Cycle 1
Health 2025-06-24 · Fire 2025-06-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mulberry, IN
Mulberry Health & Rehabilitation Center
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
502 W Jackson St, Mulberry, IN
(765) 296-2911
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
159
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-07-12
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
0.72
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.44
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
4,335
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.74
Baseline 23.53% · Performance 17.52% · Measure score 8.74 · Achievement 8.44 · Improvement 8.74
Healthcare-associated infections
1.83
Baseline 6.90% · Performance 7.29% · Measure score 1.83 · Achievement 1.83 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.54
Baseline 3.13 hours · Performance 3.52 hours · Measure score 1.54 · Achievement 1.54 · Improvement 0.95
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 5.71% · Lower 95% interval 5.49% |
| Discharge to community | 51.56% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 51.14% · Lower 95% interval 42.35% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.92% |
95.27%
1.7 pts better
|
Numerator 63 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 30 · Denominator 55 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 30 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 65 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 7.43% |
8.2%
0.8 pts worse
|
Numerator 13 · Denominator 175 |
| Staff flu vaccination coverage | 4.03% |
42%
38 pts worse
|
Numerator 10 · Denominator 248 |
| Discharge function score | 52.73% |
56.45%
3.7 pts worse
|
Numerator 29 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| 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 | 13.89% |
25.2%
11.3 pts worse
|
Numerator 5 · Denominator 36 |
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 0.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
93.6%
5.9 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.4%
2.1 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.8%
0.3 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.5% · Q3 2.7% · Q4 2.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.1% |
24.6%
13.5 pts better
|
11.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.9% · Q3 12.8% · Q4 13.0% · 4Q avg 11.1% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.6%
0.7 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.3% · Q3 8.4% · Q4 6.3% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
23.5%
12.9 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.4% · Q3 11.5% · Q4 10.5% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
14.8%
3.4 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 20.2% · Q3 16.5% · Q4 13.8% · 4Q avg 18.2% · 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 | 14.8% |
13.3%
1.5 pts worse
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 29.7% · Q3 8.4% · Q4 11.6% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
11.7%
7.7 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 37.6% · Q3 9.9% · Q4 15.9% · 4Q avg 19.4% · 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% · Q4 0.0% · 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 · 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 | 35.0% |
24.2%
10.8 pts worse
|
19.8%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 39.3% · Q3 39.7% · Q4 29.1% · 4Q avg 35.0% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.1%
3.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
81.6%
12.1 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 93.2% · Q3 94.9% · Q4 97.5% · 4Q avg 93.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
10.5%
2.7 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.2% |
79.0%
5.2 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
22.4%
4.8 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 22.4% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-17 · Fire 2023-02-17
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-21
E · Potential for more than minimal harm
2025-06-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-24
F · Potential for more than minimal harm
2024-05-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-24
F · Potential for more than minimal harm
2023-02-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-02-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-02-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-02-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-02-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
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 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-02-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-24
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 2025-06-25
D · Potential for more than minimal harm
2024-05-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-08
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 2024-06-17
F · Potential for more than minimal harm
2023-02-17
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 2023-03-17
D · Potential for more than minimal harm
2023-02-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-17
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 2023-03-17
D · Potential for more than minimal harm
2023-02-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-17
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 2023-03-17
Penalties and ownership
What sits behind the stars
Ownership
Henry County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Dodt, Keven
Operational/Managerial Control · Individual
Dynes, Sheldon
Corporate Director · Individual
Mhrc, LLC
Operational/Managerial Control · Organization
Mulberry Health & Retirement Community, Inc
Operational/Managerial Control · Organization
Mutz, John
Operational/Managerial Control · Individual
Pidgeon, John
Operational/Managerial Control · Individual
Pidgeon, John
Corporate Director · Individual
Ring, Brian
Operational/Managerial Control · Individual
Ring, Brian
Corporate Officer · Individual
Shore, Marion
Corporate Director · Individual
Thomas, John
Operational/Managerial Control · Individual
Wallar, Heidi
Operational/Managerial Control · Individual
Ware, Deborah
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Milner Community Health Care
Rossville, IN
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Wesley Manor Health Center
Frankfort, IN
3-star overall rating with 3-star inspections with $20,826 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Creasy Springs Health Campus
Lafayette, IN
3-star overall rating with 2-star inspections with $8,018 in total fines with 14 recent health deficiencies
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