St Elizabeth Healthcare Center
701 Armory Rd, Delphi, IN 46923 · Non profit - Corporation · 64 certified beds · (765) 564-6380 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.3% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.6% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.1% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 48.6% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 15.2% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.8% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.63 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.44 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.2%CMS range 55.9–72.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 8.7–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.5%CMS range 3.0–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 64 beds and averages 52.6 residents a day — about 82% occupied, or roughly 11 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.71 hrs/resident/day on weekends vs 3.47 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.96 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · D2026-03-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure alternative food choices were offered to residents who chose to receive meals in their room for 3 of 3 residents reviewed for resident rights. (Resident 4, 40 and 41)Findings include:During an interview, on 3/5/26 at 2:04 p.m., Resident 4 indicated the alternative food choices offered on the menu were not available to residents who chose to eat their meals in their rooms. During an interview, on 3/9/26 at 11:47 a.m., Resident 40 indicated she chose to eat in her room and not eat in the dining room. She had to go to the dining room to pick up her meal and bring it back to the room herself in order receive food from the alternative menu. Resident 40 indicated this was a recent new change and she had not always had to do that.During an interview, on 3/9/26 at 11:51 a.m., Resident 41 indicated a new policy had recently been put in place and he was unable to receive food choices from the alternative menu unless he went to the dining room to eat for meals.During an interview, on 3/9/26 at 3:04 p.m., the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis added for 1 of 5 residents reviewed for PASARR. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A PASARR level II, dated 6/19/22, had the diagnosis of post-traumatic stress disorder (PTSD) handwritten on the document. During an interview, on 3/9/26 at 3:15 p.m., the Director of Nursing (DON) indicated Resident 24 had a diagnosis of PTSD. During an interview, on 3/11/26 at 10:40 a.m., the PASARR help desk indicated they did not have any records of Resident 24 having a diagnosis of PTSD on the PASARR level II, dated 6/19/22. Whenever a resident had a new mental health diagnosis added, a new PASARR level I needed to be completed, and it was not. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 1 of 2 residents reviewed for care plans. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A PASARR level II, dated 6/19/22, had a diagnosis of PTSD handwritten on the document. The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 5/5/24.There was no care plan located in Resident 24's electronic record related to post-traumatic stress disorder.During an interview, on 3/9/26 at 3:15 p.m., the Director of Nursing (DON) indicated the resident had a diagnosis of PTSD. During an interview, on 3/11/26 at 12:20 p.m., the Social Service Director (SSD) indicated Resident 24 did not have a care plan for PTSD and should have one. A current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident received a medication timely according to the scheduled administration time and to ensure a resident had a physician's order in place for a non-pressure skin impairment for 2 of 3 residents reviewed for quality of care. (Resident 24 and 56) Findings include: 1. During an interview, on 3/5/26 at 10:21 a.m., Resident 24 indicated she did not always receive her medication on time. She had to turn her call light on, ask for her pills, and would have to wait a very long time. The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), osteoarthritis of the left shoulder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A care plan, dated 6/3/24, indicated Resident 24 had the potential for cardiovascular distress. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 2/28/25, indicated to administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment, person-centered care plan, and physician's orders were implemented for the use of an assistive device with transfers for 1 of 1 resident reviewed for range of motion and mobility. (Resident 44)Findings include:The clinical record for Resident 44 was reviewed on 3/5/26 at 2:19 p.m. The diagnoses included, but were not limited to, displaced spiral fracture of the shaft of the right femur, venous insufficiency, moderate protein-calorie malnutrition, history of falls, fracture of the shaft of the left tibia and left fibula, difficulty walking, osteoporosis, disorders of bone density and structure, and osteoarthritis.A nursing progress note, dated 12/11/25 at 3:20p.m., indicated Resident 44 had returned to the facility from a hospital stay for a right femur fracture.A therapy recommendation, dated 12/12/25, indicated a slide board was placed in Resident 44's room. The recommendation indicated the slide board was to be used for transfers with two people and a gait belt. The