Cycle 1
Health 2024-09-24 · Fire 2024-09-24
10 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Columbus, IN
Belmont Health & Rehabilitation, The
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
540 Belmont Drive, Columbus, IN
(812) 669-5500
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
125
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.21
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
2.47
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
0.72
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
1.85
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.19
CMS adjusted RN staffing hours
Adjusted total hours
2.17
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.69% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.99
Baseline 6.83% · Performance 6.64% · Measure score 3.99 · Achievement 3.99 · Improvement 0.52
Total nurse turnover
5.84
Baseline 64.79% · Performance 39.82% · Measure score 5.84 · Achievement 5.84 · Improvement 5.75
Adjusted total nurse staffing
0
Baseline 3.39 hours · Performance 2.97 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.69% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 213 · Observed rate 13.62% · Lower 95% interval 9.14% |
| Discharge to community | 55.57% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 49.07% · Lower 95% interval 48.92% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 151 · Denominator 151 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 151 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 54 · Denominator 114 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 54 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 2.65% |
2.29%
0.4 pts worse
|
Numerator 4 · Denominator 151 · Adjusted rate 2.75% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 6.16% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 34.91% |
42%
7.1 pts worse
|
Numerator 37 · Denominator 106 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 57 · Denominator 114 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | 94.87% |
96.28%
1.4 pts worse
|
Numerator 37 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 24.05% |
25.2%
1.1 pts worse
|
Numerator 19 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.8 · 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 | 5.7% |
3.8%
1.9 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.6% · Q3 5.7% · Q4 6.4% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.7% |
24.6%
1.9 pts better
|
11.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 24.2% · Q3 23.4% · Q4 25.0% · 4Q avg 22.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.0% · Q3 4.3% · Q4 2.2% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
23.5%
4.7 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 25.5% · Q3 29.2% · Q4 30.9% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
14.8%
6.6 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.5% · Q3 9.1% · Q4 8.6% · 4Q avg 8.2% · 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 | 25.9% |
13.3%
12.6 pts worse
|
16.3%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 28.9% · Q3 22.0% · Q4 15.6% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
11.7%
12.9 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 26.1% · Q3 22.5% · Q4 22.0% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.8% |
1.2%
11.6 pts worse
|
1.7%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 10.4% · Q3 12.5% · Q4 16.2% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
24.2%
3.5 pts better
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 19.3% · Q3 17.2% · Q4 25.3% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.1%
1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 2.3% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
81.6%
17.9 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 98.8% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
10.5%
4.2 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 15.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
79.0%
20.3 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
22.4%
3.6 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 29.3% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-22 · Fire 2022-08-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-12
F · Potential for more than minimal harm
2024-09-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-12
F · Potential for more than minimal harm
2024-09-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-09-24
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-11-12
F · Potential for more than minimal harm
2023-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2022-08-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-22
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-09-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-28
E · Potential for more than minimal harm
2024-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-24
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 2024-10-09
D · Potential for more than minimal harm
2024-09-24
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 2024-10-09
D · Potential for more than minimal harm
2024-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-05-03
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 2024-05-20
D · Potential for more than minimal harm
2024-05-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-20
E · Potential for more than minimal harm
2023-07-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-13
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 2023-08-07
D · Potential for more than minimal harm
2023-07-13
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 2023-08-07
D · Potential for more than minimal harm
2023-07-13
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 2023-08-07
D · Potential for more than minimal harm
2023-07-13
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 2023-08-07
E · Potential for more than minimal harm
2022-08-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-22
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 2022-09-09
D · Potential for more than minimal harm
2022-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-22
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 2022-09-09
D · Potential for more than minimal harm
2022-08-22
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 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
Columbus Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Bickel, James
Operational/Managerial Control · Individual
Bickel, James
Corporate Officer · Individual
Chastain, Denise
Corporate Officer · Individual
Desonia, Becky
Operational/Managerial Control · Individual
Doup, David
Corporate Director · Individual
Ellison, Zack
Corporate Director · Individual
Jobe, Annette
Operational/Managerial Control · Individual
Jobe, Annette
Corporate Officer · Individual
Kiser, Raymond
Operational/Managerial Control · Individual
Kiser, Raymond
Corporate Officer · Individual
Magnolia Health Management Viii, LLC
Operational/Managerial Control · Organization
Magnolia Health Systems 72, LLC
5% Or Greater Mortgage Interest · Organization
Magnolia Health Systems Inc
Operational/Managerial Control · Organization
Michael, Donald
Corporate Director · Individual
Paracha, Ibrar
Operational/Managerial Control · Individual
Reed, Stuart
Operational/Managerial Control · Individual
Reed, Tyler
Operational/Managerial Control · Individual
Schumaker, Kevina
Corporate Director · Individual
Shedd, Frederick
Corporate Director · Individual
Trapp, Don
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Willow Crossing Health & Rehabilitation Center
Columbus, IN
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Silver Oaks Health Campus
Columbus, IN
4-star overall rating with 3-star inspections with $8,824 in total fines with 6 recent health deficiencies
#3
Four Seasons Retirement Center
Columbus, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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