Cycle 1
Health 2024-10-16 · Fire 2024-10-16
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Bedford, IN
Stonebridge Health Campus
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3100 Shawnee Drive South, Bedford, IN
(812) 278-8195
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2004-02-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 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
0.71
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,122
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9992
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.55
Baseline 17.92% · Performance 19.32% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Healthcare-associated infections
5.85
Baseline 7.26% · Performance 6.09% · Measure score 5.85 · Achievement 5.85 · Improvement 4.68
Total nurse turnover
7.97
Baseline 46.00% · Performance 31.11% · Measure score 7.97 · Achievement 7.97 · Improvement 6.54
Adjusted total nurse staffing
0
Baseline 2.79 hours · Performance 2.82 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.74% |
10.72%
4 pts worse
|
Worse than the National Rate · Eligible stays 254 · Observed rate 18.11% · Lower 95% interval 11.65% |
| Discharge to community | 72.12% |
50.57%
21.6 pts better
|
Better than the National Rate · Eligible stays 208 · Observed rate 63.94% · Lower 95% interval 65.1% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 178 · Denominator 178 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 178 |
| Discharge self-care score | 86.01% |
53.69%
32.3 pts better
|
Numerator 123 · Denominator 143 |
| Discharge mobility score | 74.83% |
50.94%
23.9 pts better
|
Numerator 107 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 178 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 6.09% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 4.9% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 16.55% |
42%
25.4 pts worse
|
Numerator 24 · Denominator 145 |
| Discharge function score | 85.31% |
56.45%
28.9 pts better
|
Numerator 122 · Denominator 143 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 84 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 39.6% |
25.2%
14.4 pts better
|
Numerator 40 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · 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 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
93.6%
3 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 88.9% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.4%
2.4 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.8%
0.4 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 4.5% · Q4 6.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.2% |
24.6%
8.4 pts better
|
11.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 22.7% · Q3 9.8% · Q4 14.3% · 4Q avg 16.2% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.6%
2.6 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 3.1% · Q4 2.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.6% |
23.5%
10.1 pts worse
|
19.6%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 32.4% · Q3 34.4% · Q4 36.1% · 4Q avg 33.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
14.8%
3.2 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.3% · Q3 15.4% · Q4 14.3% · 4Q avg 11.6% · 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 | 2.9% |
13.3%
10.4 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.3% |
11.7%
9.4 pts better
|
14.9%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 3.2% · Q4 0.0% · 4Q avg 2.3% · 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 | 19.6% |
24.2%
4.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 20.1% · Q3 19.8% · Q4 8.5% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
4.1%
3.7 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
81.6%
6 pts better
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 85.9% · Q3 82.0% · Q4 86.7% · 4Q avg 87.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
10.5%
5.1 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 16.1% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
79.0%
4.9 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
22.4%
1 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 26.7% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-10 · Fire 2023-10-10
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-06 · Fire 2022-12-06
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-16
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 2024-11-11
E · Potential for more than minimal harm
2024-10-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-11
C · Minimal harm
2022-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-31
Inspection history
Recent health citations
C · Minimal harm
2024-10-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-01
D · Potential for more than minimal harm
2023-10-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-10
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 2023-10-25
D · Potential for more than minimal harm
2023-10-10
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-10-25
G · Actual harm
2022-12-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-06
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 2022-12-28
D · Potential for more than minimal harm
2022-12-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-06
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 2022-12-28
Penalties and ownership
What sits behind the stars
Ownership
Jackson County Schneck Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Alldredge, Megan
Operational/Managerial Control · Individual
Fish, Eric
Operational/Managerial Control · Individual
Mann, Deborah
Operational/Managerial Control · Individual
Neese, Kevin
Operational/Managerial Control · Individual
Orix Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Trilogy Healthcare Of Stonebridge, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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White River Lodge
Bedford, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
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
#3
Westview Nursing And Rehabilitation Center
Bedford, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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