Ridgewood Health Campus
181 Campus Dr, Lawrenceburg, IN 47025 · For profit - Corporation · 71 certified beds · (812) 537-5700 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (16) — 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
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) | 4 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
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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 fell from 4 to 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 | 7.1% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 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 | 61.8% | 25.2% | 6.5% | worse 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 | 3.2% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 8.3% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.5% | 23.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.2% | 13.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.4% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.0% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.9% | 10.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.53 | 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.
56.3% 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 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.6% 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 67 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 0.38 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 56.3%CMS range 50.3–63.7 | 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 | 14.1%CMS range 10.1–18.4 | 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 | 77.6% | 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 | 73.1% | 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 | 70.2% | 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 | 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 | 1.2% | 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 | 8.3%CMS range 5.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 71 beds and averages 66.9 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.15 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.79 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 4.39 hrs/resident/day on weekends vs 4.68 on weekdays — 6% thinner on weekends. RN hours go from 1.21 to 1.00 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 23% 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 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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · E2025-07-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to maintain resident snack refrigerators appropriately related to proper labeling for 2 of 2 snack refrigerators observed. (Resident snack refrigerator in the Main Building and the Resident snack refrigerator in the Legacy Building) Findings include: 1. The residents' snack refrigerator for the Main Building was observed on 06/30/25 at 2:33 P.M., with the Assistant Director of Nursing (ADON), and contained the following: - A clear plastic bag in a bottom drawer containing a large soft taco with no resident name or date. - A brown plastic bag with to-go containers. The bag was labeled with a resident's first name and dated 06/21/25. The ADON indicated they kept resident food in the refrigerator for 30 days; it depended on what it was. The bag contained a cup cake, coleslaw, and a fried chicken dinner. The ADON indicated it was probably not good anymore. - A white bag, dated 6/25/25, with no resident name. The bag contained salad dressing, hot sauce packets, and crackers. - A plastic container with a salad, dated 06/25/25, with…
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 before2025-07-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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, observation, and record review, the facility failed to provided Activities of Daily Living (ADL) care related to toileting a dependent resident in a timely manner for 4 of 24 residents reviewed. (Residents 8, 30, 25, and 23) Findings include: 1. During an interview, on 06/25/25 at 10:53 A.M., Resident 8, who resided on the 200 Hall, indicated she could not get help down here. It took two staff members to help her with toileting. She had been here in the facility for five years and did not have any trouble until this year. The clinical record for Resident 8 was reviewed on 06/26/25 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, fibula fracture, stroke, and Chronic Obstructive Pulmonary Disease (COPD). The resident required substantial/maximal assistance from staff for toileting. 2. During an interview, on 06/26/25 at 10:20 A.M., Resident 30, who…
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 before2025-07-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 proper positioning of a resident's indwelling urinary catheter drainage bag related to a resident who had a history of Urinary Tract Infections (UTIs) for 1 of 4 residents reviewed for urinary catheters / UTIs. (Resident 48) Findings include: During an observation, on 06/30/25 at 11:59 A.M., Resident 48 was in the Assisted Dining Room in her wheelchair. Her indwelling urinary catheter bag was hanging under her wheelchair and touching the floor. There was a bend in the bag with a quarter inch by approximately four inches of the bag touching the floor. During an observation, on 06/30/25 at 1:12 P.M., the resident was sitting in her wheelchair in the common area across from the nurses' station on the 200 Hall. One of her soft protective boots was kicked off and on the floor in front of the resident. Her indwelling urinary catheter bag was hanging under her wheelchair and touching the floor. There was a bend in the bag with a quarter inch by approximately four inches of the bag touching the floor. On…
