St Mary Healthcare Center
2201 Cason St, Lafayette, IN 47904 · For profit - Corporation · 79 certified beds · (765) 447-4102 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2023
- a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 3 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 | 10.4% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.3% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.6% | 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 | 4.4% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 23.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 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 | 16.9% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.2% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 35.1% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.9% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.43 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.35 | 1.44 | 1.80 | better |
‡ 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.
48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.0% 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 25 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 48.6%CMS range 36.5–61.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 8.6–21.4 | 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 | 68.0% | 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 | 64.0% | 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 | 52.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 7.0%CMS range 3.6–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 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 79 beds and averages 65.6 residents a day — about 83% occupied, or roughly 13 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above 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 2.97 hrs/resident/day on weekends vs 3.67 on weekdays — 19% thinner on weekends. RN hours go from 0.68 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%.
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 fewer than at the previous inspection — improving. 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.
20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.
- Potential for harm · F2026-03-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 the food preparation area did not contain employee drinks and frozen food was sealed in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 65 of 65 residents who received food from the kitchen.Findings include:During the kitchen observation, on 3/24/26 at 9:36 a.m., with the Dietary Manager, the following were observed:a. The food preparation counter had two unopened cans of energy drinks and a white cup with a lid and straw stored next to a jar of peanut butter and loaf of bread.b. On the second shelf in the walk-in freezer, there was a large opened plastic bag containing one skinless chicken breast. The chicken breast had a small amount of ice buildup on the upper left corner.c. On the second shelf in the walk-in freezer, there was a large cardboard box of skinless chicken breasts. The chicken was left in an untied plastic bag, and the cardboard lid was left wide open. During an interview, on 3/24/26 at 9:45 a.m., the Dietary Manager indicated the drinks belonged to the staff…
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 before2026-03-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician's orders were followed, a medication was administered according to the ordered parameters, and to obtain an admission weight for 3 of 3 residents reviewed for quality of care. (Resident 6, 17 and 44)Findings Include: 1. The clinical record for Resident 6 was reviewed on 3/25/26 at 10:59 a.m. The diagnoses included, but were not limited to, hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia.A care plan, dated 3/19/26, indicated the resident had a potential for cardiovascular distress related to the diagnosis of hypotension. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 3/11/26, indicated to administer midodrine (a medication for low blood pressure) 5 milligrams (mg), four times a day, and to hold the medication for a systolic blood pressure greater than 110. A medication administration record (MAR), dated 3/11/26 through 3/25/26, indicated…
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 · D2025-08-22 · tag F0628 — isolatedProvide 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
Based on interview and record review, the facility failed to ensure a resident's discharge paperwork provided to the receiving facility was accurate for 1 of 3 residents reviewed for discharge. (Resident C)Findings include: During an interview, on 8/20/25 at 2:09 p.m., an anonymous interviewee indicated Resident C was transferred, on 7/31/25, to their group home. She indicated Resident C came with discharge paperwork. The discharge assessment indicated Resident C required assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off footwear. She indicated Resident C was independent and did not need assistance.The clinical record for Resident C was reviewed on 8/20/25 at 3:55 p.m. The diagnoses included, but were not limited to, asthma, tracheostomy status, and congenital malformation of the musculoskeletal system.The clinical record indicated Resident C was cognitively intact and was capable of making her own decisions.A nursing progress note, dated 7/29/25 at 12:23 p.m., indicated the resident's discharge plan was to discharge to a group…
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 · E2025-05-19 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observation, interview and record review, the facility failed to ensure residents were served their meals together, staff were seated while eating with the residents, and a resident was able to complete their meal before being removed from the dining room for 1 of 2 dining rooms reviewed for dignity. (the legacy dining room) Findings include: 1. During an observation, on 5/14/25 at 12:00 p.m., the residents were seated in the legacy dining room. CNA 15 took a resident's meal ticket, gave the ticket to Dining Assistant 12, and he prepared the resident's plate. The CNAs passed out plates to residents seated at different tables randomly until all residents were served. During an interview, on 5/14/25 at 11:54 a.m., CNA 11 indicated Dining Assistant 12 told her to take a resident's meal ticket and pass the food out in the order of the tickets. CNA 11 told Dining Assistant 12 they should serve one table at a time. During an interview, on 5/14/25 at 12:12 p.m., Activity Associate 13 indicated normally the trays were passed out one table at a time until all the residents had…
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 · D2025-05-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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.
