Four Seasons Retirement Center
1901 Taylor Rd, Columbus, IN 47203 · Non profit - Corporation · 30 certified beds · (812) 372-8481 Medicare only — no Medicaid
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.5% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 12.9% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.8% | 10.8% | 12.0% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
67.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 244 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 88 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 1.81 therapist hours per resident per day in 2025Q4 — more than 100% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 67.5%CMS range 62.2–73.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 8.2–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 48.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 43.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 38.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.5–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 30 beds and averages 14.2 residents a day — about 47% occupied, or roughly 16 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.86 hrs/resident/day on weekends vs 5.15 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 2.20 to 1.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 20% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
10 citations, most serious first — scroll within the box to see all.
- Potential for harm · E2026-07-09 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify the physician of residents' changes in condition related to blood glucose levels and weights for 4 of 10 residents reviewed for notification of change. (Residents 9, 2, 1, and 3)Findings include: 1. The clinical record for Resident 9 was reviewed on 07/07/2026 at 10:00 A.M. An admission Minimum Data Set (MDS) assessment, dated 06/10/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, diabetes (high blood sugar). A physician's order, dated 06/05/2026 through 07/02/2026, indicated the staff were to check the resident's blood glucose level four times a day. The physician was to be notified if the resident's blood glucose was less than 70 or greater than 300. The clinical record lacked indication that the physician had been notified of the blood glucose level being greater than 300 on the following dates and times: - On 06/06/2026 at P.M., when the blood glucose was 443 and at bedtime, when the blood glucose was 341, - On 06/08/2026 at P.M., when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to implement a resident's care planned intervention following a fall for 1 of 10 residents' care plans reviewed. (Resident 2)Findings include:The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, a hip fracture.A Progress Note, dated 05/01/2026 at 7:45 A.M., indicated the resident had an unwitnessed fall in her room. The resident was trying to reposition herself for breakfast using her walker. The walker slid to the side and she lost her balance, falling to the left. She put her left hand out to catch herself. The resident was found on the floor on her left side with the left arm to the left side of her body. The resident had visible injuries and complaints of left wrist pain and left hip pain. The resident was sent to the local emergency room. A Progress Note, dated 05/08/2026 at 2:41 P.M., indicated the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a cardiac medication for 1 of 10 residents reviewed for quality of care. (Resident 14)Findings include:Resident 14's clinical record was reviewed on 07/06/2026 at 2:24 P.M. A 5-day Minimum Data Set (MDS) assessment, dated 06/25/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, high blood pressure. A current, open-ended physician's order, with a start date of 06/24/2026, indicated the resident was to receive atenolol 25 mg (milligrams), one time a day for high blood pressure. Nursing staff were to hold (not administer) the medication when the resident's systolic blood pressure (SBP, the top number) was less than 100. The Electronic Health Record indicated the medication was given on the following dates when the resident's vital signs were outside of the prescribed parameters:- On 06/26/2026, the resident's SBP was 97,- On 06/28/2026, the resident's SBP was 97, - On 07/02/2026, the resident's SBP was 88, -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow physician's orders related to obtaining residents' weights for 2 of 3 residents reviewed for nutrition. (Residents 2 and 3) Findings include: 1. The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure) and a hip fracture. A current physician's order, with a start date of 06/04/2026, indicated the staff were to weigh the resident daily on day shift. The resident was to be weighed at the same time and on the same scale with the same personal equipment. The clinical record lacked documented weights for the resident on 06/21/2026 and 07/04/2026. During an interview, on 07/08/2028 at 1:07 P.M., the Director of Nursing (DON) indicated the resident's weights should have been documented. 2. The clinical Record for Resident 3 was reviewed on 07/07/2026 at 10:15 A.M. An admission MDS assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to appropriately manage a resident's respiratory needs for 1 of 1 resident reviewed for respiratory care. (Resident 10)Findings include:During an interview and observation, on 07/06/2026 at 11:10 A.M., Resident 10 indicated she required supplemental oxygen. She used it at home before she came to the facility and wore it all the time in the facility. The resident was sitting in a chair in her room. Oxygen tubing was in place under the resident's nose and connected to an oxygen concentrator set to administer three liters of oxygen per minute. An undated humidifier bottle was attached to the concentrator. The resident was not sure how often staff changed her oxygen tubing or the humidifier bottle. The resident was observed seated in the main dining room on 07/07/2026 at 11:39 A.M. The resident's oxygen tubing was in place and connected to a portable oxygen concentrator hanging from the back of the resident's chair. The resident was observed sitting in her chair in her room on 07/08/2026 at 10:40 A.M. The resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-09 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to verify the accuracy of a resident's healthcare physician/Nurse Practitioner (NP) order/assessment related to the resident's medication regimen for 1 of 10 resident records reviewed. (Resident 2)Findings include:The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure), anxiety, and depression. A Psychiatry Initial Consult Note, dated 04/15/2026, indicated the resident didn't feel like her current depression medication was working. It was discussed to start Lexapro (an antidepressant). The assessment and plan were to