Madison, IN

River Terrace Health Campus

2-star overall rating with 2-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

120 Presbyterian Ave, Madison, IN

(812) 265-0080

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

57

Certified beds

Average residents

38

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2016-05-10

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

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.34

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.43

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.20

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

3.82

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

1.06

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.18

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.23

CMS adjusted RN staffing hours

Adjusted total hours

3.84

CMS adjusted total nurse staffing hours

Case-mix index

1.50

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,022

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

24.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9836

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.38% · Performance 22.56% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

7.20

Baseline 7.15% · Performance 5.68% · Measure score 7.20 · Achievement 7.20 · Improvement 6.31

Total nurse turnover

1.78

Baseline 50.00% · Performance 56.41% · Measure score 1.78 · Achievement 1.78 · Improvement 0

Adjusted total nurse staffing

1.02

Baseline 2.86 hours · Performance 3.30 hours · Measure score 1.02 · Achievement 0.78 · Improvement 1.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.77%	10.72% 2 pts worse	No Different than the National Rate · Eligible stays 220 · Observed rate 15% · Lower 95% interval 9.74%
Discharge to community	68.92%	50.57% 18.4 pts better	Better than the National Rate · Eligible stays 206 · Observed rate 63.59% · Lower 95% interval 59.58%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 134 · Denominator 134
Falls with major injury	0.75%	0.77% About the same	Numerator 1 · Denominator 134
Discharge self-care score	63.83%	53.69% 10.1 pts better	Numerator 60 · Denominator 94
Discharge mobility score	67.02%	50.94% 16.1 pts better	Numerator 63 · Denominator 94
Pressure ulcers or injuries, new or worsened	0.75%	2.29% 1.5 pts better	Numerator 1 · Denominator 134 · Adjusted rate 0.84%
Healthcare-associated infections requiring hospitalization	5.68%	7.12% 1.4 pts better	No Different than the National Rate · Eligible stays 116 · Observed rate 3.45% · Lower 95% interval 3.09%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 78
Staff flu vaccination coverage	0.94%	42% 41.1 pts worse	Numerator 1 · Denominator 106
Discharge function score	70.21%	56.45% 13.8 pts better	Numerator 66 · Denominator 94
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 41 · Denominator 41
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 81 · Denominator 81
Resident COVID-19 vaccinations up to date	93.24%	25.2% 68 pts better	Numerator 69 · Denominator 74

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.9	1.6 1.3 pts worse	1.9 1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.8 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.9	1.5 1.4 pts worse	1.8 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · 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	1.1%	3.8% 2.7 pts better	3.3% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	13.9%	24.6% 10.7 pts better	11.4% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q4 14.3% · 4Q avg 13.9%
Percentage of long-stay residents who lose too much weight	4.9%	5.6% 0.7 pts better	5.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.2%	23.5% 7.7 pts worse	19.6% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 31.2%
Percentage of long-stay residents who received an antipsychotic medication	11.6%	14.8% 3.2 pts better	16.7% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · 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	11.6%	13.3% 1.7 pts better	16.3% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.8%	11.7% 12.1 pts worse	14.9% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	0.4% 1 pts worse	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.2% About the same	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.6%	24.2% 5.4 pts worse	19.8% 9.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 27.9% · Q4 37.1% · 4Q avg 29.6%
Percentage of long-stay residents with pressure ulcers	5.6%	4.1% 1.5 pts worse	5.1% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 5.7% · Q4 9.9% · 4Q avg 5.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.8%	81.6% 16.2 pts better	81.7% 16.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 99.2% · Q3 96.6% · Q4 97.1% · 4Q avg 97.8%
Percentage of short-stay residents who had an outpatient emergency department visit	20.7%	10.5% 10.2 pts worse	12.0% 8.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.3% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.3% 1 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.7%	79.0% 17.7 pts better	79.7% 17 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.3%	22.4% 7.9 pts worse	23.9% 6.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 30.5% · Expected 24.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-22 · Fire 2025-01-22

6 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2023-12-04 · Fire 2023-12-04

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-12-05 · Fire 2022-12-05

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

C · Minimal harm 2025-01-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-02-19

F · Potential for more than minimal harm 2023-12-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-01-18

F · Potential for more than minimal harm 2023-12-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-18

B · Minimal harm 2023-12-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-18

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-03-28

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 2025-04-14

E · Potential for more than minimal harm 2025-03-28

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 2025-04-14

D · Potential for more than minimal harm 2025-03-28

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-01-22

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 2025-02-09

D · Potential for more than minimal harm 2025-01-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-09

D · Potential for more than minimal harm 2025-01-22

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-09

D · Potential for more than minimal harm 2024-12-10

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 2024-11-18

E · Potential for more than minimal harm 2023-12-04

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-12-04

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-12-04

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 2023-12-22