Cycle 1
Health 2024-08-16 · Fire 2024-08-16
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Portland, IN
Persimmon Ridge Rehabilitation Centre
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
200 N Park St, Portland, IN
(260) 726-9355
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Hcf Management Indiana
Operator or chain grouping
Approved since
1994-06-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 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
0.50
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
970
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0166
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.29
Baseline 19.19% · Performance 18.05% · Measure score 7.29 · Achievement 7.29 · Improvement 4.76
Healthcare-associated infections
7.64
Baseline 6.04% · Performance 5.55% · Measure score 7.64 · Achievement 7.64 · Improvement 4.15
Total nurse turnover
9.46
Baseline 36.73% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
Adjusted total nurse staffing
0.23
Baseline 2.85 hours · Performance 3.07 hours · Measure score 0.23 · Achievement 0 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 9.52% · Lower 95% interval 7.26% |
| Discharge to community | 58.88% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 59.18% · Lower 95% interval 48.92% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 56.6% |
53.69%
2.9 pts better
|
Numerator 30 · Denominator 53 |
| Discharge mobility score | 54.72% |
50.94%
3.8 pts better
|
Numerator 29 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 5.55% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 0% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | 20.47% |
42%
21.5 pts worse
|
Numerator 26 · Denominator 127 |
| Discharge function score | 64.15% |
56.45%
7.7 pts better
|
Numerator 34 · Denominator 53 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 8 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · 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 | 2.2% |
3.8%
1.6 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.4% · Q3 1.3% · Q4 1.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.2% |
24.6%
0.6 pts worse
|
11.4%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 23.9% · Q3 22.1% · Q4 28.1% · 4Q avg 25.2% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.6%
0.4 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 8.0% · Q3 7.1% · Q4 4.8% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
23.5%
6.3 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 17.3% · Q3 16.9% · Q4 16.4% · 4Q avg 17.2% |
| 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 13.7% · Q2 19.2% · Q3 15.6% · Q4 17.9% · 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 | 19.8% |
13.3%
6.5 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 16.6% · Q3 16.1% · Q4 16.0% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
11.7%
3.9 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 14.9% · Q3 17.4% · Q4 18.8% · 4Q avg 15.6% · 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 | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.3% · Q4 4.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
24.2%
4.5 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 30.3% · Q3 20.3% · Q4 30.1% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.1%
1.7 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.3% · Q3 1.3% · Q4 4.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
81.6%
14.7 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 95.3% · Q3 100.0% · Q4 97.1% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
10.5%
0.7 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 4.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
79.0%
16.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
22.4%
3.2 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 23.1% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-30 · Fire 2023-10-30
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-08-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-07
E · Potential for more than minimal harm
2023-10-30
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 2023-12-12
E · Potential for more than minimal harm
2023-10-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-10-30
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 2023-12-12
D · Potential for more than minimal harm
2023-10-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-10-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-12
E · Potential for more than minimal harm
2022-12-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-31
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.
Not marked corrected
D · Potential for more than minimal harm
2025-07-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2025-04-16
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 2025-02-24
D · Potential for more than minimal harm
2025-04-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-08-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-16
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 2024-09-13
D · Potential for more than minimal harm
2024-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-27
F · Potential for more than minimal harm
2023-10-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-30
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-30
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-30
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 2023-11-17
D · Potential for more than minimal harm
2023-10-30
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-04-19
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 2023-04-27
D · Potential for more than minimal harm
2022-12-02
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 2022-12-20
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Hodgson, Melinda
Operational/Managerial Control · Individual
Hornbecker, Michael
Corporate Director · Individual
Magnolia Health Management Xxiv LLC
Operational/Managerial Control · Organization
Reagan, Julie
Corporate Director · Individual
Reed, Stuart
Operational/Managerial Control · Individual
Sellers, Daniel
Corporate Officer · Individual
Vormohr, J. Frank
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Waters Of Dunkirk Skilled Nursing Facility, The
Dunkirk, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Envive Of Berne
Berne, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Swiss Village
Berne, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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