River Terrace Health Campus
120 Presbyterian Ave, Madison, IN 47250 · For profit - Corporation · 57 certified beds · (812) 265-0080 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
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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 | 4 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 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 | 13.6% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.5% | 5.4% | check this* — see note marked star below the table |
| 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 | 12.8% | 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 | 2.2% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.7% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.9% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 13.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.7% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.6% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 24.0% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.58 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.44 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
68.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 206 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.0% 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 95 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 68.9%CMS range 59.6–76.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 9.7–17.0 | 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 | 81.0% | 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 | 72.6% | 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 | 72.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 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 | 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 | 1.6% | 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 | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.7%CMS range 3.1–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 57 beds and averages 41.9 residents a day — about 74% occupied, or roughly 15 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 4.38 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 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 3.69 hrs/resident/day on weekends vs 4.66 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.71 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as 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 11 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · G2023-09-27 · 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 staff irrigated a resident's (Resident B) Indwelling catheter with the correct dosage of acetic acid which resulted in burning pain and a transfer to the emergency department for 1 of 3 residents reviewed for Indwelling catheters. Findings include: During an interview on 9/27/23 at 2:40 p.m., Resident B was observed resting in bed with her eyes open. She indicated RN 2 came in her room and asked if the stuff for her catheter was in her room and Resident B told her no. A few minutes later, RN 2 came in her room with a big jug and said she had gotten some vinegar to irrigate her catheter. As soon as the vinegar hit up in there, she told RN 2 to stop because it was screaming burning. RN 2 replaced her catheter and then flushed it with normal saline. She ended up going to the emergency department (ED) due to the pain she had in her bladder. While at the ED, the physician explained to her that she had a chemical burn and that he needed to remove her catheter so he could insert lidocane (used for pain) gel.…
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 · F2026-03-06 · 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, record review and interview, the facility failed to ensure the kitchen was clean and in good repair for 2 of 2 observations. This deficient practice had the potential to affect 44 of 44 residents who received meals from the kitchen.Findings include:During the initial tour of the kitchen on 3/2/26 at 10:20 a.m., the following concerns were observed:Under the right long rack and center rack, next to the wall in the walk-in freezer, there were a handful of frozen french fries on the floor.The outside of the six white bins holding sugar, oatmeal, thickener, bread flour, bread crumbs, and all purpose flour, had brown dirt and streaks going down the front, back and sides of the bins.The inside shelf of the deep fryer had a moderate amount of yellow crumbs on the inside shelf above the oil. Around the outside front, and both sides of the fryer had heavy grease streaks which ran the length of the fryer.The left oven had a moderate build-up of orange brown spills on the inside bottom and oven door.The inside of the hot box (where the cooks put the hot items they have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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, record review and interview, the facility failed to ensure the medical provider addressed the consultant pharmacist's recommendations for 2 of 45 residents reviewed for Drug Regimen Review. (Residents 36 and 44)Findings include:1.The record for Resident 36 was reviewed on 3/3/26 at 1:50 p.m., The resident's diagnoses included, but were not limited to, Alzheimer's disease with late onset (a progressive irreversible neurological disorder that destroys memory, thinking skills, and eventually the inability to perform simple tasks); major depressive disorder ( a serious mental health condition characterized by at least 2 weeks of persistent severe sadness, loss of interest, and fatigue, which significantly disrupt daily life); hallucinations (seeing, hearing, smelling feeling things that seem real but are created by the mind without external stimuli) and tremors (an involuntary quivering moment). The Consultant Pharmacist Review, dated 2/9/26, indicated the resident was admitted on [DATE] with 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 · F2025-03-28 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the facility was staffed to provide adequate care for the residents related to toileting and as needed pain medication. This deficient practice had the potential to affect 41 of 41 residents residing in the facility. Findings include: An observation of the 2nd floor 200 Hallways, on 3/26/25 at 7:08 p.m., indicated no staff were observed on