slide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician's order for the use of oxygen was implemented for 1 of 1 resident reviewed for respiratory care. (Resident 62) Findings include:During an observation, on 3/6/26 at 10:03 a.m., Resident 62's oxygen concentrator (a device used to provide supplemental oxygen therapy) was set on 3 liters per minute (L). During an observation, on 3/6/26 at 9:38 a.m., the resident was receiving 2 L of oxygen. The clinical record for Resident 62 was reviewed on 3/6/26 at 10:03 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, major depressive disorder, and hypertension.A care plan, dated 6/18/24, indicated Resident 62 received oxygen therapy. Interventions included, but were not limited to, monitor oxygen saturation, monitor signs and symptoms of respiratory distress, and administer oxygen by nasal cannula as ordered.A physician's order was not implemented until after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the care strategies to meet the individual needs of a resident who had a history of post-traumatic stress disorder (PTSD) were documented and implemented for 1 of 1 resident reviewed for post-traumatic stress disorder. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), panic disorder, major depressive disorder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. The clinical record indicated post-traumatic stress disorder was added to the resident's diagnoses list on 5/5/24.The clinical record did not contain a care plan related to post-traumatic stress disorder, the root cause, the triggers to watch for, or the interventions to implement in response to a trigger.Resident 24's profile care guide indicated Cultural Preferences and Trauma Triggers: There was no documentation after the statement to indicate what the cultural…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-07 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. The clinical record for Resident 27 was reviewed on 5/6/25 at 11:03 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, pneumonitis due to inhalation of food and vomit, diabetes type 2, hypertension, depression, anxiety, dysphagia, pain, heart attack, stroke, and myalgia. A progress note, dated 4/29/25 at 11:35 a.m., indicated Resident 27 was sent to the emergency room for symptoms of a stroke. The record did not contain documentation to indicate Resident 27 or the resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital or the facility's bed hold policy, including the facility's charge to hold a bed. During an interview, on 5/5/25 at 1:42 p.m., the Director of Nursing (DON) indicated the discharge paperwork was usually printed and sent to the hospital with the resident, but there was no specific indication in the chart the transfer form and the bed hold policy with charges were given to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure staff had documented training prior to administering 2 step Mantoux skin tests for tuberculosis (TB) and all parts of the procedure were documented to ensure accuracy for 1 of 5 employees and 3 of 7 residents reviewed for infection control. (CNA 16, Resident 2, 20, and 50) Findings include: 1. A facility tuberculin testing for employees' form indicated CNA 16 was given a second step Mantoux test on 4/10/24 and read on 4/12/24. There was no documentation to indicate the time the second step test was given or read to ensure there was a 48-hour lapse before reading the test. 2. The clinical record for Resident 2 was reviewed on 5/1/25 at 11:49 a.m. The diagnoses included, but were not limited to, spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, major depressive disorder with psychotic symptoms, anxiety disorder, and neuromuscular dysfunction of bladder. A TB skin test record, dated 2/2/24, indicated LPN 3 administered the skin test. There was no documentation to indicate LPN 3 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-07 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure resident council concerns and grievances were resolved for 3 of 5 residents reviewed for resident council concerns. (Resident 28, 37 and B) Findings include: A meeting with the resident council was conducted on 5/5/25 at 10:01 a.m. The residents in attendance indicated call light wait times had been an ongoing concern. The resident council meeting minutes were reviewed and indicated: a. On 2/24/25, the residents indicated the call light waiting time was long. b. On 3/19/25, the residents indicated the call light response time remained untimely. The call light concerns from 2/24/25 were included with no resolution. c. On 4/21/25, the residents indicated there were concerns with the call lights being answered in a timely manner. The call light concerns from 3/19/25 were included with no resolution. 1. During an interview, on 4/30/25 at 10:34 a.m., Resident B indicated she had laid in her feces and urine before and there had been times when Resident B waited over an hour before someone cleaned her up. It could take…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · D2025-05-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure staff obtained a follow-up weight to determine if a significant weight loss or gain had occurred and to document if a resident refused for 1 of 3 residents reviewed for nutrition. