Cycle 1
Health 2025-03-28 · Fire 2025-03-28
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bedford, IN
Majestic Care Of Bedford
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2111 Norton Ln, Bedford, IN
(812) 277-3730
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1969-08-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing
LPN hours / resident day
0.77
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
2.96
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
93.6%
1.8 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
95.4%
3.5 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.8%
0.3 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 36.6% |
24.6%
12 pts worse
|
11.4%
25.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.6%
2.1 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
23.5%
5.2 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
14.8%
4.8 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.5% |
13.3%
8.8 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
11.7%
7.7 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.3% |
24.2%
9.9 pts better
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.1%
1.2 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
81.6%
7.9 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
10.5%
0.5 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.1% |
79.0%
2.9 pts worse
|
79.7%
3.6 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.5% |
22.4%
8.9 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-06-12 · Fire 2023-06-12
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-12
C · Minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-20
F · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-26
C · Minimal harm
2024-06-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-07-26
C · Minimal harm
2024-06-13
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-07-26
C · Minimal harm
2024-06-13
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-26
C · Minimal harm
2024-06-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-26
E · Potential for more than minimal harm
2023-06-12
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 2023-07-10
D · Potential for more than minimal harm
2023-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-26
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 2025-06-28
E · Potential for more than minimal harm
2025-03-28
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 2025-04-02
D · Potential for more than minimal harm
2025-03-28
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 2025-04-02
D · Potential for more than minimal harm
2025-03-28
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 2025-04-02
D · Potential for more than minimal harm
2025-03-28
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 2025-04-02
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-07-12
D · Potential for more than minimal harm
2023-10-26
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 2023-11-10
D · Potential for more than minimal harm
2023-10-26
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 2023-11-10
D · Potential for more than minimal harm
2023-06-12
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 2023-06-28
D · Potential for more than minimal harm
2023-06-12
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 2023-06-28
D · Potential for more than minimal harm
2023-06-12
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 2023-07-12
D · Potential for more than minimal harm
2023-06-12
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
Ownership
Columbus Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Alexander, James
Operational/Managerial Control · Individual
Bickel, James
Operational/Managerial Control · Individual
Jobe, Annette
Operational/Managerial Control · Individual
Kiser, Raymond
Operational/Managerial Control · Individual
Majestic Care Of Bb Consulting LLC
Operational/Managerial Control · Organization
Majestic Care Of Bedford, LLC
Operational/Managerial Control · Organization
Neese, Kevin
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Taybior, Alberta
Operational/Managerial Control · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Stonebridge Health Campus
Bedford, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Westview Nursing And Rehabilitation Center
Bedford, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
White River Lodge
Bedford, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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