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 do not resuscitate (DNR) order was updated when received for 1 of 1 resident reviewed for advanced directives. (Resident 21) The deficient practice was corrected on 4/28/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident 21 was reviewed on 5/16/25 at 11:34 a.m. The diagnoses included, but were not limited to, adult failure to thrive, heart failure, coronary artery disease, hypertension, Parkinson's disease, type 2 diabetes, obesity, schizophrenia, iron deficiency anemia, and hypothyroidism. A physician's order dated 3/25/25 indicated full code status. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form indicated the resident was to be a DNR. The form was signed by the resident representative and witness on 4/1/25. The form was signed by the physician on 4/14/25. A physician's order, dated 4/22/25, indicated DNR code status. During an interview, on 5/19/25 at 10:19 a.m., LPN 10 indicated that when she received 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 · D2025-05-19 · 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 record review and interview, the facility failed to ensure the residents were issued SNF ABN's (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 2 of 3 residents reviewed for beneficiary notification. (Resident 1 and 20) The deficient practice was corrected on 2/13/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: 1. Resident 1 started on Medicare Part A services on 11/3/24. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The last covered day of Part A Service was 12/13/24. There was no SNF ABN or NOMNC provided to Resident 1. 2. Resident 20 started on Medicare Part A services on 10/22/24. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The last covered day of Part A Service was 12/23/24. There was no SNF ABN or NOMNC provided to Resident 20. During an interview, on 5/15/25 at 11:22 a.m., the DON (Director of Nursing) indicated the beneficiary notices were not being completed prior to February…
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 · D2025-05-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 Minimum Data Set (MDS) assessment was correctly coded for 1 of 1 resident reviewed for resident assessments. (Resident 49) Findings include: The clinical record for Resident 49 was reviewed on 5/14/25 at 3:56 p.m. The diagnoses included, but were not limited to, schizophrenia, bipolar disorder, and cognitive communication deficit. A Preadmission Screening and Resident Review (PASARR), dated 12/18/24, indicated the resident did not have any known recent or current mental health conditions. An admission minimum data set (MDS) assessment, dated 12/24/24, indicated the resident did not have a diagnosis of schizophrenia. A resident information sheet, last reviewed by the physician on 3/13/25, indicated the resident had a diagnosis of schizophrenia and bipolar disorder. A significant change in status MDS assessment, dated 3/26/25, indicated Resident 49 had a diagnosis of schizophrenia. Resident 49's physician's orders did not include any antipsychotic medications for the treatment of schizophrenia or bipolar disorder.…
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 before2025-05-19 · 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 vital signs and neurological assessments were documented for 1 of 1 resident reviewed for assessments. (Resident 70) The deficient practice was corrected on 5/10/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident 70 was reviewed on 5/15/25 at 1:37 p.m. The diagnoses included, but were not limited to, hypertension, chronic kidney disease, type 2 diabetes mellitus, and retention of urine, A facility event and incident report, dated 12/13/24 at 6:41 p.m., indicated the resident had an unwitnessed fall. The report did not include documentation for the 72-hour follow-up vital signs or neurological assessments. A facility event and incident report, dated 4/1/25 at 10:20 a.m., indicated the resident had an unwitnessed fall. The report did not include documentation for the 72-hour follow-up vital signs or neurological assessments. During an interview, on 5/15/25 at 9:48 a.m., the Director of Nursing (DON) indicated neurological assessments were not…
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 · D2025-05-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure a resident's diagnoses in the medical record were accurate and correct for 1 of 1 resident reviewed for documentation. (Residents 49) Findings include: The clinical record for Resident 49 was reviewed on 5/14/25 at 3:56 p.m. The diagnoses included, but were not limited to, schizophrenia, bipolar disorder, and cognitive communication deficit. A facility resident information sheet, last reviewed by the physician on 3/13/25, indicated the resident had a diagnosis of schizophrenia and bipolar disorder. The physician's orders did not include any antipsychotic medications for the treatment of schizophrenia or bipolar disorder. During an interview, on 5/16/25 at 2:00 p.m., the Director of Nursing (DON) indicated Resident 49 did not have schizophrenia or a bipolar diagnosis. During an interview, on 5/19/25 at 11:09 a.m., the DON indicated the incorrect diagnoses were incorrect and should not have been listed on the diagnoses list. Upon exit, the facility was unable to provide an accurate records policy. 3.1-50(a)(2)