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/1/25 at 1:44 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, diabetes mellitus, morbid obesity, hypertension, major depressive disorder, post-traumatic stress disorder, major depressive disorder, panic disorder, bipolar disorder, anxiety disorder, and chronic pain. Resident B had the following weights: 1. On 11/2/24, the weight was 322.6 pounds. 2. On 12/16/24, the weight was 246.3 pounds. Resident B had a 23.65 % weight loss in 1 month. 3. On 1/1/25, the weight was 314.0 pounds. Resident B had a 27.49 % weight gain in 1 month. There was no documentation, between 11/1/24 to 5/7/25, of the significant gain or loss, no indication the resident was re-weighed, and no indication the physician, dietician, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-19 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3a. The clinical record for Resident 31 was reviewed on 4/18/24 at 12:22 p.m. The diagnoses included, but were not limited to, pneumonia, type 2 diabetes mellitus, chronic anemia, dementia, pleural effusion, atelectasis (partial collapse or closure of part of the lung), and diastolic congestive heart failure. A care plan for Resident 31, dated 3/27/24, indicated the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. A long-term goal indicated the resident would be free of symptoms of hypo/hyperglycemia through the next review. A physician's order, dated 3/8/24, indicated insulin Aspart U-100 per sliding scale and to call MD if blood sugar was greater than 400 mg/dL. A progress note, dated 3/8/24 at 5:20 p.m., indicated Resident 31 had a blood glucose level of 591 prior to dinner. The physician was called and gave a new order for NovoLog 6 units now and to recheck the blood glucose in 2 hours. If the repeat blood sugar was in normal range, the nurse did not need to call the provider. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
2. During an observation, on 4/15/24 at 12:45 p.m., Resident 31 was wearing oxygen tubing connected to an empty portable oxygen tank. During an interview, on 4/15/24 at 12:49 p.m., CNA 10 indicated the portable tank was empty and the resident relied on supplemental oxygen. CNA 10 indicated she would fill up the tank. During an observation, on 4/16/24 at 10:28 a.m., the portable oxygen tank for Resident 31 was empty and the flow rate dial was set on 2.5 liters while he was sitting in the activities room in his reclining wheelchair (Broda chair). The nurse was notified. LPN 9 took the portable oxygen tank off Resident 31's Broda chair and refilled tank. LPN 9 returned the refilled portable oxygen tank to Resident 31 and reconnected the oxygen tubing. The flow rate remained at 2.5 liters of oxygen. During an observation, on 4/16/24 at 3:53 p.m., the oxygen tubing was not dated, and the flow rate was set at 3 liters. During an observation, on 4/17/24 at 3:31 p.m., Resident 31 was in bed, the oxygen tubing was not dated, and the flow rate was set at just under 3 liters of oxygen. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed infection control standards related to handwashing during food service, following enhanced barrier precautions during wound care, during incontinence care, for urinary catheters, for storing linens and clothes in rooms, and disposing of soiled linens for 6 of 6 staff and 3 of 3 residents randomly observed for infection control practices. (Assistant Food Director, Guest Relations 5, Director of Health Services, RN 6, QMA 2, Resident 40, Resident 5, Resident 149 and CNA7) Findings include: 1. During an observation, on 4/15/24 at 12:12 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/15/24 at 12:15 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/15/24 at 12:17 p.m., the Assistant Food Director served a plate of food to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-19 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure resident council concerns and grievances were addressed and the resolutions to the concerns/grievances were documented in the meeting minutes for 4 of 12 months reviewed for resident council meeting minutes. (July 2023, January 2024, February 2024, March 2024. Finding includes: During the resident council meeting, on 4/17/24 at 10:00 a.m., the residents indicated the call lights continued to be an ongoing concern. The resident council meeting minutes were reviewed and indicated the following: a. On 7/14/23, there were concerns voiced with the call light response times. The resident council meeting minutes, dated 8/14/23, did not indicate the call light concerns from 7/14/23 were discussed and no resolution was included in the meeting minutes. b. On 1/15/24, there were concerns voiced about the call light response times at night being extended. c. On 2/19/24, there were concerns voiced about the call lights in the evening. The minutes did not include the call light concerns from 1/15/24 were reviewed or resolved. d.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-19 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage was given 48 hours prior to the Medicare benefits ending date for 2 of 3 residents reviewed for beneficiary notices. (Resident 38 and 101) Findings include: 1. The Notice of Medicare Non-Coverage (NOMNC) for Resident 38 indicated the Medicare services would end on 3/13/24 and Medicare probably would not pay for Skilled Nursing and Therapy after 3/13/24. Resident 38 signed the NOMC on 3/12/24. This was only a 24-hour notice prior to the end of the Medicare covered services. 