Lafayette, IN

Springs At Lafayette, The

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2402 South Street, Lafayette, IN

(765) 446-9229

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

70

Certified beds

Average residents

42

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2015-03-24

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

1.24

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.06

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.01

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

3.30

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.88

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.02

CMS adjusted RN staffing hours

Adjusted total hours

3.33

CMS adjusted total nurse staffing hours

Case-mix index

1.65

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,925

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

Performance score

31.30

Composite VBP score used to determine payment impact.

Payment multiplier

0.9864

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.47

Baseline 20.72% · Performance 19.36% · Measure score 4.47 · Achievement 4.47 · Improvement 3.18

Healthcare-associated infections

0.57

Baseline 8.40% · Performance 8.04% · Measure score 0.57 · Achievement 0 · Improvement 0.57

Total nurse turnover

5.79

Baseline 50.91% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 3.69

Adjusted total nurse staffing

1.69

Baseline 2.49 hours · Performance 3.21 hours · Measure score 1.69 · Achievement 0 · Improvement 1.69

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.71%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 221 · Observed rate 12.67% · Lower 95% interval 9.27%
Discharge to community	62.99%	50.57% 12.4 pts better	Better than the National Rate · Eligible stays 198 · Observed rate 59.09% · Lower 95% interval 54.92%
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 109 · Denominator 109
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 109
Discharge self-care score	71.6%	53.69% 17.9 pts better	Numerator 58 · Denominator 81
Discharge mobility score	87.65%	50.94% 36.7 pts better	Numerator 71 · Denominator 81
Pressure ulcers or injuries, new or worsened	1.83%	2.29% 0.5 pts better	Numerator 2 · Denominator 109 · Adjusted rate 1.2%
Healthcare-associated infections requiring hospitalization	8.04%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 112 · Observed rate 8.93% · Lower 95% interval 5.1%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 88
Staff flu vaccination coverage	46.85%	42% 4.9 pts better	Numerator 52 · Denominator 111
Discharge function score	86.42%	56.45% 30 pts better	Numerator 70 · Denominator 81
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 82 · Denominator 82
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	31.15%	25.2% 5.9 pts better	Numerator 19 · Denominator 61

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.6 About the same	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.5 · Expected 2.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.5 0.2 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	93.6% 5.4 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.5% · Q4 100.0% · 4Q avg 99.0%
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	0.0%	3.8% 3.8 pts better	3.3% 3.3 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 who have depressive symptoms	15.2%	24.6% 9.4 pts better	11.4% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 13.6% · Q4 13.6% · 4Q avg 15.2%
Percentage of long-stay residents who lose too much weight	2.3%	5.6% 3.3 pts better	5.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · 4Q avg 2.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	36.4%	23.5% 12.9 pts worse	19.6% 16.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 36.0% · 4Q avg 36.4%
Percentage of long-stay residents who received an antipsychotic medication	13.2%	14.8% 1.6 pts better	16.7% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · 4Q avg 13.2% · 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	3.8%	13.3% 9.5 pts better	16.3% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.6%	11.7% 8.1 pts better	14.9% 11.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.4% 0.4 pts worse	1.0% 0.2 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 a urinary tract infection	0.0%	1.2% 1.2 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	28.1%	24.2% 3.9 pts worse	19.8% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 25.5% · Q4 22.8% · 4Q avg 28.1%
Percentage of long-stay residents with pressure ulcers	0.6%	4.1% 3.5 pts better	5.1% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	81.6% 16.1 pts better	81.7% 16 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 95.9% · Q3 99.1% · Q4 99.3% · 4Q avg 97.7%
Percentage of short-stay residents who had an outpatient emergency department visit	11.8%	10.5% 1.3 pts worse	12.0% 0.2 pts better	Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.5% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.3%	1.3% About the same	1.6% 0.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.7% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.2%	79.0% 15.2 pts better	79.7% 14.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.0%	22.4% 2.4 pts better	23.9% 3.9 pts better	Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.8% · Expected 24.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-24 · Fire 2025-09-24

4 health deficiencies

Top issue: Resident Rights (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-09-10 · Fire 2024-09-10

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-07-19 · Fire 2023-07-19

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-24

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-12-21

E · Potential for more than minimal harm 2025-09-24

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 2025-12-11

E · Potential for more than minimal harm 2025-09-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-12-15

E · Potential for more than minimal harm 2025-09-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-15

E · Potential for more than minimal harm 2025-09-24

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-12-15

F · Potential for more than minimal harm 2024-09-10

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-13

E · Potential for more than minimal harm 2024-09-10

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 2024-11-13

E · Potential for more than minimal harm 2024-09-10

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-13

E · Potential for more than minimal harm 2024-09-10

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-11-13

E · Potential for more than minimal harm 2023-07-19

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-08-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-24

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 2025-11-26

D · Potential for more than minimal harm 2025-09-24

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-09-24

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 2025-11-26

D · Potential for more than minimal harm 2025-09-24

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-11-26

D · Potential for more than minimal harm 2024-09-10

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 2024-02-21

D · Potential for more than minimal harm 2024-09-10

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 2024-08-24

D · Potential for more than minimal harm 2024-09-10

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 2024-10-01

G · Actual harm 2024-06-18

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-05

E · Potential for more than minimal harm 2023-07-19

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-19

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-19

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-19

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-19

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 2023-09-08

D · Potential for more than minimal harm 2023-07-19

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 2023-09-08

Penalties and ownership

What sits behind the stars

Ownership

Witham Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 29 facilities 2015-07-01

Bardoczi, Stephen

Corporate Officer · Individual

0% 18 facilities 2013-09-03

Bayston, Brett