- Potential for harm · D2025-05-19 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 the policy and procedure related to administering two (2) step Mantoux skin tests for tuberculosis were followed for 4 of 5 employees reviewed for infection control. (QMA 6, QMA 7, CNA 8 and CNA 9) Findings include: 1. A facility tuberculin testing for employees' form, dated 9/25/24, indicated QMA 6 was given the first step tuberculosis (TB) test on 9/25/24 and was read on 9/28/24. The second step was given on 10/10/24 and read on 10/12/24. There was no documentation indicating the time the first and second step tests were read. 2. A facility tuberculin testing for employees' form, dated 8/14/24, indicated QMA 7 was given the first step TB test on 8/14/24 and was read on 8/16/24. The second step was given on 8/30/24 and read on 9/1/24. There was no documentation indicating the time the first and second step test was read. 3. A facility tuberculin testing for employees' form, dated 1/19/25, indicated CNA 8 was given the first step TB test on 1/19/25 and was read on 1/21/25. The second step was given on 2/1/25 and…
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 10 citations
- Potential for harm · Dcited before2024-11-14 · 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 medications per the physician's order for 1 of 1 resident reviewed for quality of care. (Resident H) This deficient practice was corrected on 6/10/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The clinical record for Resident H was reviewed on 11/14/24 at 12:30 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, chronic kidney disease, and anxiety. The resident had a severe cognitive deficit and was receiving hospice care. A review of the Medication Administration Record (MAR) indicated the resident did not receive her ordered dose of Morphine concentrate (a pain medication) every 6 hours on 5/25/24 at 10:00 p.m., 5/26/24 at 4:00 a.m., 10:00 a.m., 4:00 p.m., 10:00 p.m., and on 5/27/24 at 4:00 a.m., 10:00 a.m., 4:00 p.m., 10:00 p.m. The MAR indicated the medication was not available for administration. The nursing notes did not indicate the resident had been assessed for pain on 5/25, 5/26, and 5/27/24. The physician…
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 · D2024-11-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 medications were documented as given, medications were disposed of properly, narcotic medication logbooks reflected the medication given to residents and medication records were reconciled for 3 of 5 medication carts reviewed. This deficient practice was corrected on 6/10/2024, prior to the start of the survey, and was therefore past noncompliance. Finding includes: 1. The narcotic sign-in and sign-out record book, from 5/1/24 thru 6/9/24 was missing 66 nursing staff signatures. 2. The medication destruction logbook, from 4/14/24 thru 6/15/24, had 24 errors. There were 7 dates missing, 11 resident names missing, 3 quantity amounts missing, 2 nursing signatures missing, and one entry was not log into the book. 3. The narcotic logbook entries did not match the resident Medication Administration Record (MAR) for 14 residents. The number of errors was 61 for the period of 4/4/24 thru 6/6/24. The narcotic book indicated 32 medications were withdrawn. The MAR did not reflect the administration of 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 · Ecited before2024-04-29 · 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
Based on observation, interview and record review, the facility failed to administer medications within the ordered time frame, assess and accurately document a resident's dental status and communicate with hospice and provide a positioning chair to meet the residents care planned needs for 6 of 6 residents reviewed for quality of care. (Residents 40, 47, 1, 20, 46 and 27) Findings include: 1. The clinical record for Resident 40 was reviewed on 4/24/24 at 3:45 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, heart failure, edema, and chronic kidney disease stage 3. A current physician's order, with a start date of 12/21/23, indicated the resident was to take buspirone (an antianxiety medication) 5 milligrams (mg) 3 times per day. Administer the first dose from 6:00 a.m. to 10:00 a.m., administer the second dose from 11:00 a.m. to 1:30 p.m., and administer the third dose from 6:00 p.m. to 10:00 p.m. A medication administration record (MAR) indicated the following administration times for buspirone: a. On 4/1/24 at 3:07 a.m. b.…
