Cycle 1
Health 2025-02-05 · Fire 2025-02-05
14 health deficiencies
Top issue: Infection Control (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lafayette, IN
Creasy Springs Health Campus
3-star overall rating with 2-star inspections with $8,018 in total fines with 14 recent health deficiencies
1750 S Creasy Ln, Lafayette, IN
(765) 447-6600
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
71
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2010-05-11
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
1.29
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.77
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,109
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9993
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.18
Baseline 22.53% · Performance 19.96% · Measure score 4.18 · Achievement 3.18 · Improvement 4.18
Healthcare-associated infections
6.84
Baseline 4.92% · Performance 5.79% · Measure score 6.84 · Achievement 6.84 · Improvement 0
Total nurse turnover
5.97
Baseline 48.94% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 3.51
Adjusted total nurse staffing
1.40
Baseline 2.86 hours · Performance 3.41 hours · Measure score 1.40 · Achievement 1.18 · Improvement 1.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 292 · Observed rate 8.22% · Lower 95% interval 7.07% |
| Discharge to community | 69.43% |
50.57%
18.9 pts better
|
Better than the National Rate · Eligible stays 263 · Observed rate 66.16% · Lower 95% interval 62.64% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 190 · Denominator 190 |
| Falls with major injury | 1.58% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 190 |
| Discharge self-care score | 67.33% |
53.69%
13.6 pts better
|
Numerator 101 · Denominator 150 |
| Discharge mobility score | 61.33% |
50.94%
10.4 pts better
|
Numerator 92 · Denominator 150 |
| Pressure ulcers or injuries, new or worsened | 3.16% |
2.29%
0.9 pts worse
|
Numerator 6 · Denominator 190 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 4.24% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 164 |
| Staff flu vaccination coverage | 65.71% |
42%
23.7 pts better
|
Numerator 138 · Denominator 210 |
| Discharge function score | 76% |
56.45%
19.5 pts better
|
Numerator 114 · Denominator 150 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 108 · Denominator 108 |
| Transfer of health information to patient | 98.33% |
96.28%
2 pts better
|
Numerator 59 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 30.77% |
25.2%
5.6 pts better
|
Numerator 28 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
93.6%
0.4 pts worse
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.1% · Q3 90.3% · Q4 84.4% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
95.4%
0.7 pts worse
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.8%
1.5 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
24.6%
22.2 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.3% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
5.6%
4.1 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 17.4% · Q3 4.2% · Q4 12.5% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
23.5%
9.8 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 8.3% · Q3 12.5% · Q4 20.0% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
14.8%
4.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.1% · Q4 14.3% · 4Q avg 10.1% · 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 | 8.8% |
11.7%
2.9 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 21.7% · Q3 4.3% · Q4 8.3% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
24.2%
2.1 pts better
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 24.6% · Q3 23.0% · Q4 11.4% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.1%
0.4 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.3% · Q3 3.1% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.0% |
81.6%
1.4 pts better
|
81.7%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.7% · Q2 89.3% · Q3 84.4% · Q4 77.4% · 4Q avg 83.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
10.5%
5 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 14.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.9% |
79.0%
4.1 pts worse
|
79.7%
4.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.4%
0.2 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 21.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-26
F · Potential for more than minimal harm
2022-10-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-09
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.
Not marked corrected
D · Potential for more than minimal harm
2025-02-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
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 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
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 2025-02-27
D · Potential for more than minimal harm
2025-02-05
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 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-05
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-02-27
G · Actual harm
2023-12-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-20
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 2024-01-15
D · Potential for more than minimal harm
2023-12-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-20
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 2023-11-24
D · Potential for more than minimal harm
2023-12-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-20
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 2024-01-15
D · Potential for more than minimal harm
2023-12-20
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-15
G · Actual harm
2022-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-10-06
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 2022-10-30
D · Potential for more than minimal harm
2022-10-06
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 2022-10-30
D · Potential for more than minimal harm
2022-10-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-10-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-10-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-10-06
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 2022-10-30
D · Potential for more than minimal harm
2022-10-06
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 2022-10-30
Penalties and ownership
What sits behind the stars
$8,018
2023-12-20
Fine
Fine · fine $8,018
Fine
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Czalbowski, Brandon
Operational/Managerial Control · Individual
Long, Steven
Operational/Managerial Control · Individual
Orix Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Thomas, John
Operational/Managerial Control · Individual
Trilogy Healthcare Of Lafayette LLC
Operational/Managerial Control · Organization
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#2
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3-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rosewalk Village At Lafayette
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3-star overall rating with 3-star inspections with 5 recent health deficiencies
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