2. The NOMNC for Resident 101 indicated the Medicare services would end on 3/5/24 and Medicare would probably not pay for Skilled Nursing and Therapy after this date. Resident 101 signed the NOMNC on 3/4/24. This was only a 24-hour notice prior to the end of the Medicare covered services. During an interview, on 4/19/24 at 12:43 p.m., the Executive Director (ED) indicated the staff who completed the notices was out of the facility on leave and was not able to be interviewed. The ED did not know the reason the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-19 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for 1 of 5 residents reviewed for PASARR. (Resident 40) Finding includes: The clinical record for Resident 40 was reviewed on 4/16/24 at 4:39 p.m. The diagnoses included, but were not limited to, depression, anxiety disorder, dementia, congestive heart failure, and hypertension. A PASARR level I, dated 3/1/24, indicated the resident did not require a level II. The PASARR level I indicated the resident was not taking any mental health medications and did not have a mental health diagnosis. The level I screen indicated if changes occurred or new information refuted these findings a new screen must be submitted. A physician's order, dated 3/27/24, indicated duloxetine delayed release (an antidepressant) 30 milligram (mg), give one capsule twice a day for depression. A care plan, dated 3/27/24, indicated the resident was at risk for developing adverse effects from the use of antidepressant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure expired medications were removed from the medication cart and medications were labeled for 1 of 3 medication carts reviewed for medication storage. (500 back hall medication cart) Finding includes: During an observation, on 4/18/24 at 11:08 a.m., the 500 back hall medication cart had a partial bottle of Robitussin DM with an expiration date of 2/22/24, and a partial bottle of Geri tussin Liquid 100/5 with an expiration date of 3/18/24. The bottom drawer contained a partial bottle of Tums unlabeled, 2 tubes of Diclofenac sodium topical gel 1% unlabeled, and a partial bottle of Childrens Tylenol with a resident's name in marker and not labeled. During an interview, on 4/18/24 at 11:30 a.m., QMA 11 indicated she did not know what resident(s) were receiving the Tums and Diclofenac gel. The expired medications should have been removed. She took expired medications to the Director of Nursing Services for destruction. A current policy, titled Medication and Storage in the facility, received from the Clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-19 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident rooms and hallways were in good repair and rooms were free of odors for 5 of 28 rooms observed for environment on the 500 hall. (room [ROOM NUMBER], 512, 517, 518 and 519). Findings include: 1. During an observation, on 4/15/24 at 11:20 a.m., the doorway of room [ROOM NUMBER] was missing approximately 18 inches of carpet. The hall between rooms [ROOM NUMBERS] had two gold floor plates which were missing pieces of carpet around them. During an interview, on 4/15/24 at 3:37 p.m., the Maintenance Director indicated there were no purchase orders for the carpet in room [ROOM NUMBER] or the 500 hall. 2 During an observation, on 4/15/24 at 3:37 p.m., room [ROOM NUMBER]'s bed was very loud when moving up and down. During an interview, on 4/15/24 at 3:38 p.m., the Maintenance Support and the Maintenance Director indicated there were approximately 50 beds like room [ROOM NUMBER]'s bed. The Maintenance Support indicated the bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 122 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 122; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WITHAM MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2015 |
| LUMENT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| BAYSTON, BRETT | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| BRAND, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2015 |
| CASTETTER, ANDREA | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| HAWKINS, CLAUDE | Individual | CORPORATE DIRECTOR | — | since 09/09/2013 |
| HORNBECKER, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| REAGAN, JULIE | Individual | CORPORATE DIRECTOR | — | since 09/25/2024 |
| BRAVERMAN, KELLY | Individual | CORPORATE OFFICER | — | since 12/01/2021 |
| SELLERS, DANIEL | Individual | CORPORATE OFFICER | — | since 06/20/2024 |
| TRILOGY HEALTHCARE OF CARROLL, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2015 |
| DYREK, SHELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/08/2025 |
| THOMAS, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/04/2026 |
| BARNEY, LEIGH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/08/2025 |
| DAVIS, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| CONTINENTAL MERGER SUB LLC | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| PARAGON OUTPATIENT REHABILITATION SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTH SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTHCARE MASTER TENANT LLC | Organization | ADP OF THE SNF | — | since 07/08/2025 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 09/19/2025 |
| TRILOGY PROPCO FINANCE LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE INDIANA II, LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
CMS files one row per role, so the 33 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted.
18 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155290. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.