the right-side Hallway of the 2nd floor. On the right-side Hallway of the 2nd floor five call lights were alarming, Resident H was lying on the floor in her room between her wheelchair and the bathroom doorway. The resident was yelling for help, and no staff were insight or within hearing distance. A staff member was located at 7:09 p.m. and notified of the resident lying on the floor yelling for help. The resident indicated to Certified Nurse Aide (CNA) 3 she had fallen and needed help. During an interview and observation, on 3/26/25 at 7:12 p.m., Resident C was sitting in her bed. The resident had a nasal canula with oxygen being administered. CNA 3 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 · Ecited before2025-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 activities of daily living (ADL) related to incontence care and personal assistance for 4 of 5 residents reviewed for ADL care. (Residents E, D, G, and C) Findings include: 1. During an interview, on 3/26/25 at 8:03 p.m., Resident E indicated she had turned her call light on for assistance to go to the bathroom and the Certified Nurse Aide (CNA) indicated she was the only one on the floor and could not help her. The resident was advised the facility did not have a walker or wheelchair for her to use at that time. After waiting over an hour the resident contacted her family member at home. The resident's family member indicated the resident called him and asked him to come and get her help. The clinical record for Resident E was reviewed on 03/28/25 at 11:07 a.m. The resident's diagnoses included, but were not limited to, femur fracture, Type 2 diabetes mellitus, diverticulosis, and hypertension. During a confidential interview, from 3/26/25 through 3/28/25, Staff 12 indicated it was very hard to care for 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 before2025-03-28 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 pain medication was administered timely after being requested for 1 of 3 residents reviewed for pain management. (Resident F) Findings Include: During an interview on 3/26/25 at 7:47 p.m., Resident F indicated he had waited for hours to receive pain pills, and it was the worst on evening shift. Once the pain increased so high it was hard for the medication to get control of the pain. The clinical record for Resident F was reviewed on 3/26/25 at 11:00 p.m., The resident's diagnoses included, but were not limited to, right femur fracture, chronic kidney disease, Type 2 diabetes mellitus, and anemia. The Nursing Progress note, dated 3/22/25 at 5:46 p.m., indicated the resident was alert and oriented. He required the extensive assistance of one staff member for transfers. He had a right hip fracture and incision. The resident rated his pain level a 6 out of 10 with a scale of 1 being the lowest and 10 being the highest pain level. The Nursing Progress note, dated 3/23/25 at 11:23 p.m., indicated 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 before2025-01-22 · 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, observation, and record review, the facility failed to ensure staff provided proper transfer techniques during transfers for 2 of 4 residents reviewed for activities of daily living. (Residents 183 and 14) Findings include: 1. During an observation on 1/15/25 at 9:13 a.m., Resident 183 was tearing up and moaning due to pain. He was unable to move his right shoulder and indicated he was in severe pain. The record for Resident 183 was reviewed on 1/17/25 at 10:24 a.m. The resident's diagnoses included, but were not limited to, primary osteoarthritis of the left shoulder, spinal stenosis, lumbar region without neurogenic claudication, and radiculopathy of the lumbar region. The admission Minimum Data Set (MDS) assessment, dated 8/15/24, indicated the resident was cognitively intact. The resident required partial to moderate assistance for transferring safely. The care plan, dated 1/13/25, indicated Resident 183 had impairment in functional status related to weakness. The interventions included, but were not limited to, encourage the resident to be independent as…
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 · D2025-01-22 · 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 observation, record review, and interview, the facility failed to ensure non-pressure wounds were documented on the Treatment Administration Record, and wound treatments were performed in a timely manner as ordered by the physician for 1 of 6 residents observed for Quality of Care. (Resident 13) Findings include: The record for Resident 13 was reviewed on 1/16/25 at 1:53 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease, severe morbid obesity due to excess calories, type 2 diabetes mellitus with diabetic chronic kidney disease, SIRS (systemic inflammatory response syndrome) of non-infectious origin with acute organ dysfunction, muscle weakness, difficulty in walking, and unsteadiness on his feet. The Quarterly MDS (Minimum Data Set) assessment, dated 11/28/24, indicated the resident was cognitively alert and oriented. The nurse's note, dated 10/11/24 at 10:47 a.m., indicated that during the weekly skin assessment, the resident was observed to have an open, draining area to the left shin with redness around the area. The MD was made aware…
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 · D2025-01-22 · 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 observation, interview and record review, the facility failed to ensure pressure ulcer dressing changes were completed per the physician order; a new pressure area was measured, tracked or treated; and interventions were in place related to floating a resident's heels for a resident at risk for pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident 14) Findings include: The record for Resident 14 was reviewed on 1/15/25 at 11:00am. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; repeated falls; and unspecified severe protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS) assessment, dated 10/27/2024, indicated the residents' cognition was severely impaired. The resident required staff assistance with Activities of Daily Living (ADL) The resident was out of the facility from…
