Cycle 1
Health 2025-09-08 · Fire 2025-09-08
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Bloomington, IN
Majestic Care Of Bloomington
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1100 S Curry Pk, Bloomington, IN
(812) 339-1657
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
158
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 health / 2 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
0.49
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.29
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.96
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.04
Baseline 20.18% · Performance 19.56% · Measure score 4.04 · Achievement 4.04 · Improvement 1.48
Healthcare-associated infections
5.23
Baseline 6.67% · Performance 6.27% · Measure score 5.23 · Achievement 5.23 · Improvement 1.89
Total nurse turnover
5.56
Performance 40.96% · Measure score 5.56 · Achievement 5.56 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.66 hours · Performance 2.89 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.46% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 19.12% · Lower 95% interval 7.36% |
| Discharge to community | 46.76% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 35.56% · Lower 95% interval 35.1% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 41.94% |
53.69%
11.8 pts worse
|
Numerator 13 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 49 · Adjusted rate 1.9% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 4.08% · Lower 95% interval 2.85% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 35.25% |
42%
6.8 pts worse
|
Numerator 49 · Denominator 139 |
| Discharge function score | 41.94% |
56.45%
14.5 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 28 |
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 0.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 64.6% |
93.6%
29 pts worse
|
93.4%
28.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.4% · Q2 57.8% · Q3 70.4% · Q4 70.1% · 4Q avg 64.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.5% |
95.4%
8.9 pts worse
|
95.5%
9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.8%
0.5 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.9% · Q3 4.1% · Q4 1.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.7% |
24.6%
2.9 pts better
|
11.4%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.6% · Q3 27.4% · Q4 19.8% · 4Q avg 21.7% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.6%
1.2 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 3.3% · Q3 9.1% · Q4 6.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
23.5%
9.9 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 10.9% · Q3 11.4% · Q4 14.8% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
14.8%
5.7 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.7% · Q3 11.0% · Q4 7.1% · 4Q avg 9.1% · 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 | 13.7% |
13.3%
0.4 pts worse
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.8% · Q3 26.0% · Q4 12.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
11.7%
4.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.6% · Q3 14.6% · Q4 6.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 28.5% |
24.2%
4.3 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 35.9% · Q3 24.7% · Q4 30.2% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
4.1%
3.3 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.7% |
81.6%
51.9 pts worse
|
81.7%
52 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 23.5% · Q3 29.9% · Q4 49.3% · 4Q avg 29.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
10.5%
2.2 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 20.2% |
79.0%
58.8 pts worse
|
79.7%
59.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 20.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
22.4%
7 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 27.8% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-04 · Fire 2024-11-04
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-12-04 · Fire 2023-12-04
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-09-26
F · Potential for more than minimal harm
2024-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-12
E · Potential for more than minimal harm
2023-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-04
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-08
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 2025-09-12
E · Potential for more than minimal harm
2025-09-08
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 2025-09-12
D · Potential for more than minimal harm
2025-09-08
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-09-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-01-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-04
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 2024-11-08
C · Minimal harm
2024-11-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-08
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
Bickel, James
Corporate Officer · Individual
Chastain, Denise
Corporate Officer · Individual
Doup, David
Corporate Director · Individual
Ellison, Zack
Corporate Director · Individual
Jobe, Annette
Operational/Managerial Control · Individual
Jobe, Annette
Corporate Officer · Individual
Kiser, Raymond
Operational/Managerial Control · Individual
Kiser, Raymond
Corporate Officer · Individual
Majestic Care Of Bb Consulting LLC
Operational/Managerial Control · Organization
Majestic Care Of Bloomington, LLC
Operational/Managerial Control · Organization
Mccreery, Warren
Operational/Managerial Control · Individual
Michael, Donald
Corporate Director · Individual
Neese, Kevin
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Schumaker, Kevina
Corporate Director · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Shedd, Frederick
Corporate Director · Individual
Trapp, Don
Corporate Director · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Stonecroft Health Campus
Bloomington, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Aperion Care Monroe
Bloomington, IN
1-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Hearthstone Health Campus
Bloomington, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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