Cycle 1
Health 2024-12-18 · Fire 2024-12-18
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Goshen, IN
Waterford Crossing
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1332 Waterford Cir, Goshen, IN
(574) 534-3920
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2006-08-31
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
1.06
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,649
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0100
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.83
Baseline 18.06% · Performance 18.73% · Measure score 5.83 · Achievement 5.83 · Improvement 0
Healthcare-associated infections
6.52
Baseline 6.77% · Performance 5.88% · Measure score 6.52 · Achievement 6.52 · Improvement 4.49
Total nurse turnover
8.82
Baseline 40.68% · Performance 27.63% · Measure score 8.82 · Achievement 8.82 · Improvement 7.74
Adjusted total nurse staffing
0.83
Baseline 2.94 hours · Performance 3.32 hours · Measure score 0.83 · Achievement 0.83 · Improvement 0.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 8.47% · Lower 95% interval 7.67% |
| Discharge to community | 60.85% |
50.57%
10.3 pts better
|
Better than the National Rate · Eligible stays 226 · Observed rate 60.18% · Lower 95% interval 53.57% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 175 · Denominator 175 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 175 |
| Discharge self-care score | 67.61% |
53.69%
13.9 pts better
|
Numerator 96 · Denominator 142 |
| Discharge mobility score | 57.04% |
50.94%
6.1 pts better
|
Numerator 81 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 0.57% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 175 · Adjusted rate 0.64% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 3.33% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 115 |
| Staff flu vaccination coverage | 41.04% |
42%
1 pts worse
|
Numerator 55 · Denominator 134 |
| Discharge function score | 63.38% |
56.45%
6.9 pts better
|
Numerator 90 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 83 · Denominator 83 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 63 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 33% |
25.2%
7.8 pts better
|
Numerator 33 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
93.6%
5.9 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.1% · 4Q avg 99.5% |
| 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 | 1.8% |
3.8%
2 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 1.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.6% |
24.6%
11 pts better
|
11.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 22.0% · Q3 16.7% · Q4 8.3% · 4Q avg 13.6% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.6%
3.4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 2.2% · Q4 2.1% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
23.5%
2.3 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.2% · Q3 21.7% · Q4 18.8% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.8%
2.8 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.4% · Q3 11.9% · Q4 15.8% · 4Q avg 12.0% · 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 · 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 | 4.2% |
13.3%
9.1 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 10.3% · Q3 0.0% · Q4 2.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
11.7%
8.8 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.8% · Q3 0.0% · Q4 4.4% · 4Q avg 2.9% · 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 | 24.6% |
24.2%
0.4 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 31.0% · Q3 23.3% · Q4 25.0% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.1%
2.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.7% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
81.6%
18.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
10.5%
0.1 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
79.0%
16.4 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
22.4%
3.1 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 16.6% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-29 · Fire 2024-01-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-04
E · Potential for more than minimal harm
2024-12-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-01-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-22
F · Potential for more than minimal harm
2022-12-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-11
D · Potential for more than minimal harm
2022-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-12-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-18
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 2025-01-02
D · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-07
E · Potential for more than minimal harm
2022-12-15
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 2023-01-10
D · Potential for more than minimal harm
2022-12-15
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 2023-01-10
D · Potential for more than minimal harm
2022-12-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-15
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 2023-01-10
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Barney, Leigh
Limited Partnership Interest · Individual
Davis, David
Limited Partnership Interest · Individual
Long, Steven
Operational/Managerial Control · Individual
Offerle, Andrew
Operational/Managerial Control · Individual
Plantinga, Judy
Operational/Managerial Control · Individual
Trilogy Healthcare Of Goshen, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Greencroft Healthcare
Goshen, IN
2-star overall rating with 1-star inspections with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of Goshen
Goshen, IN
1-star overall rating with 1-star inspections with $16,036 in total fines with 15 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#3
Restoracy Of Goshen, The
Goshen, IN
3-star overall rating with 2-star inspections with $3,300 in total fines with 6 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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