Cycle 1
Health 2024-11-26 · Fire 2024-11-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Middletown, IN
Middletown Nursing And Rehabilitation Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
131 S 10th St, Middletown, IN
(765) 354-2223
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
16
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-05-01
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
0.96
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
22%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 6 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 58.97% |
42%
17 pts better
|
Numerator 23 · Denominator 39 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
93.6%
4.2 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.9% |
3.8%
5.1 pts worse
|
3.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
24.6%
19.9 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.6%
0.6 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.1% |
23.5%
4.6 pts worse
|
19.6%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.8%
14.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.5% |
11.7%
26.8 pts worse
|
14.9%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.5% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.2% |
24.2%
15 pts worse
|
19.8%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.1%
1.4 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
81.6%
8.9 pts better
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 95.2% · 4Q avg 90.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.7% |
1.3%
4.4 pts worse
|
1.6%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
2 health deficiencies
Top issue: Administration (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-05 · Fire 2022-08-05
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-11-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-11-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-11-26
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-11-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-11-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-11-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-11-26
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 2025-12-15
E · Potential for more than minimal harm
2024-11-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-16
D · Potential for more than minimal harm
2024-11-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-15
C · Minimal harm
2024-11-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-15
F · Potential for more than minimal harm
2023-09-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-09-22
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 2023-12-22
E · Potential for more than minimal harm
2023-09-22
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 2023-12-22
E · Potential for more than minimal harm
2023-09-22
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-28
C · Minimal harm
2023-09-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-12-22
F · Potential for more than minimal harm
2022-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
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 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
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 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-08-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-15
C · Minimal harm
2022-08-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-15
C · Minimal harm
2022-08-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-26
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 2024-12-12
D · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-12
F · Potential for more than minimal harm
2023-09-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-22
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 2023-10-12
E · Potential for more than minimal harm
2022-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-05
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-05
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 2022-08-26
D · Potential for more than minimal harm
2022-08-05
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 2022-08-26
D · Potential for more than minimal harm
2022-08-05
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-26
Penalties and ownership
What sits behind the stars
Ownership
Case, Janet
W-2 Managing Employee · Individual
Moore Healthcare Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Moore Healthcare Enterprises Inc
Operational/Managerial Control · Organization
Moore, Jerrod
Operational/Managerial Control · Individual
Moore, Kimberly
5% Or Greater Direct Ownership Interest · Individual
Moore, Kimberly
Corporate Officer · Individual
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3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
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