8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rochester, IN
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
827 W 13th St, Rochester, IN
(574) 223-4331
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
108
Certified beds
Average residents
47
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1991-06-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 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
RN hours / resident day
0.62
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
4,858
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
4.14
Baseline 6.21% · Performance 6.60% · Measure score 4.14 · Achievement 4.14 · Improvement 0
Total nurse turnover
5.20
Baseline 68.49% · Performance 43.64% · Measure score 5.20 · Achievement 4.90 · Improvement 5.20
Adjusted total nurse staffing
2.16
Baseline 3.80 hours · Performance 3.69 hours · Measure score 2.16 · Achievement 2.16 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 14.29% · Lower 95% interval 7.81% |
| Discharge to community | 42.3% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 33.33% · Lower 95% interval 28.83% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 80.95% |
53.69%
27.3 pts better
|
Numerator 17 · Denominator 21 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 12 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 2.72% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 5.88% |
42%
36.1 pts worse
|
Numerator 5 · Denominator 85 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 14 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
93.6%
6.2 pts worse
|
93.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 82.2% · Q3 85.7% · Q4 82.5% · 4Q avg 87.4% |
| 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 | 2.3% |
3.8%
1.5 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 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 who lose too much weight | 13.1% |
5.6%
7.5 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.9% · Q3 12.8% · Q4 10.5% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
23.5%
3 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 29.5% · Q3 22.5% · Q4 23.1% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
14.8%
1.7 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 16.7% · Q3 14.3% · Q4 14.3% · 4Q avg 13.1% · 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 ability to walk independently worsened | 1.6% |
13.3%
11.7 pts better
|
16.3%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.2% |
11.7%
10.5 pts better
|
14.9%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.7% · Q4 0.0% · 4Q avg 1.2% · 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 | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
24.2%
0.7 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 35.9% · Q3 24.0% · Q4 25.9% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.1%
0.2 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.6% · Q3 7.8% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.3% |
81.6%
29.3 pts worse
|
81.7%
29.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.1% · Q2 48.8% · Q3 40.0% · Q4 43.3% · 4Q avg 52.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.2% |
10.5%
18.7 pts worse
|
12.0%
17.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 31.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.3%
2.1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 5.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.5% |
79.0%
39.5 pts worse
|
79.7%
40.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 39.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
22.4%
3 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 24.1% · Expected 29.7% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-29
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-12-29
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-02-19
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-19
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-29
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-12-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-29
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-12-29
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-11-18
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-11-18
Fire Safety
Develop a communication plan.
Corrected 2024-11-18
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-11-18
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-18
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-18
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-18
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-11
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-11-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-18
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-18
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-18
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-18
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-18
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-18
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-18
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-18
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-18
Fire Safety
Have an externally vented heating system.
Corrected 2023-08-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-18
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-18
Inspection history
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-10-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-20
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-20
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-10-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-20
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-20
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-18
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-18
Health
Notify 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.
Corrected 2024-10-18
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-10-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-18
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 2024-10-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-13
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-13
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-14
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-14
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 2023-07-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-14
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-14
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 2023-07-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Rochester, IN
2-star overall rating with 2-star inspections with $14,901 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Culver, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Plymouth, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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