Cycle 1
Health 2025-05-13 · Fire 2025-05-13
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Anderson, IN
Bethany Pointe Health Campus
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1707 Bethany Rd, Anderson, IN
(765) 622-1211
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2002-05-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 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
1.01
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.07
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
10%
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
1,988
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0070
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Baseline 20.02% · Performance 19.47% · Measure score 4.23 · Achievement 4.23 · Improvement 1.33
Healthcare-associated infections
10
Baseline 5.34% · Performance 4.88% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
4.16
Baseline 60.87% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 3.44
Adjusted total nurse staffing
2.58
Baseline 2.58 hours · Performance 3.57 hours · Measure score 2.58 · Achievement 1.72 · Improvement 2.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 293 · Observed rate 9.22% · Lower 95% interval 7.52% |
| Discharge to community | 61.38% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 262 · Observed rate 56.87% · Lower 95% interval 53.97% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 155 · Denominator 155 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 155 |
| Discharge self-care score | 52.31% |
53.69%
1.4 pts worse
|
Numerator 68 · Denominator 130 |
| Discharge mobility score | 78.46% |
50.94%
27.5 pts better
|
Numerator 102 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 155 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.88% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 2.33% · Lower 95% interval 2.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 50 · Denominator 200 |
| Discharge function score | 76.92% |
56.45%
20.5 pts better
|
Numerator 100 · Denominator 130 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 51.81% |
25.2%
26.6 pts better
|
Numerator 43 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · 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 | 0.8% |
3.8%
3 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.4% |
24.6%
2.2 pts better
|
11.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 16.7% · Q3 17.2% · Q4 22.2% · 4Q avg 22.4% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.6%
3.3 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 4.8% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
23.5%
13.3 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.5% · Q3 8.3% · Q4 9.1% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
14.8%
1.6 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · 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 | 8.2% |
13.3%
5.1 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
11.7%
7.2 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 0.0% · Q3 0.0% · Q4 9.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
24.2%
6.8 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.1% · Q3 8.6% · Q4 25.1% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.1%
3.9 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.8% · Q3 9.5% · Q4 5.9% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
81.6%
15.7 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 96.1% · Q3 97.2% · Q4 98.7% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
10.5%
0.3 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.6% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
79.0%
14.5 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
22.4%
About the same
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 21.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-19 · Fire 2024-06-19
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-06-06 · Fire 2023-06-06
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-05-13
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-05-13
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-05-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-16
E · Potential for more than minimal harm
2024-06-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-25
E · Potential for more than minimal harm
2023-06-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-06-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-06-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2025-05-13
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-13
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 2025-06-03
D · Potential for more than minimal harm
2025-05-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-03
E · Potential for more than minimal harm
2024-06-19
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 2024-07-03
D · Potential for more than minimal harm
2024-06-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-03
D · Potential for more than minimal harm
2023-10-31
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 2023-11-24
D · Potential for more than minimal harm
2023-06-06
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 2023-06-30
D · Potential for more than minimal harm
2023-06-06
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 2023-06-30
D · Potential for more than minimal harm
2023-05-17
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 2023-06-12
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Anderson, Robert
Operational/Managerial Control · Individual
Lambert, Alicia
Operational/Managerial Control · Individual
Long, Steven
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Trilogy Healthcare Of Anderson, LLC
Operational/Managerial Control · Organization
Nearby options
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3-star overall rating with 3-star inspections with $8,390 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
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4-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Waters Of Chesterfield Skilled Nursing Facility
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3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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