Cycle 1
Health 2025-04-17 · Fire 2025-04-17
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Columbus, IN
Silver Oaks Health Campus
4-star overall rating with 3-star inspections with $8,824 in total fines with 6 recent health deficiencies
2011 Chapa Street, Columbus, IN
(812) 373-0787
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
80
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2001-08-29
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
1.09
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.24
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.47
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,107
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.08% · Performance 24.28% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.74
Baseline 8.48% · Performance 8.05% · Measure score 0.74 · Achievement 0 · Improvement 0.74
Total nurse turnover
8.76
Baseline 31.82% · Performance 27.87% · Measure score 8.76 · Achievement 8.76 · Improvement 5.17
Adjusted total nurse staffing
1.61
Baseline 3.25 hours · Performance 3.54 hours · Measure score 1.61 · Achievement 1.61 · Improvement 0.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.03% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 340 · Observed rate 14.41% · Lower 95% interval 10.11% |
| Discharge to community | 66.59% |
50.57%
16 pts better
|
Better than the National Rate · Eligible stays 313 · Observed rate 60.38% · Lower 95% interval 60.69% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 230 · Denominator 230 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 230 |
| Discharge self-care score | 78.71% |
53.69%
25 pts better
|
Numerator 122 · Denominator 155 |
| Discharge mobility score | 50.32% |
50.94%
0.6 pts worse
|
Numerator 78 · Denominator 155 |
| Pressure ulcers or injuries, new or worsened | 0.87% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 230 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 223 · Observed rate 8.07% · Lower 95% interval 5.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 57.93% |
42%
15.9 pts better
|
Numerator 84 · Denominator 145 |
| Discharge function score | 78.06% |
56.45%
21.6 pts better
|
Numerator 121 · Denominator 155 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 113 · Denominator 113 |
| Transfer of health information to patient | 95.88% |
96.28%
0.4 pts worse
|
Numerator 93 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 25.98% |
25.2%
0.8 pts better
|
Numerator 33 · Denominator 127 |
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 0.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.7 · 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 | 97.0% |
95.4%
1.6 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.2% |
3.8%
6.4 pts worse
|
3.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.6% · Q3 5.9% · Q4 6.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
24.6%
15.7 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 12.9% · Q3 9.1% · Q4 6.7% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.6%
0.7 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 4.0% · Q4 12.5% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
23.5%
6.7 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 17.4% · Q3 16.0% · Q4 20.8% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
14.8%
7.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 9.1% · Q4 4.3% · 4Q avg 7.1% · 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 | 20.8% |
13.3%
7.5 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
11.7%
7.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 0.0% · Q4 0.0% · 4Q avg 4.3% · 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 | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · 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 | 26.9% |
24.2%
2.7 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 36.6% · Q3 23.4% · Q4 17.9% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.1%
1.4 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.8% · Q3 2.1% · Q4 2.3% · 4Q avg 5.5% · Used in QM five-star |
| 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 · Q1 98.7% · Q2 98.9% · Q3 98.2% · Q4 97.8% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
10.5%
1.3 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.1% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 2.0% · Q4 2.6% · 4Q avg 1.8% · 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 | 28.0% |
22.4%
5.6 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 30.3% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-03
F · Potential for more than minimal harm
2023-04-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-04-14
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 2023-06-16
E · Potential for more than minimal harm
2023-04-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-17
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 2025-05-09
D · Potential for more than minimal harm
2025-04-17
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 2025-05-09
D · Potential for more than minimal harm
2025-04-17
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 2025-05-09
D · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
G · Actual harm
2024-09-09
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.
Corrected 2024-08-14
G · Actual harm
2024-05-08
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-05-08
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 2024-05-30
D · Potential for more than minimal harm
2024-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-08
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 2024-05-30
D · Potential for more than minimal harm
2024-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-27
E · Potential for more than minimal harm
2023-04-14
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 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-14
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 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-14
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 2023-05-01
D · Potential for more than minimal harm
2023-04-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-05-01
Penalties and ownership
What sits behind the stars
$8,824
2024-09-09
Fine
Fine · fine $8,824
Fine
Ownership
Henry County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Cole, Pamela
Operational/Managerial Control · Individual
Mustaklem, Marwan
Operational/Managerial Control · Individual
Ring, Brian
Operational/Managerial Control · Individual
Trilogy Healthcare Of Columbus, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Willow Crossing Health & Rehabilitation Center
Columbus, IN
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Four Seasons Retirement Center
Columbus, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hickory Creek At Columbus
Columbus, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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