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 before2025-07-02 · 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 record review and interview, the facility failed to ensure a resident's medications were accurately administered for 1 of 5 residents reviewed for pharmacy services. (Resident 20) Findings include: Resident 20's clinical record was reviewed on 06/30/25 at 10:21 A.M. A Significant Change Minimum Data Set assessment, dated 05/27/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, anemia, anxiety, and depression. The resident received antianxiety medications during the assessment review period. The resident's current physician's order included, but was not limited to, an open-ended order, with a start date of 05/20/25, for lorazepam (a medication for anxiety), 0.5 milligram (mg) tablet. Give 1/2 of a tablet three times a day. A Progress Note, dated 05/23/25 at 8:50 P.M., indicated the resident received an incorrect dose of routine lorazepam. The physician's order was for lorazepam 0.5 tablets, administer half of a 0.5 mg tablet, for a dose of 0.25 mg. The pharmacy sent whole tablets instead of half tablets. 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 · D2025-07-02 · 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 observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 1 of 18 residents reviewed for infection control. (Resident 3) Findings include: On 06/27/25 at 10:47 A.M., Resident 3 was observed in a wheelchair in the beauty shop. Her indwelling urinary catheter bag was touching the floor. The Beautician proceeded to push the resident down the hallway and back to her room. A half an inch of her catheter bag was dragging on the floor. On 06/27/25 at 11:22 A.M., the resident was observed sitting in her wheelchair in her room talking with her roommate and a visitor. Her indwelling urinary catheter bag was hanging under her wheelchair with two inches of it touching the floor. On 06/27/25 at 12:27 P.M., the resident was observed in her wheelchair in her room eating lunch. Her indwelling urinary catheter bag was hanging under her wheelchair with two inches of it touching the floor. On 06/30/25 at 10:58 A.M., the resident was observed sitting in her wheelchair in her room. Her indwelling urinary catheter…
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 · D2025-07-02 · 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 and interview, the facility failed to provide a sanitary homelike environment related to odors for 1 of 3 resident room hallways observed. (200 Hall) Findings include: On 06/25/25 at 10:50 A.M., the 200 Hall smelled strongly of urine. During an interview and observation, on 06/25/25 at 10:53 A.M., Resident 8, who resided on the 200 Hall, indicated it smelled bad in the facility, and she had her family members bring her air freshener spray. The resident had a can of air freshener. The clinical record for Resident 8 was reviewed on 06/26/25 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, indicated the resident was moderately cognitively impaired. On 06/25/25 at 1:06 P.M., the 200 Hall smelled strongly of urine with the odor increasing around rooms [ROOM NUMBERS]. On 06/26/25 at 9:45 A.M., the 200 Hall smelled strongly of urine from Rooms 210 to 215. On 06/26/25 at 3:37 P.M., the 200 Hall smelled strongly of urine. On 06/30/25 at 1:29 P.M., the 200 Hall smelled…
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 · D2025-07-02 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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 staff had the required six hours of dementia training within six months of hire and three hours annually thereafter for 2 of 10 employee records reviewed. (Qualified Medication Aid [QMA]8 Certified Nurse Aide [CNA] 9) Findings include: The employee records were provided by the Employee Experience Manager on 06/27/25. The following staff members failed to have the required number of hours of dementia training: - Qualified Medication Aide (QMA) 8 was hired on 10/05/21 and failed to have any current dementia training in her file. - Certified Nurse Aide (CNA) 9 was hired on 07/18/24 and had 3 hours of dementia training. On 06/30/25 at 10:00 A.M., the Administrator provided three hours of dementia training for QMA 8. The training was completed on 06/27/25. She had no additional dementia training for CNA 9. During an interview, on 06/30/25 at 3:47 P.M., the Administrator indicated the Employee Experience Manager had noticed some staff had missed their date for mandatory training. The Employee Experience Manager 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 · Dcited before2024-07-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the scheduled Activities of Daily Living care related to bathing for 1 of 3 residents reviewed. (Resident 64) Findings include: During an interview on 07/22/24 at 2:13 P.M., Resident 64 indicated she was lucky to get a shower once a week. At home she showered every other day. The resident's clinical record was reviewed on 07/24/24 at 10:02 A.M. An admission MDS (Minimum Data Set) assessment, dated 06/29/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, a right hip fracture, Clostridioides difficile (C-diff, a bacteria that causes watery Diarrhea), and urinary tract infection. The resident tested positive