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 · D2024-04-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for 1 of 1 resident reviewed for comprehensive care plans. (Resident 29). Finding includes: The clinical record for Resident 29 was reviewed on 4/25/24 at 11:40 a.m. The diagnoses included, but were not limited to, epilepsy without status epilepticus, dementia with other behavioral disturbance, delusions disorder, depression, anxiety disorder, and insomnia. A physician's order, dated 2/20/24, indicated to give lamotrigine (an anticonvulsant) 100 milligrams (mg) twice a day for epilepsy. A care plan, dated 3/15/24, did not include the risk for seizures with an epilepsy diagnosis. There were no approaches for monitoring seizure activity or safety measures for seizures. A care plan, dated 3/15/24, did not include the resident receiving an anticonvulsant medication for epilepsy. There were no approaches for monitoring for seizure medication side effects. During an interview, on 4/26/24 at 2:35 p.m., the Clinical Support…
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 · D2024-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 post fall interventions were evaluated for effectiveness and a rationale was documented prior to removing the interventions from the comprehensive care plan for 2 of 3 residents reviewed for accidents. (Resident 23 and 54) Findings include: 1. The clinical record for Resident 23 was reviewed on 4/25/24 at 3:42 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the pancreas, unspecified dementia with other behavioral disturbance, and chronic kidney disease stage 3. A fall event, dated 9/24/23 at 5:53 p.m., indicated the resident was ambulating back from the dining room toward her room using a walker. The resident's legs became weak, and she was lowered to the ground. An interdisciplinary team (IDT) note, dated 9/25/23 at 9:46 a.m., indicated the new intervention was for hospice to re-evaluate the use of ambulatory device and weakness. The intervention for hospice to re-evaluate the use of ambulatory device and weakness was not on the current care plan and the progress notes did not include 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 · D2024-04-29 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 on a fluid restriction was monitored for 1 of 1 resident reviewed for a fluid restriction related to dialysis. (Resident 47) Finding includes: The clinical record for Resident 47 was reviewed on 4/24/24 at 3:54 p.m. The diagnoses included, but were not limited to, dependence on renal dialysis, diabetes mellitus, depression, and end stage renal disease. A care plan, dated 10/27/21, indicated the resident had a potential for weight fluctuations and alterations in labs due to receiving dialysis treatments. The interventions included, but were not limited to, limit fluid intake if a fluid restriction was ordered. A care plan, dated 10/27/21, indicated the resident had a diagnosis of renal failure. The interventions included, but were not limited to, treatment to dialysis site per physician's order, observe catheter site per orders, and fluid restriction per orders. A physician's order, dated 12/28/23, indicated to encourage a 1200 milliliters (ml's) daily fluid restriction. The order indicated to give 240…
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 · D2024-04-29 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to include monitoring for seizure medication side effects and seizure activity and to review a resident's history for 1 of 5 residents reviewed for unnecessary medications. (Resident 29). Finding includes: The clinical record for Resident 29 was reviewed on 4/25/24 at 11:40 a.m. The diagnoses included, but were not limited to, epilepsy without status epilepticus, dementia with other behavioral disturbance, delusions disorder, depression, anxiety disorder, hyperlipidemia, insomnia, and deficiency of other specified B group vitamins. A psychiatric unit after visit care note, dated 12/14/23, indicated lamotrigine was for mood stabilization related to diagnoses of dementia with behavior disturbance, major depressive disorder, and anxiety disorder. A physician's order, dated 2/20/24, indicated to give lamotrigine (an anticonvulsant) 100 milligrams (mg) twice a day for epilepsy. The original physician's order indicated related diagnosis dementia, seizures? A care plan, dated 3/15/24, did not include risk for seizures with an…
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 · D2024-04-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