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 · D2024-12-10 · 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 interview and record review, the facility failed to ensure a resident (Resident B) received Lantus (long-acting diabetic medication) as ordered by the physician for 1 of 3 residents reviewed for pharmacy services. Findings include: The clinical record for Resident B was reviewed on 12/9/24 at 8:05 p.m. The resident's diagnosis included, but was not limited to, diabetes. The Care Plan, dated 11/18/24, indicated the resident was at risk for hypoglycemia/hyperglycemia due to diabetes mellitus and staff were to administer the resident's medications as ordered. The admission Order, dated 11/14/24, indicated the resident was to receive Lantus insulin, 20 units subcutaneous at bedtime. The EDK (emergency drug kit) record indicated, on 11/14/24 at 9:33 p.m., a Lantus Solostar insulin pen was removed for Resident B. The November 2024 Medication Administration Record indicated the resident received 20 units of the Lantus insulin at bedtime on 11/14/24. The progress note, dated 11/16/24 at 11:57 a.m., indicated the resident was sweating and her blood sugar was 504. The physician was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-04 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 2 of 5 residents or responsible parties were provided written notice of Transfer/Discharge upon transfer to an acute care facility. (Residents 10 and 14) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact A nurse's note, dated 12/13/23 at 10:36 p.m., indicated the resident was short of air with oxygen levels between 78 and 84% (percent) on room air and between 88 and 90% on 2 liters of oxygen. The physician was made aware and gave a new order for the resident to be transferred to the hospital. The resident's daughter was made aware and was agreeable. A nurse's note, dated 12/19/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · E2023-12-04 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 5 of 8 months reviewed. (April, May, June, August and October 2023). This deficiency had the potential to affect all 36 residents currently residing in the facility. Findings include: Review of the April to December 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: - On 4/1 (Saturday) only 6.25 hours, - On 4/2 (Sunday) only 6.25 hours, - On 4/15 (Saturday) only 6 hours, - On 4/16 (Sunday) only 6 hours, - On 4/29 (Saturday) only 6 hours, - On 4/30 (Sunday only 6.5 hours. - On 5/13 (Saturday) only 6 hours, - On 5/27 (Saturday) only 7.75 hours, - On 5/28 (Sunday) only 6.0 hours. - On 6/10 (Saturday) only 5.5 hours. - On 8/12 (Saturday) only 6 hours, - On 8/26 (Saturday) only 6 hours. - On 10/7 (Saturday) only 6 hours, - On 10/8 (Sunday) only 6 hours. During an interview on 11/27/23 at 10:00 a.m., the Executive Director (ED) indicated there were no nursing waivers. During an interview with the ED on 12/1/23 at 3:15 p.m., she…
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 · E2023-12-04 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, record review, and interview, the facility failed to ensure proper storage and disposal of medications for 2 of 2 medication storage rooms reviewed for medication storage. (200 A Hall Medication Room and 200 B Hall Medication Room) Findings include: 1. During an observation on 11/30/23 at 12:13 p.m., of the 200 A Hall Medication Storage Room with RN 11 the following concerns were observed: - In the refrigerator there was one bottle of Humulin R injection solution 100 units/mL which indicated a staff members name as the recipient. - In a basket in the cabinet under the right side of the sink there were three unlabeled bottle of nystatin 100,000 units per gram powder, and one container of magic butt cream with a partially destroyed label, which indicated it was prepared on 2/11/22 and best used by 8/11/22. - In a clear bag there were several tubes of topical creams, including 1 open tube of mupirocin 2% cream, 2 tubes of venelex ointment, and 1 open tube of metronidazole gel 0.75%, and one bottle of nystatin powder. There were no labels on any of the medications.…
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 · D2023-12-04 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to assess and re-evaluate 2 of 2 residents for self-administration of respiratory treatments or medications (inhalers). (Residents 10 and 14) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact and had no impairment in functional range of motion of upper extremities. The December 2023 monthly physician's order, indicated the resident had an order, dated 12/22/22, for albuterol sulfate solution for nebulization, 1 vial inhalation for SOA (shortness of air) every 6 hours PRN (as needed). The Medication Administration Record (MAR), dated between September and November 2023, indicated the following…
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 · D2023-12-04 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 3 of 5 residents or responsible parties were provided written notice of and signed the facility's bed hold policy upon transfer to an acute care facility. (Residents 10,14 and 31) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact A nurse's note, dated 12/13/23 at 10:36 p.m., indicated the resident was short of air with oxygen levels between 78 and 84% (percent) on room air and between 88 and 90% on 2 liters of oxygen. The physician was made aware and gave a new order for the resident to be transferred to the hospital. The resident's daughter was made aware and was agreeable. A nurse'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 · D2023-12-04 · 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 record review and interview, the facility failed to develop a Self-Administration of Medication plan of care for 2 of 2 residents who were self-administering respiratory treatments and inhalers. (Residents 10 and 14). Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact and had no impairment in functional range of motion of upper extremities. The December 2023 monthly physician;s order indicated the resident had an order, dated 12/22/22, for albuterol sulfate solution for nebulization, 1 vial inhalation for SOA (shortness of air) every 6 hours PRN (as needed). The MARs indicated that during the months of September to November 2023, the resident…
