Cycle 1
Health 2025-03-24 · Fire 2025-03-24
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lowell, IN
Cedar Creek Health Campus
4-star overall rating with 3-star inspections with $8,021 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
18275 Burr Street, Lowell, IN
(219) 696-6750
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
58
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-07-10
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,326
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.59% · Performance 22.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.12
Baseline 7.81% · Performance 6.01% · Measure score 6.12 · Achievement 6.12 · Improvement 5.91
Total nurse turnover
4.85
Baseline 44.83% · Performance 43.84% · Measure score 4.85 · Achievement 4.85 · Improvement 0
Adjusted total nurse staffing
1.05
Baseline 2.60 hours · Performance 3.09 hours · Measure score 1.05 · Achievement 0 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.94% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 15.38% · Lower 95% interval 9.6% |
| Discharge to community | 58.56% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 150 · Observed rate 56% · Lower 95% interval 52.6% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 135 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 68.04% |
53.69%
14.4 pts better
|
Numerator 66 · Denominator 97 |
| Discharge mobility score | 60.82% |
50.94%
9.9 pts better
|
Numerator 59 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 135 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.01% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 4.03% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 43.06% |
42%
1.1 pts better
|
Numerator 62 · Denominator 144 |
| Discharge function score | 72.16% |
56.45%
15.7 pts better
|
Numerator 70 · Denominator 97 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 42.53% |
25.2%
17.3 pts better
|
Numerator 37 · Denominator 87 |
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 0.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.5 · 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 | 2.8% |
3.8%
1 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 3.0% · Q4 5.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
24.6%
23.1 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.2% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.6%
1.3 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 12.9% · Q3 0.0% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
23.5%
3.2 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 25.0% · Q3 32.1% · Q4 28.6% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
14.8%
6.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.3% · Q3 7.7% · Q4 7.7% · 4Q avg 8.5% · 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 need for help with daily activities has increased | 9.4% |
11.7%
2.3 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.7% · Q3 7.4% · Q4 14.8% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · 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 2.7% · Q2 0.0% · Q3 0.0% · 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 | 26.4% |
24.2%
2.2 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 33.0% · Q3 21.1% · Q4 26.5% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.1%
1.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.3% · Q4 6.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
81.6%
17.4 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 98.2% · Q3 98.5% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
10.5%
4.8 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 4.9% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 2.1% · Q4 1.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
79.0%
19.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
22.4%
0.8 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 21.6% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
8 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-05-22 · Fire 2023-05-22
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-12
D · Potential for more than minimal harm
2024-05-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-19
E · Potential for more than minimal harm
2023-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-03-24
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 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-24
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 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-01-21
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-09-04
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-09-20
J · Immediate jeopardy
2024-06-05
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 2024-05-26
D · Potential for more than minimal harm
2024-05-03
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 2024-05-14
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-03
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 2024-05-14
D · Potential for more than minimal harm
2024-01-04
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 2024-01-22
D · Potential for more than minimal harm
2024-01-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-05-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-22
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 2023-06-08
D · Potential for more than minimal harm
2023-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-22
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 2023-06-08
D · Potential for more than minimal harm
2023-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-22
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 2023-06-08
Penalties and ownership
What sits behind the stars
$8,021
2024-05-28
Fine
Fine · fine $8,021
Fine
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Bond, Maria
Corporate Director · Individual
Clark, Timothy
Corporate Director · Individual
Daugherty, Joshua
Corporate Director · Individual
Dyrek, Shelly
Operational/Managerial Control · Individual
Felker, Dean
Corporate Director · Individual
Joyner, Sara
Corporate Director · Individual
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Teodori, Kristine
Operational/Managerial Control · Individual
Trilogy Healthcare Of Lowell LLC
Operational/Managerial Control · Organization
Wilson, Roy
Corporate Director · Individual
Nearby options
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Lowell Healthcare
Lowell, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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Crown Point, IN
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Saint Anthony
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1-star overall rating with 1-star inspections with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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