Cycle 1
Health 2025-09-10 · Fire 2025-09-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hanover, IN
Thornton Terrace Health Campus
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
188 Thornton Rd, Hanover, IN
(812) 866-8396
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
55
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2004-08-06
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
1.05
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
25%
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
3,351
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.07
Baseline 23.25% · Performance 17.92% · Measure score 8.07 · Achievement 7.58 · Improvement 8.07
Healthcare-associated infections
1.82
Baseline 5.49% · Performance 7.29% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Total nurse turnover
6.28
Baseline 26.83% · Performance 38.00% · Measure score 6.28 · Achievement 6.28 · Improvement 0
Adjusted total nurse staffing
1.74
Baseline 3.13 hours · Performance 3.57 hours · Measure score 1.74 · Achievement 1.74 · Improvement 1.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 7.69% · Lower 95% interval 7.14% |
| Discharge to community | 60% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 124 · Observed rate 58.87% · Lower 95% interval 52.76% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 35 · Denominator 55 |
| Discharge mobility score | 67.27% |
50.94%
16.3 pts better
|
Numerator 37 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 2.34% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 6.94% · Lower 95% interval 4.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 89 |
| Staff flu vaccination coverage | 27.78% |
42%
14.2 pts worse
|
Numerator 35 · Denominator 126 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 40 · Denominator 55 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 75% |
25.2%
49.8 pts better
|
Numerator 30 · Denominator 40 |
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 0.5 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
93.6%
1.8 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 97.3% · Q3 100.0% · Q4 100.0% · 4Q avg 95.4% |
| 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 | 6.5% |
3.8%
2.7 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.1% · Q3 7.5% · Q4 2.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.9% |
24.6%
5.7 pts better
|
11.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.6% · Q3 27.0% · Q4 10.3% · 4Q avg 18.9% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.6%
5.6 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 18.4% |
23.5%
5.1 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 19.2% · Q3 16.7% · Q4 17.2% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
14.8%
11.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 3.7% · Q4 0.0% · 4Q avg 2.9% · 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 | 7.7% |
13.3%
5.6 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
11.7%
3.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 8.0% · Q3 6.9% · Q4 7.1% · 4Q avg 8.2% · 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 | 14.0% |
24.2%
10.2 pts better
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 16.3% · Q3 7.3% · Q4 11.9% · 4Q avg 14.0% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
4.1%
3.7 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
81.6%
13.4 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 91.2% · Q3 98.4% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
10.5%
5.1 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 14.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
79.0%
16.1 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.4%
1.3 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 23.0% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-07-03 · Fire 2023-07-03
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-09-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-26
E · Potential for more than minimal harm
2024-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-04
F · Potential for more than minimal harm
2023-07-03
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-07-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-07-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-10
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 2025-10-04
D · Potential for more than minimal harm
2025-09-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-04
D · Potential for more than minimal harm
2024-08-21
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 2024-08-31
D · Potential for more than minimal harm
2024-08-21
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 2024-08-31
D · Potential for more than minimal harm
2024-01-11
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 2024-01-31
D · Potential for more than minimal harm
2024-01-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-07-03
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 2023-07-21
D · Potential for more than minimal harm
2023-07-03
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 2023-07-21
D · Potential for more than minimal harm
2023-07-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-05-15
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 2023-05-04
Penalties and ownership
What sits behind the stars
Ownership
Harrison County Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams, Theresa
Operational/Managerial Control · Individual
Clunie, Lisa
Operational/Managerial Control · Individual
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Murphy, Scott
Operational/Managerial Control · Individual
Trilogy Healthcare Of Hanover LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Aperion Care Hanover
Hanover, IN
1-star overall rating with 1-star inspections with $53,874 in total fines with 13 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
#2
Waters Of Clifty Falls, The
Madison, IN
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
River Terrace Health Campus
Madison, IN
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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