Cycle 1
Health 2024-10-16 · Fire 2024-10-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Warsaw, IN
Paddock Springs
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2695 Sheldon Street, Warsaw, IN
(574) 658-9455
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
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
1993-07-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
2.87
Nurse aide staffing
Weekend hours
3.75
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.8%
0.2 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
24.6%
22.5 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.6%
1.5 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
23.5%
12.5 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
14.8%
7.3 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
13.3%
7.1 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
11.7%
5.8 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
24.2%
0.6 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.1%
3.4 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
81.6%
16.8 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
10.5%
5 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
79.0%
18.3 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
22.4%
8.2 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-07-25 · Fire 2022-07-25
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-10-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-29
C · Minimal harm
2024-10-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-29
C · Minimal harm
2024-10-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-29
F · Potential for more than minimal harm
2023-09-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-09-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-09-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-09-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-09-22
K321 · Smoke Deficiencies
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 2023-11-29
E · Potential for more than minimal harm
2023-09-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-09-22
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-11-29
C · Minimal harm
2023-09-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-29
F · Potential for more than minimal harm
2022-07-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-07-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-07-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-07-25
K379 · Smoke Deficiencies
Fire Safety
Have proper openings in smoke barrier doors.
Corrected 2023-01-01
F · Potential for more than minimal harm
2022-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-01
E · Potential for more than minimal harm
2022-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-07-25
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-10-05
C · Minimal harm
2022-07-25
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-10-05
C · Minimal harm
2022-07-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-10-05
C · Minimal harm
2022-07-25
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-10-05
C · Minimal harm
2022-07-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-10-05
C · Minimal harm
2022-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-14
G · Actual harm
2024-10-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-16
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 2024-11-07
D · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
D · Potential for more than minimal harm
2022-07-25
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-08-05
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Long, Steven
Operational/Managerial Control · Individual
Mathew, Pekkakuzhiyil
Operational/Managerial Control · Individual
Nunez, Humberto
Operational/Managerial Control · Individual
Trilogy Healthcare Of Milford, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Warsaw Meadows
Warsaw, IN
1-star overall rating with 1-star inspections with abuse icon flag with $105,073 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Miller's Merry Manor
Warsaw, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Mason Health Care Center
Warsaw, IN
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out