Cycle 1
Health 2024-11-25 · Fire 2024-11-25
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
West Lafayette, IN
University Place Health Center And Assisted Living
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1750 Lindberg Rd, West Lafayette, IN
(765) 464-5600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
26
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Franciscan Communities
Operator or chain grouping
Approved since
2004-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
1.74
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
5.09
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
7.58
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.49
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
6.99
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.23
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
1.74
CMS adjusted RN staffing hours
Adjusted total hours
7.60
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,611
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0026
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.26
Baseline 16.48% · Performance 18.07% · Measure score 7.26 · Achievement 7.26 · Improvement 0
Healthcare-associated infections
4.84
Baseline 5.79% · Performance 6.39% · Measure score 4.84 · Achievement 4.84 · Improvement 0
Total nurse turnover
3.58
Baseline 84.21% · Performance 60.00% · Measure score 3.58 · Achievement 0.9 · Improvement 3.58
Adjusted total nurse staffing
3.81
Baseline 3.50 hours · Performance 4.16 hours · Measure score 3.81 · Achievement 3.81 · Improvement 2.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 9.58% · Lower 95% interval 7.68% |
| Discharge to community | 53.48% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 47.27% · Lower 95% interval 46.44% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 73.74% |
95.27%
21.5 pts worse
|
Numerator 73 · Denominator 99 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 99 |
| Discharge self-care score | 59.38% |
53.69%
5.7 pts better
|
Numerator 38 · Denominator 64 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 36 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 99 · Adjusted rate 3.22% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 4.65% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0.85% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 118 |
| Staff flu vaccination coverage | 25.49% |
42%
16.5 pts worse
|
Numerator 26 · Denominator 102 |
| Discharge function score | 73.44% |
56.45%
17 pts better
|
Numerator 47 · Denominator 64 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 44 · Denominator 45 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 28.89% |
25.2%
3.7 pts better
|
Numerator 13 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
93.6%
1.3 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.8%
3 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.2% |
23.5%
19.7 pts worse
|
19.6%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 43.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.8%
14.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
11.7%
2 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.1% |
24.2%
12.9 pts worse
|
19.8%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.1% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
4.1%
6.1 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
81.6%
14.5 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 96.8% · Q3 100.0% · Q4 100.0% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
10.5%
11.8 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 20.5% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
79.0%
14.9 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
22.4%
4.3 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 16.4% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-25 · Fire 2022-10-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-11-25
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-04
B · Minimal harm
2022-10-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-25
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 2025-02-10
D · Potential for more than minimal harm
2024-11-25
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 2025-02-10
D · Potential for more than minimal harm
2024-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-11-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-11-25
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-11-25
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 2025-02-10
D · Potential for more than minimal harm
2024-11-25
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 2025-02-10
E · Potential for more than minimal harm
2023-12-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
D · Potential for more than minimal harm
2023-12-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
C · Minimal harm
2023-12-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-30
D · Potential for more than minimal harm
2022-10-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-11-20
D · Potential for more than minimal harm
2022-10-25
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 2022-11-20
D · Potential for more than minimal harm
2022-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-20
D · Potential for more than minimal harm
2022-10-25
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 2022-11-20
D · Potential for more than minimal harm
2022-10-25
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 2022-11-20
Penalties and ownership
What sits behind the stars
Ownership
Franciscan Sisters Of Chicago Services Corporation
5% Or Greater Indirect Ownership Interest · Organization
University Place Inc
5% Or Greater Direct Ownership Interest · Organization
Dodt, Keven
Operational/Managerial Control · Individual
Franciscan Sisters Of Chicago Services Corporation
Operational/Managerial Control · Organization
High, Amanda
Operational/Managerial Control · Individual
Kinder, David
Operational/Managerial Control · Individual
Rosenberger, Robert
Corporate Officer · Individual
Shearer, Tracy
Corporate Officer · Individual
Stark, James
Corporate Director · Individual
Stark, James
Corporate Officer · Individual
Umanskiy, Regina
Corporate Director · Individual
Umanskiy, Regina
Corporate Officer · Individual
University Place Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Cumberland Pointe Health Campus
West Lafayette, IN
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Westminster Village - West Lafayette
West Lafayette, IN
5-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Heritage Healthcare
West Lafayette, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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