Cycle 1
Health 2025-02-28 · Fire 2025-02-28
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Mitchell, IN
Mitchell Manor
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
24 Teke Burton Dr, Mitchell, IN
(812) 849-2221
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1988-09-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 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
0.99
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,786
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
2.10
Baseline 50.82% · Performance 55.10% · Measure score 2.10 · Achievement 2.10 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 7.92% |
| Discharge to community | 62.98% |
50.57%
12.4 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 62.16% · Lower 95% interval 47.31% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 82.76% |
53.69%
29.1 pts better
|
Numerator 24 · Denominator 29 |
| Discharge mobility score | 82.76% |
50.94%
31.8 pts better
|
Numerator 24 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 4.88% |
2.29%
2.6 pts worse
|
Numerator 2 · Denominator 41 · Adjusted rate 4.14% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 4 · Denominator 80 |
| Staff flu vaccination coverage | 18.95% |
42%
23.1 pts worse
|
Numerator 18 · Denominator 95 |
| Discharge function score | 89.66% |
56.45%
33.2 pts better
|
Numerator 26 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.78% |
25.2%
9.6 pts better
|
Numerator 8 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 0.0% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.5% |
24.6%
4.1 pts better
|
11.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.6% · Q3 32.0% · Q4 11.8% · 4Q avg 20.5% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
5.6%
3.8 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.5% · Q3 16.3% · Q4 5.6% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
23.5%
7.4 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 32.1% · Q3 36.0% · Q4 25.5% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
14.8%
1.8 pts worse
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 12.2% · Q3 18.9% · Q4 19.4% · 4Q avg 16.6% · 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 | 5.4% |
13.3%
7.9 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 3.4% · Q4 11.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
11.7%
6.7 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 8.2% · Q4 9.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 3.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.2%
0.3 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
24.2%
5.6 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 18.4% · Q3 20.4% · Q4 16.3% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.1%
2.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
81.6%
17.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.4% · Q3 98.3% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
10.5%
5.4 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.9% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
1.3%
3.1 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 9.1% · Q4 4.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
79.0%
16.3 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
22.4%
2.5 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 25.0% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-25 · Fire 2024-03-25
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-05-09 · Fire 2023-05-09
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-07
E · Potential for more than minimal harm
2024-03-25
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 2024-04-24
E · Potential for more than minimal harm
2024-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-24
C · Minimal harm
2024-03-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-05-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-09
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 2023-05-31
E · Potential for more than minimal harm
2023-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-31
C · Minimal harm
2023-05-09
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-05-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-12-18
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 2025-11-18
D · Potential for more than minimal harm
2025-12-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-08-18
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 2025-08-19
E · Potential for more than minimal harm
2025-02-28
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 2025-03-19
D · Potential for more than minimal harm
2025-02-28
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 2025-03-19
D · Potential for more than minimal harm
2025-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-28
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 2025-03-19
E · Potential for more than minimal harm
2024-03-25
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 2024-04-18
E · Potential for more than minimal harm
2024-03-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-25
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 2024-04-18
D · Potential for more than minimal harm
2024-03-25
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 2024-04-18
D · Potential for more than minimal harm
2024-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-18
C · Minimal harm
2024-03-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-18
D · Potential for more than minimal harm
2023-07-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-05-09
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 2023-06-01
E · Potential for more than minimal harm
2023-05-09
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 2023-06-01
D · Potential for more than minimal harm
2023-05-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-09
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 2023-06-01
D · Potential for more than minimal harm
2023-05-09
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 2023-06-01
D · Potential for more than minimal harm
2023-05-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-01
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Fenoughty, Deanna
Operational/Managerial Control · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Fletcher, Todd
Operational/Managerial Control · Individual
Henry, Terry
Operational/Managerial Control · Individual
Hignite, Katherine
Operational/Managerial Control · Individual
Lay, Lisa
Operational/Managerial Control · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Mitchell Medical Investors, LLC
Operational/Managerial Control · Organization
Preston, Aubrey
Operational/Managerial Control · Individual
Preston, Forrest
Operational/Managerial Control · Individual
Radadiya, Pragneshkumar
Operational/Managerial Control · Individual
Swanker, Richard
Operational/Managerial Control · Individual
Thurmond, Joan
Operational/Managerial Control · Individual
Ziegler, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
White River Lodge
Bedford, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
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
#3
Majestic Care Of Bedford
Bedford, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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