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 assessments for side effects for antipsychotic medications were completed timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 54) Finding includes: The clinical record for Resident 54 was reviewed on 4/24/24 at 2:59 p.m. The diagnoses included, but were not limited to, unspecified dementia with anxiety, major depressive disorder, anxiety disorder, and a cognitive communication deficit. A physician's order, dated 5/25/23 through 10/27/24, indicated to give olanzapine (an antipsychotic) 5 milligram (mg) at bedtime. There was no diagnosis with the order. A physician's order, dated 10/27/23 through 1/13/23, indicated to give olanzapine 2.5 mg at bedtime. There was no diagnosis with the order. An Abnormal Involuntary Movement Scale (AIMS) was completed on 6/21/23. This was 27 days after the medication was ordered. A physician's order, dated 1/25/24 and open ended, indicated to give Risperdal (an antipsychotic) 0.5 mg once a day. An AIMS assessment was completed on 1/25/24. This was 7 months…
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 · D2024-04-29 · 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 the facility was free of strong odors, the walls, doors, and carpet were maintained, and the trash was disposed of in 2 of 3 units observed for environment. (200 hall and 100 hall) Finding includes: During an observation, on 4/23/24 at 11:00 a.m., the back hallway had a strong odor. The odor was stronger near the riser room. During an observation, on 4/23/24 at 12:07p.m., the lower portion of the walls in the dementia unit dining room had brown paint with gouges in the corners and white paint showing through. The lower half of the doors throughout the hallway had black marks. The carpet in the hallways had faded areas and dark stains. During an observation, on 4/23/24 at 2:44 p.m., an odor of urine was noted in the bathroom of room [ROOM NUMBER]. A urine-soaked brief was observed in the trash can. During an observation, on 4/23/24 at 1:27 p.m., the carpet in room [ROOM NUMBER] was very wet and slick. A resident was walking on 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 · D2023-10-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident from misappropriation of medication when a medication card for narcotics (30 tablets) was discovered to be missing from the facility's double locked medication cart for 1 of 1 resident reviewed for misappropriation of property. (Resident G) The deficient practice was corrected on 9/21/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The record for Resident G was reviewed on 10/5/2023 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, chronic kidney disease, anxiety, chronic pain, and anemia. An incident report to the Indiana Department of Health, on 8/30/2023, indicated it was reported Resident G's narcotic medication card was missing from the narcotic locked box. A search and investigation did not find the narcotic card with 30 hydroco/APAP 5-325 tablets. The physician and police were notified. A packing slip, dated 8/24/2023, from the pharmacy indicated the medication hydroco/APAP tab 5-325 mg 30 tablets for Resident G was delivered to 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.
“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 | 3 of 5 | 4.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.8 | -0.8 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 11/01/2014 |
| TRILOGY HEALTHCARE HOLDINGS INC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2015 |
| KEYBANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 04/27/2017 |
| 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 09/01/2013 |
| HORNBECKER, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| REAGAN, JULIE | Individual | CORPORATE DIRECTOR | — | since 09/25/2024 |
| BARDOCZI, STEPHEN | Individual | CORPORATE OFFICER | — | since 09/03/2013 |
| BRAVERMAN, KELLY | Individual | CORPORATE OFFICER | — | since 12/01/2021 |
| SELLERS, DANIEL | Individual | CORPORATE OFFICER | — | since 06/20/2024 |
| TRILOGY HEALTHCARE OF LAKE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2014 |
| GRENARD, HOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/07/2022 |
| THOMAS, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/15/2025 |
| BARNEY, LEIGH | Individual | LIMITED PARTNERSHIP INTEREST | — | since 12/01/2015 |
| DAVIS, DAVID | Individual | LIMITED PARTNERSHIP INTEREST | — | since 12/31/2019 |
| 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 03/01/2009 |
| TRILOGY HEALTHCARE MASTER TENANT II, LLC | Organization | ADP OF THE SNF | — | since 07/07/2025 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 11/10/2025 |
| TRILOGY PROPCO FINANCE LLC | Organization | ADP OF THE SNF | — | since 03/01/2009 |
| TRILOGY PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 03/01/2009 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE OF LAFAYETTE, LLC | Organization | ADP OF THE SNF | — | since 03/01/2009 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
CMS files one row per role, so the 35 rows in the source record cover these 32 parties — each is shown once here with every role it holds. Nothing is omitted.
19 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 $904K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 155094. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-31, 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.