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 before2023-12-04 · 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 ensure showers were provided for dependent residents for 2 of 5 residents reviewed for Activities of Daily Living. (Residents 8 and 22) Findings included: 1. The clinical record for Resident 8 was reviewed on 12/1/23 at 11:00 a.m. The diagnoses included, but were not limited to, lack of coordination, abnormalities of gait and mobility, unsteadiness on his feet, generalized weakness, and hemiplegia affecting the right dominant side. The Quarterly MDS (Minimum Data Set) assessment, dated 11/5/23, indicated the resident was cognitively intact. He required maximal assistance with bathing. The care plan, dated 2/28/22, indicated the resident had impairments in functional status regarding bed mobility, transfers, toileting, and eating related to CVA (cardiovascular accident) with hemiplegia. The interventions included, but were not limited to, mobility bars to bed (dated 8/12/23), keep nails trimmed (dated 5/1/23); and the resident required set up and assist with eating, stand up lift assist with transfers, assist with bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-04 · 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 record review, and interview, the facility failed to ensure a resident received adequate supervision and interventions were properly implemented to prevent accidents for 2 of 3 residents reviewed for accidents. (Residents 8 and 23) Findings include: 1. The record for Resident 8 was reviewed on 11/28/23 at 8:15 a.m. The diagnoses included, but were not limited to, acute cholecystitis; ataxia following cerebral infarction occlusion and stenosis of left vertebral artery; type 2 diabetes mellitus; attention-deficit hyperactivity disorder; shortness of breath; lack of coordination; abnormalities of gait and mobility; unsteadiness on feet; difficulty in walking; muscle weakness; and hemiplegia affecting the right dominant side. The Quarterly MDS (Minimum Data Set) assessment, dated 11/5/23, indicated the resident was moderately cognitively intact. He required maximum assistance for ADL's (Activities of Daily Living). The care plan, dated 8/29/22 and revised on 2/22/23, indicated the resident was at risk for falls related to decreased mobility, weakness, a history of falls 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.
- Potential for harm · Dcited before2023-12-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 appropriate pain management related to standards of practice for administering narcotic pain medication as prescribed for 1 of 5 residents reviewed for pain management. (Resident 13) Findings include: The record for Resident 13 was reviewed on 11/28/23 at 2:00 p.m. The diagnoses included, but were not limited to, fibromyalgia, right lower quadrant pain, chronic bladder pain, pain in left knee, and systemic lupus erythematosus. The Quarterly MDS (Minimum Data Set) assessment, dated 8/25/23, indicated the resident was cognitively intact, experienced mild pain, and was on a scheduled pain medication regimen. The physician's order, dated 10/25/23, indicated the resident was to receive hydrocodone 10/325 mg (milligrams) four times daily for pain. The scheduled times were between 6:00 a.m. and 10:00 a.m., between 11:00 a.m. and 1:30 p.m., between 4:00 p.m. and 7:00 p.m., and between 8:00 p.m. and 11:00 p.m. The orders lacked documentation of any parameters for how far apart to administer the doses. The October MAR for 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 · D2023-12-04 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 behavioral care plans were updated to reflect allegations of suicidal statements and physical aggression for 1 of 5 residents reviewed for behavioral care. (Resident 23) Findings include: The record for Resident 23 was reviewed on 11/29/23 at 10:09 a.m. The diagnoses included, but were not limited to, Parksinsonism, dementia with behavioral disturbance, Parkinson's disease, and major depressive disorder. The care plan, initiated on 4/27/23 and last revised on 11/3/23, indicated the resident had altered behaviors included a history of delusions. The interventions included, but were not limited to, administer medications per orders, monitor the resident's behaviors with all hands on care and contacts, and psychiatric services as needed (all initiated on 4/27/23). The late entry nurse's note, authored on 7/27/23 at 9:52 a.m., was dated for 7/26/2023 at 6:20 p.m., indicated the resident's family member came to the DHS (Director of Health Services) and reported he was trying to scare her by saying he was going to jump…
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 |
|---|---|---|---|---|
| HARRISON COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/08/2018 |
| BODNEY, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 01/01/2022 |
| BROWN, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 06/15/1991 |
| CLUNIE, LISA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/08/2022 |
| HESS, JUDY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2016 |
| SHICKLES, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 02/01/2022 |
| SHIREMAN, KATHY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/01/2014 |
| WHITIS, HARRIS | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 01/01/2021 |
| WISEMAN, MARK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 09/01/2021 |
| WILEY, CHARLES | Individual | CORPORATE OFFICER | — | since 01/01/2019 |
| TRILOGY HEALTHCARE OPERATIONS OF MADISON, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2019 |
| GIBSON, RHONDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2022 |
| TOTTEN, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/15/2025 |
| BARNEY, LEIGH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/27/2025 |
| DAVIS, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/18/2025 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| CONTINENTAL MERGER SUB LLC | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| PARAGON OUTPATIENT REHABILITATION SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE MADISON LLC | Organization | ADP OF THE SNF | — | since 08/18/2025 |
| 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 26 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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 155849. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, 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.