for C-diff Toxins on 07/03/24. The Electronic Health Record History and the Shower Sheets indicated the resident had the following showers or complete bed baths from admission to the facility from 06/26/24 to 07/26/24: - On 07/04/24 the resident refused a shower. - On 07/08/24 the resident received a complete bed bath. - On 07/15/24 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 before2024-07-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Basedonobservation recordreview andinterview thefacilityfailedtofollowappropriateinfectioncontrolguidelineswhileprovidingindwellingurinarycathetercareforresidentswithahistoryofUTIs (UrinaryTractInfections for2 of3 residentsreviewedforUTIs (Residents62 and26) Findingsinclude 1. IndwellingurinarycathetercarewasobservedforResident62 on07/25/24 at2:15 PM, with CNA (Certified Nurse Aide) 2 and CNA3. ThestaffdonnedgownsfromthecartthatwasjustinsidetheresidentsroomdoorduetotheresidentbeinginEnhancedBarrierPrecautionsandplacedaplasticbagcontaining cleanlinensonthefootoftheresidentsbed Thestaffdonnedgloves CNA2 preparedwaterinabasininthebathroomfortheprocedure CNA3, wearinghergloves proceededtoshutthewindowblind turnedonthelight over the bed andadjustedtheresidentsbed using the bed controls. CNA2 broughtthepanofwateroutandplaceditontheoverthebedtable Thetwostaffmemberspulledtheresidentspantsdownandrolledtheresidentsidetoside placingatowelundertheirbuttocks CNA3…
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 · D2023-06-21 · 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 accurately complete comprehensive MDS (Minimum Data Set) assessments for 3 of 18 resident records reviewed for accuracy of assessments. (Residents 70, 37, and 31) Findings include: 1. The clinical record for Resident 70 was reviewed on 06/16/23 at 1:43 P.M. An admission MDS assessment, dated 03/21/23, indicated the resident was admitted to the facility from an acute hospital. The diagnoses included, but were not limited to, stroke, coronary artery disease, and diabetes. A Discharge MDS assessment, dated 05/03/23, indicated the resident discharged from the facility and returned to an acute hospital. A Progress Note, dated 05/03/2023 at 10:09 A.M., indicated the resident discharged from the facility and was moving to the Assisted Living facility. The family helped move the resident's belongings, and the facility nurse gave report and resident paperwork to the Assisted Living nurse. During an interview on 06/21/23 at 11:21 A.M., the MDS Coordinator indicated the resident did not discharge to a hospital from the facility on…
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 6 citations
- Potential for harm · D2023-06-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to prevent the development of an unstageable (obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, moist dead tissue, or eschar, dry dead tissue) pressure ulcer (Resident 57), and failed to implement Care Plan interventions to prevent the development of pressure ulcers (Resident 2) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. During an interview on 06/15/23 at 1:09 P.M., Resident 57 indicated she had skin conditions the facility was treating. They put ointment on her bottom. There was just one tiny place on her bottom now. They put a little patch on it just as a precaution. The resident's sacral/coccyx area was observed with RN 14 on 06/20/23 at 1:57 P.M. There was a pencil eraser sized, light cream-colored scab at the top of the gluteal cleft, and a dime-sized red area on the right buttock. The clinical record was reviewed on 06/21/23…
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 · D2023-06-21 · 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 observation, interview, and record review, the facility failed to ensure care planned interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident 3) Findings include: Resident 3's bathroom was observed on 06/16/23 at 11:23 A.M. The resident's call light had several pieces of bright pink colored tap on the pull string. Toilet safety rails were observed in place on each side of the toilet. The rails were gray in color. The resident's clinical record was reviewed on 06/20/23 at 1:55 P.M., A Quarterly MDS (Minimum Data Set) assessment, dated 02/24/23, indicated the resident was severely cognitively impaired. The resident required the extensive assistance of two staff members for transferring, toileting, and personal hygiene. The diagnoses included, but were not limited to, stroke, hemiplegia and hemiparesis, and diabetes. The resident's vision was severely impaired. The resident's upper and lower extremities were impaired on one side. The resident experienced two or more falls without injury since the last assessment. A progress note, dated…
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 · D2023-06-21 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post nurse staffing daily for 2 of 7 days during the survey period. Findings include: During an observation on 06/15/23 at 10:10 A.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an observation on 06/15/23 at 2:48 P.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an observation on 06/16/23 at 8:55 A.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an interview on 06/21/23 at 1:15 P.M., the Scheduling Coordinator indicated she was responsible for ensuring staffing information was posted each day. She had been on vacation since 06/12/23 and today was her first day back at the facility. Staffing should be posted everyday. During an interview on 06/21/23 at 1:22 P.M., the Administrator indicated the Scheduling Coordinator handled staff posting. When she was on vacation, several staff members stepped in to update staff posting. The current facility policy, titled Guidelines for Staff Posting, with a review date on…