start the resident on Lexapro 10 milligrams (mg) once daily. New orders for the visit were Lexapro 10 mg daily. A physician's order, dated 04/16/2026 through 05/04/2026, indicated the resident was to receive Lexapro 20 mg daily. The order was entered into the Electronic Health Record by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter care for 1 of 1 resident reviewed for Urinary Catheter Care. (Resident 116) Findings include: During an observation, on 06/16/25 at 12:29 P.M., Resident 116 was sitting in a recliner in his room. His indwelling urinary catheter bag was hanging on the side of a small trash can with an inch of the bag touching the floor. There was no barrier between the bag and the floor and the trash can was one third full. During an observation and interview, on 06/19/25 at 11:09 A.M., Resident 116's indwelling urinary catheter bag and cover had between one to two inches of the bag touching the floor. The resident indicated staff helped him move it when he wanted to get up. The bag was hanging under his recliner's footrest. During an observation and interview, with Certified Nurse Aide (CNA) 2, on 06/19/25 at 3:33 P.M., the resident was sitting in his room in his recliner. His indwelling urinary catheter bag was hanging under his recliner…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an extended-release medication was administered as recommended for 1 of 10 medication observations related to pharmacy services. (Resident 65) Findings include: During an observation, on 06/19/25 at 10:57 A.M., RN 3 sanitized her hands and prepared medications for Resident 65. She placed all the medications into a cup and handed the cup to the resident. The resident requested all large pills to be crushed and placed in applesauce. Upon returning to the medication cart, RN 3 poured the medications that included, but were not limited to, Klor-Con M20 Extended Release (a Potassium Chloride Microencapsulated Crystals Extended-Release 20 milliequivalent tablet), into a pouch, crushed the medications, placed them back into the medication cup, and added applesauce. The medications were then administered to the resident. The resident was not educated by the nurse related to the risk of crushing an extended-release tablet. The current, open-ended physician's order, with a start date of 06/07/25, indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain STAT (immediate) labs for 1 of 2 residents reviewed for laboratory services. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 04/02/24. The resident's diagnoses included, but were not limited to, fracture of the right femur, anemia, kidney disease, and hypertension. A Progress Note, dated 03/28/24 at 12:08 P.M., indicated the resident completed and antibiotic for a UTI (Urinary Tract Infection) the day before, on 03/27/24. The resident had slightly bloody urine. The Nurse Practitioner was notified. A Progress Note, dated 03/29/24 at 11:51 A.M., indicated the resident continued with blood in her urine. A new order was received for a STAT CBC (Complete Blood Count) and UA (Urinalysis). The resident's Eliquis (a blood thinning medication) was put on hold for 48 hours. A Progress Note, dated 03/29/24 at 2:09 P.M., indicated the resident's urine specimen was obtained for the UA. They were waiting for the lab to come and draw the CBC and pick up the urine. A Progress Note, dated 03/29/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-04-05 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. The clinical record for Resident 5 was reviewed on 04/03/24 at 10:28 A.M. An admission MDS assessment, dated 01/25/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, cancer, left humerus fracture, and a seizure disorder. The resident's physician conducted a regulatory nursing home visit on 01/23/24. The resident was a new admission to the facility. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff, NP documentation, and the resident's plan of care was reviewed. The physician's visit documentation was electronically signed and provided to the facility by the physician on 02/06/24 at 7:34 A.M. The resident's physician conducted a routine regulatory nursing home visit on 02/20/24. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff, NP documentation, and the resident's plan of care was reviewed. The physician's visit documentation was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BHI SENIOR LIVING — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 3.8 | +1.2 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 8 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COMPUTERSHARE CORPORATE TRUST COMPANY, NA | Organization | 5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| BLOOMSTROM, JOHN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| CALDWELL, JEFFREY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| DALTON, DOUGLASS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| ELLIS, BRIAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| HASH, SHERRI | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| JONES, L. DEAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| KELLY, BETH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| KOSELKE, ELIZABETH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| LEWIS-HAGEN, TONYA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LUDWIG, LONI | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| MEREDITH, WENDY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| MILLER, ROGER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| RICHARDSON, JANE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| ROBBINS, FRED | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| SEIGEL, JANE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| SMILLIE, DAVID | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| STENNER, REBECCA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| CARR, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/02/2018 |
| DATTILO, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/01/2025 |
| PRIFOGLE, MARK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| WEIDEMAN II, ROGER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| BHI SENIOR LIVING, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HEALTHCARE THERAPY SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| NEESE, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 06/01/2023 |
| PLANTE & MORAN PLLC | Organization | ADP OF THE SNF | since 01/01/2025 |
| SCHMIDT, MELINDA | Individual | ADP OF THE SNF | since 01/01/2025 |
| SMITH, ANGELA | Individual | ADP OF THE SNF | since 01/01/2025 |
| THOMPSON, KELLY | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 64 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $560K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Indiana Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 155471. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.