Cycle 1
Health 2024-12-09 · Fire 2024-12-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Freelandville, IN
Freelandville Community Home
2-star overall rating with 2-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
310 W Carlisle Street, Freelandville, IN
(812) 328-2134
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-04-11
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
1.09
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.17
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.52
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
13,516
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 63.33% · Performance 100.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.85
Performance 3.32 hours · Measure score 0.85 · Achievement 0.85 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 6.97% |
| Discharge to community | 35.52% |
50.57%
15 pts worse
|
Worse than the National Rate · Eligible stays 27 · Observed rate 22.22% · Lower 95% interval 21.47% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92% |
95.27%
3.3 pts worse
|
Numerator 23 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 52 |
| Staff flu vaccination coverage | 30% |
42%
12 pts worse
|
Numerator 21 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.6% |
93.6%
14 pts worse
|
93.4%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.4% · Q2 76.7% · Q3 84.0% · Q4 81.5% · 4Q avg 79.6% |
| 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 | 4.4% |
3.8%
0.6 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 8.0% · Q4 7.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.4% |
24.6%
4.2 pts better
|
11.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 40.0% · Q3 42.9% · Q4 4.2% · 4Q avg 20.4% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.6%
3.6 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 4.5% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
23.5%
11.2 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.3% · Q3 13.0% · Q4 4.0% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
14.8%
3.4 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 13.0% · Q4 9.1% · 4Q avg 11.4% · 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 | 33.7% |
13.3%
20.4 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 44.0% |
11.7%
32.3 pts worse
|
14.9%
29.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 50.0% · Q3 20.0% · Q4 57.1% · 4Q avg 44.0% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
1.2%
3.5 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 4.2% · Q4 4.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.6% |
24.2%
12.4 pts worse
|
19.8%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 47.0% · Q3 16.0% · Q4 45.4% · 4Q avg 36.6% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.1%
3.2 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.7% |
81.6%
40.9 pts worse
|
81.7%
41 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 40.7% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
3 health deficiencies
Top issue: Resident Rights (3 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-12-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-09
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 2025-01-09
D · Potential for more than minimal harm
2024-12-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-17
F · Potential for more than minimal harm
2023-11-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-16
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-03
F · Potential for more than minimal harm
2022-04-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-07-10
F · Potential for more than minimal harm
2022-04-21
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-07-10
F · Potential for more than minimal harm
2022-04-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-10
F · Potential for more than minimal harm
2022-04-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-10
F · Potential for more than minimal harm
2022-04-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-10
E · Potential for more than minimal harm
2022-04-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-10
E · Potential for more than minimal harm
2022-04-21
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-04-21
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-07-10
Inspection history
Recent health citations
G · Actual harm
2024-12-09
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 2025-01-06
E · Potential for more than minimal harm
2024-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-12-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-09
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 2025-01-06
E · Potential for more than minimal harm
2023-11-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
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 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-16
D · Potential for more than minimal harm
2022-04-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-09
D · Potential for more than minimal harm
2022-04-21
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 2022-05-09
D · Potential for more than minimal harm
2022-04-21
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-05-09
Penalties and ownership
What sits behind the stars
Ownership
Greene County General Hospital
5% Or Greater Direct Ownership Interest · Organization
Abrams, Nate
Corporate Director · Individual
Bedwell, Harry
Corporate Director · Individual
Crane, Michael
Corporate Officer · Individual
Freelandville Community Home, Inc.
Operational/Managerial Control · Organization
Fuller, Jimmy
Corporate Director · Individual
Graves, Rick
Corporate Director · Individual
Hamilton, Cheryl
Corporate Director · Individual
Hudson, Nancy
Corporate Director · Individual
Michael, Edward
Corporate Director · Individual
Powers, Peter
Corporate Director · Individual
Reetz, Brenda
Corporate Officer · Individual
Russell, Michelle
W-2 Managing Employee · Individual
Warrick, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Oak Village
Oaktown, IN
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Health Center At Glenburn Home
Linton, IN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Aperion Care Vincennes
Vincennes, IN
1-star overall rating with 1-star inspections with Special Focus status with 23 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out