harm
2023-10-12
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 2023-11-03
D · Potential for more than minimal harm
2023-10-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-04-11
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 2023-04-28
E · Potential for more than minimal harm
2022-09-01
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 2022-10-01
E · Potential for more than minimal harm
2022-09-01
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 2022-10-01
E · Potential for more than minimal harm
2022-09-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-09-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-09-01
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 2022-10-01
E · Potential for more than minimal harm
2022-09-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
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 2022-10-01
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Cross, Cindy
Operational/Managerial Control · Individual
Fenoughty, Deanna
Operational/Managerial Control · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Fletcher, Todd
Operational/Managerial Control · Individual
Henry, Terry
Operational/Managerial Control · Individual
Lay, Lisa
Operational/Managerial Control · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Linenberger, Charity
Operational/Managerial Control · Individual
Preston, Aubrey
Operational/Managerial Control · Individual
Preston, Forrest
Operational/Managerial Control · Individual
Swanker, Richard
Operational/Managerial Control · Individual
Thurmond, Joan
Operational/Managerial Control · Individual
Walbridge, Timothy
Operational/Managerial Control · Individual
Westside SNF Operations LLC
Operational/Managerial Control · Organization
Ziegler, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Wellbrooke Of Avon
Indianapolis, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Brooke Knoll Village
Avon, IN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Eagle Valley Meadows
Indianapolis, IN
2-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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