Lafayette, IN

St Mary Healthcare Center

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

2201 Cason St, Lafayette, IN

(765) 447-4102

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

1969-05-26

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

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

0.74

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.30

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.21

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.25

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.04

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.68

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.60

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.73

CMS adjusted RN staffing hours

Adjusted total hours

3.20

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,115

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

Performance score

41.22

Composite VBP score used to determine payment impact.

Payment multiplier

0.9941

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.76

Baseline 20.17% · Performance 19.69% · Measure score 3.76 · Achievement 3.76 · Improvement 1.02

Healthcare-associated infections

2.83

Baseline 7.35% · Performance 6.99% · Measure score 2.83 · Achievement 2.83 · Improvement 1.03

Total nurse turnover

7.88

Baseline 40.00% · Performance 31.48% · Measure score 7.88 · Achievement 7.88 · Improvement 5.12

Adjusted total nurse staffing

2.03

Baseline 2.43 hours · Performance 3.28 hours · Measure score 2.03 · Achievement 0.70 · Improvement 2.03

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.22%	10.72% 2.5 pts worse	No Different than the National Rate · Eligible stays 61 · Observed rate 21.31% · Lower 95% interval 8.63%
Discharge to community	48.62%	50.57% 2 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 44.23% · Lower 95% interval 36.55%
Medicare spending per beneficiary	1.23	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 34 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	62.96%	53.69% 9.3 pts better	Numerator 17 · Denominator 27
Discharge mobility score	62.96%	50.94% 12 pts better	Numerator 17 · Denominator 27
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 34 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.99%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.64%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 84
Staff flu vaccination coverage	1.79%	42% 40.2 pts worse	Numerator 2 · Denominator 112
Discharge function score	66.67%	56.45% 10.2 pts better	Numerator 18 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.6 0.7 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.5 0.5 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	93.6% 6 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.8%	95.4% 1.4 pts better	95.5% 1.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	3.8% 0.7 pts better	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 3.5% · Q4 5.4% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.1%	24.6% 18.5 pts better	11.4% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.4% · Q3 6.0% · Q4 7.5% · 4Q avg 6.1%
Percentage of long-stay residents who lose too much weight	2.4%	5.6% 3.2 pts better	5.4% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.3% · Q3 0.0% · Q4 2.3% · 4Q avg 2.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.1%	23.5% 2.4 pts better	19.6% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 20.9% · Q3 15.6% · Q4 22.7% · 4Q avg 21.1%
Percentage of long-stay residents who received an antipsychotic medication	20.5%	14.8% 5.7 pts worse	16.7% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 25.0% · Q3 17.5% · Q4 14.7% · 4Q avg 20.5% · 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	7.6%	13.3% 5.7 pts better	16.3% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.9% · Q3 6.8% · Q4 12.8% · 4Q avg 7.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.3%	11.7% 4.4 pts better	14.9% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 11.6% · Q4 11.6% · 4Q avg 7.3% · 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	0.0%	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	14.4%	24.2% 9.8 pts better	19.8% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 17.4% · Q3 13.7% · Q4 15.2% · 4Q avg 14.4%
Percentage of long-stay residents with pressure ulcers	1.3%	4.1% 2.8 pts better	5.1% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	81.6% 15.4 pts better	81.7% 15.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.8% · Q3 96.2% · Q4 98.2% · 4Q avg 97.0%
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	10.5% 0.3 pts worse	12.0% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.9% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.1%	1.3% 1.8 pts worse	1.6% 1.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q4 4.2% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.8%	79.0% 14.8 pts better	79.7% 14.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.9%	22.4% 0.5 pts worse	23.9% 1 pts better	Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 25.8% · Expected 26.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-19 · Fire 2025-05-19

8 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-04-29 · Fire 2024-04-29

9 health deficiencies

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

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-02-13 · Fire 2023-02-13

9 health deficiencies

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

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-19

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-06-16

E · Potential for more than minimal harm 2025-05-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-16

E · Potential for more than minimal harm 2025-05-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-06-16

E · Potential for more than minimal harm 2024-04-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-22

E · Potential for more than minimal harm 2023-02-13

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 2023-03-31

E · Potential for more than minimal harm 2023-02-13

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-04-03

C · Minimal harm 2023-02-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-04-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-22

F628 · Resident Rights Deficiencies

Health

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

Corrected 2025-09-19

E · Potential for more than minimal harm 2025-05-19

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-19

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-04-28

D · Potential for more than minimal harm 2025-05-19

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-02-13

D · Potential for more than minimal harm 2025-05-19

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-19

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-10

D · Potential for more than minimal harm 2025-05-19

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-06

D · Potential for more than minimal harm 2024-11-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-11-14

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 2024-06-10

E · Potential for more than minimal harm 2024-04-29

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-04-29

F657 · Resident Assessment and Care Planning Deficiencies

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 2024-05-31

D · Potential for more than minimal harm 2024-04-29

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 2024-05-31

D · Potential for more than minimal harm 2024-04-29

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-04-29

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-04-29

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 2024-05-31

D · Potential for more than minimal harm 2024-04-29

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-05-31

D · Potential for more than minimal harm 2023-10-05

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-09-21

E · Potential for more than minimal harm 2023-02-13