Cycle 1
Health 2025-06-23 · Fire 2025-06-23
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Columbus, IN
Four Seasons Retirement Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1901 Taylor Rd, Columbus, IN
(812) 372-8481
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
30
Certified beds
Average residents
14
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bhi Senior Living
Operator or chain grouping
Approved since
1992-12-01
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 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
1.82
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
5.11
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.77
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.16
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.01
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.35
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
5.11
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
779
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.88
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.13
Baseline 17.52% · Performance 18.59% · Measure score 6.13 · Achievement 6.13 · Improvement 0
Healthcare-associated infections
6.65
Baseline 6.31% · Performance 5.85% · Measure score 6.65 · Achievement 6.65 · Improvement 3.01
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.75% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 254 · Observed rate 11.81% · Lower 95% interval 8.21% |
| Discharge to community | 67.52% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 244 · Observed rate 64.34% · Lower 95% interval 62.23% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.15% |
95.27%
3.9 pts better
|
Numerator 116 · Denominator 117 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 3 · Denominator 117 |
| Discharge self-care score | 48.94% |
53.69%
4.8 pts worse
|
Numerator 46 · Denominator 94 |
| Discharge mobility score | 45.74% |
50.94%
5.2 pts worse
|
Numerator 43 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 3 · Denominator 117 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 5.85% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 3.76% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 1.28% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 78 |
| Staff flu vaccination coverage | 27.06% |
42%
14.9 pts worse
|
Numerator 23 · Denominator 85 |
| Discharge function score | 55.32% |
56.45%
1.1 pts worse
|
Numerator 52 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 32.08% |
25.2%
6.9 pts better
|
Numerator 17 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
81.6%
18.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
10.5%
4.8 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 13.1% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.5% |
79.0%
2.5 pts better
|
79.7%
1.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.4%
3.9 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 15.2% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
2 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
4 health deficiencies
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-21
F · Potential for more than minimal harm
2025-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-21
F · Potential for more than minimal harm
2025-06-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-21
F · Potential for more than minimal harm
2024-04-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-05
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-05
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-13
F · Potential for more than minimal harm
2023-02-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-02-07
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 2023-03-02
D · Potential for more than minimal harm
2023-02-07
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-03-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-23
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 2025-07-10
D · Potential for more than minimal harm
2025-06-23
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 2025-07-10
D · Potential for more than minimal harm
2024-04-05
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-04-30
B · Minimal harm
2024-04-05
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-04-30
D · Potential for more than minimal harm
2023-02-07
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 2023-02-24
D · Potential for more than minimal harm
2023-02-07
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 2023-02-24
D · Potential for more than minimal harm
2023-02-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-02-07
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-02-24
Penalties and ownership
What sits behind the stars
Ownership
Bhi Senior Living, Inc.
Operational/Managerial Control · Organization
Carr, Brian
Corporate Officer · Individual
Dattilo, John
Corporate Officer · Individual
Jones, L. Dean
Corporate Director · Individual
Meredith, Wendy
Corporate Director · Individual
Nelson, Nancy
Corporate Officer · Individual
Seigel, Jane
Corporate Director · Individual
Stenner, Rebecca
W-2 Managing Employee · Individual
Weideman Ii, Roger
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Hickory Creek At Columbus
Columbus, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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
#3
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
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