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Nursing Home Inspect > Indiana > Tippecanoe County Data as of March 2024

    St Mary Healthcare Center

    For profit - Limited Liability company  ·  2201 Cason St, Lafayette, IN 47904  ·  See home’s Medicare page

    Affiliated With Trilogy Health Services
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    3.00
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 3.6
    51.9%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 54.9%
    79
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    61
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Witham Memorial Hospital (100%)
    Indirect owners
    No indirect owner information
    Managerial control
    Trilogy Healthcare Of Lake, Llc since Nov, 2014
    Justin Rife since Nov, 2014
    Managing employee(s)
    Stephen Bardoczi since Sep, 2013

    Inspection Reports

    39

    total deficiencies

    2

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Oct 5, 2023
    Complaint report
    1 deficiency
    D
    Full report
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0602
    Failure to: Protect each resident from the wrongful use of the resident's belongings or money.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Feb 13, 2023
    Standard report
    8 deficiencies
    D

     to E
    E
    Full report
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0697
    Failure to: Provide safe, appropriate pain management for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0744
    Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0804
    Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Environmental Deficiency — F0921
    Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Jun 7, 2022
    Complaint report
    2 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to J
    J
    Full report
    Infection Control Deficiency — F0888
    Failure to: Ensure staff are vaccinated for COVID-19
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Jan 24, 2022
    Complaint report
    6 deficiencies
    D

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Environmental Deficiency — F0921
    Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Jan 23, 2020
    Standard report
    5 deficiencies
    D
    Full report
    Resident Rights Deficiency — F0582
    Failure to: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0744
    Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Oct 23, 2018
    Standard report
    17 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    C

     to E
    E
    Full report
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0644
    Failure to: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0676
    Failure to: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0697
    Failure to: Provide safe, appropriate pain management for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0710
    Failure to: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0740
    Failure to: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0745
    Failure to: Provide medically-related social services to help each resident achieve the highest possible quality of life.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0791
    Failure to: Provide or obtain dental services for each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0881
    Failure to: Implement a program that monitors antibiotic use.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0732
    Failure to: Post nurse staffing information every day.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C

    Penalties

    This home has no record of fines or payment suspensions for the past three years.