Cycle 1
Health 2025-08-13 · Fire 2025-08-13
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Shelbyville, IN
Ashford Place Health Campus
4-star overall rating with 3-star inspections with 6 recent health deficiencies
2200 N Riley Hwy, Shelbyville, IN
(317) 398-8422
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2004-12-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,773
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9957
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.08
Baseline 22.35% · Performance 19.38% · Measure score 5.08 · Achievement 4.42 · Improvement 5.08
Healthcare-associated infections
6.14
Baseline 8.03% · Performance 6.02% · Measure score 6.14 · Achievement 6.09 · Improvement 6.14
Total nurse turnover
5.89
Baseline 21.28% · Performance 39.62% · Measure score 5.89 · Achievement 5.89 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.10 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.81% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 201 · Observed rate 14.93% · Lower 95% interval 9.77% |
| Discharge to community | 62.31% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 181 · Observed rate 57.46% · Lower 95% interval 55.01% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 132 · Denominator 132 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 4 · Denominator 132 |
| Discharge self-care score | 75.51% |
53.69%
21.8 pts better
|
Numerator 74 · Denominator 98 |
| Discharge mobility score | 73.47% |
50.94%
22.5 pts better
|
Numerator 72 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 0.76% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 132 · Adjusted rate 0.45% |
| Healthcare-associated infections requiring hospitalization | 6.01% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 4.55% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 153 |
| Discharge function score | 82.65% |
56.45%
26.2 pts better
|
Numerator 81 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 22.73% |
25.2%
2.5 pts worse
|
Numerator 15 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.8%
1.6 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 6.1% · Q3 2.8% · Q4 0.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.9% |
24.6%
1.7 pts better
|
11.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.2% · Q3 17.1% · Q4 24.3% · 4Q avg 22.9% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
5.6%
4.8 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
23.5%
4.7 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 28.0% · Q3 32.3% · Q4 25.7% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
14.8%
11.3 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.2% · Q3 3.4% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.8% |
13.3%
7.5 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
11.7%
6.2 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 14.3% · Q4 3.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
24.2%
6.1 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 22.1% · Q3 21.3% · Q4 15.7% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
4.1%
3.8 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
81.6%
16.4 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 96.9% · Q3 97.7% · Q4 100.0% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
10.5%
4.8 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 13.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.2% |
79.0%
4.8 pts worse
|
79.7%
5.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.4%
4.4 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 17.1% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-06-21
E · Potential for more than minimal harm
2023-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-16
E · Potential for more than minimal harm
2023-01-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-16
C · Minimal harm
2023-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-04-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-22
G · Actual harm
2024-08-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-05-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
J · Immediate jeopardy
2023-01-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-11
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-08
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Barney, Leigh
Limited Partnership Interest · Individual
Davis, David
Limited Partnership Interest · Individual
Long, Steven
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Miles, Nancy
Operational/Managerial Control · Individual
Simpson, Zachary
Operational/Managerial Control · Individual
Trilogy Healthcare Operations Of Shelbyville, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Willows Of Shelbyville
Shelbyville, IN
1-star overall rating with 2-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Especially Kidz Health & Rehab
Shelbyville, IN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Morristown Manor
Morristown, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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