Cycle 1
Health 2025-07-29 · Fire 2025-07-29
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Peru, IN
Blair Ridge Health Campus
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
269 Meadowview Dr, Peru, IN
(765) 472-8049
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
55
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2011-06-21
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
0.87
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
393
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0228
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.09% · Performance 16.52% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.82
Baseline 9.44% · Performance 5.74% · Measure score 7.82 · Achievement 7.01 · Improvement 7.82
Total nurse turnover
7.29
Baseline 35.42% · Performance 33.87% · Measure score 7.29 · Achievement 7.29 · Improvement 0.96
Adjusted total nurse staffing
3.19
Baseline 3.33 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 2.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 174 · Observed rate 9.77% · Lower 95% interval 7.61% |
| Discharge to community | 63.67% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 153 · Observed rate 62.09% · Lower 95% interval 54.74% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 94 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 48 · Denominator 81 |
| Discharge mobility score | 71.6% |
50.94%
20.7 pts better
|
Numerator 58 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1.06% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 94 · Adjusted rate 0.75% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 3% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 47.95% |
42%
6 pts better
|
Numerator 70 · Denominator 146 |
| Discharge function score | 74.07% |
56.45%
17.6 pts better
|
Numerator 60 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 5.66% |
25.2%
19.5 pts worse
|
Numerator 3 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.6
1.3 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.4 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · 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 | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.4% · Q3 3.0% · Q4 5.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
24.6%
21.6 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.4% · Q3 3.1% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.6%
0.9 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.8% · Q3 3.3% · Q4 3.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
23.5%
7.5 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 17.6% · Q3 13.3% · Q4 9.7% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.3% |
14.8%
13.5 pts worse
|
16.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q3 30.8% · Q4 18.5% · 4Q avg 28.3% · 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 | 7.7% |
13.3%
5.6 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 3.7% · Q4 11.7% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
11.7%
5.7 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.2% · Q3 3.6% · Q4 10.0% · 4Q avg 6.0% · 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 | 23.2% |
24.2%
1 pts better
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.5% · Q3 33.7% · Q4 22.6% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.1%
2.3 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 4.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
81.6%
16.4 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 96.4% · Q3 97.9% · Q4 100.0% · 4Q avg 98.0% |
| 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 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.3% · Q3 1.5% · Q4 1.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
79.0%
18.6 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.4%
1.6 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 22.2% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-06-13 · Fire 2023-06-13
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-29
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 2025-09-08
E · Potential for more than minimal harm
2025-07-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-17
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 2024-08-30
E · Potential for more than minimal harm
2023-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-06-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-29
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 2025-08-24
D · Potential for more than minimal harm
2025-07-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-29
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 2025-08-24
D · Potential for more than minimal harm
2025-07-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-24
F · Potential for more than minimal harm
2024-07-17
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 2024-08-12
D · Potential for more than minimal harm
2024-07-17
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 2024-08-12
D · Potential for more than minimal harm
2024-07-17
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 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Corporate Officer · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Hoover, William
Operational/Managerial Control · Individual
Hornbecker, Michael
Corporate Officer · Individual
Reagan, Julie
Corporate Director · Individual
Sellers, Daniel
Corporate Officer · Individual
Tinsley, Tamara
Operational/Managerial Control · Individual
Trilogy Healthcare Of Miami, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Waters Of Peru Skilled Nursing Facility, The
Peru, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Hickory Creek At Peru
Peru, IN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Aperion Care Peru
Peru, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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