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 before2023-06-21 · 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 record review and interview, that facility failed to provide medications for 1 of 18 residents reviewed for pharmacy services. (Resident 46) Findings include: 1a. The clinical record for Resident 46 was reviewed on 06/16/23 at 2:21 P.M. Am admission MDS (Minimum Data Set) assessment, dated 05/05/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, malnutrition, and depression. A Progress Note, dated 06/08/23 at 4:24 P.M., indicated the resident's doxepin (an antidepressant medication) was reduced to 5 mg (milligrams) daily for seven days and then discontinue. A Progress Note, dated 06/13/23 at 1:40 P.M., indicated the pharmacy called and they were unable to split the doxepin capsule. The medication only came in 3 mg and 6 mg forms. The NP (Nurse Practitioner) was notified and a new order was obtained to start doxepin 3 mg everyday and continue with the original discontinue date. A physician's order, dated 05/02/23 through 06/08/23, indicated the resident was to receive doxepin 10 mg, once a day. A physician's…
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 · D2023-06-21 · 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
2. The clinical record for Resident 49 was reviewed on 06/19/23 at 10:30 A.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, anemia, hypertension, and renal insufficiency. An open-ended physician's order, with a start date of 05/10/23, indicated the staff were to administer metoprolol succinate, 25 mg once a day. The staff were to hold the medication if the resident's systolic blood pressure was less than 120 or the heart rate was less than 60. The May 2023 EMAR indicated the resident had received the medication when the systolic blood pressure was less than 120 on the following date and times: - On 05/10/23, the blood pressure was 106/68, - On 05/12/23, the blood pressure was 112/71, - On 05/19/23, the blood pressure was 111/76, - On 05/20/23, the blood pressure was 114/68, and - On 05/29/23, the blood pressure was 94/61. During an interview on 06/20/23 at 1:07 P.M., LPN 12 indicated if a resident's blood pressure medication had hold parameters, she would check 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 · D2023-06-21 · 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 and interview, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (200 Hall front medication cart and 200 Hall back medication cart) Findings include: 1. The 200 Hall front medication cart was observed on 06/15/23 at 10:25 AM., with QMA (Qualified Medication Aide) 2. The top drawer contained two nested pill cups that were not labeled with a resident's name or room number. The bottom cup had a large round flat tablet that the QMA identified as a Tums. The top cup contained eight pills. The QMA indicated there were no narcotics in the cup and the resident was taking a nap. The QMA indicated the pills were for Resident 13. The current physician's orders for Resident 13 were provided by the DON (Director of Nursing) on 06/21/23 at 2:47 P.M. The record indicated the resident was to receive the following medications between 6:00 A.M., and 10:00 A.M.: - Amlodipine, - Tums, - Aspirin, - Vitamin D3, - Colace, - Lasix, - Lexapro (an antidepressant), - Tylenol Arthritis, and - Wellbutrin (an antidepressant). 2. The 200 Hall back…
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 | 4 of 5 | 3.3 | +0.7 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 |
|---|---|---|---|---|
| HARRISON COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2020 |
| ORIX REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| BROWN, RICHARD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/18/2022 |
| TRILOGY HEALTHCARE OF DEARBORN LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2025 |
| CLUNIE, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/08/2022 |
| BARNEY, LEIGH | Individual | LIMITED PARTNERSHIP INTEREST | — | since 12/01/2015 |
| DAVIS, DAVID | Individual | LIMITED PARTNERSHIP INTEREST | — | since 12/31/2019 |
| BODNEY, STEPHEN | Individual | TRUSTEE OF THE SNF | — | since 01/01/2022 |
| HESS, JUDY | Individual | TRUSTEE OF THE SNF | — | since 01/01/2016 |
| SHICKLES, LARRY | Individual | TRUSTEE OF THE SNF | — | since 02/01/2022 |
| SHIREMAN, KATHY | Individual | TRUSTEE OF THE SNF | — | since 05/01/2024 |
| WHITIS, HARRIS | Individual | TRUSTEE OF THE SNF | — | since 01/01/2021 |
| WISEMAN, MARK | Individual | TRUSTEE OF THE SNF | — | since 09/01/2021 |
| 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 |
| TRILOGY HEALTHCARE HOLDINGS INC | Organization | ADP OF THE SNF | — | since 07/01/2025 |
| TRILOGY HEALTHCARE MASTER TENANT V, LLC | Organization | ADP OF THE SNF | — | since 07/01/2025 |
| TRILOGY HEALTHCARE OF LAWRENCEBURG LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY OPCO LLC | Organization | ADP OF THE SNF | — | since 07/01/2025 |
| 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 28 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
15 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 $1.6M 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 155789. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-02, 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.