01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-31 | 3 | 2026-03-31 | 2 |
| Cycle 2 | 2025-05-19 | 9 | 2025-05-19 | 3 |
| Cycle 3 | 2024-04-29 | 8 | 2024-04-29 | 1 |
CMS CCN 1550942026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
St Mary Healthcare Center
2201 Cason St · Lafayette, IN 47904 · Tippecanoe County
Certified beds79CMS provider file
Recent citation rows26current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
26 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 1 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-31 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2026-06-112026-03-31 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-152026-03-31 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-152026-03-31 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2026-05-292025-08-22 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-09-19 · complaint2025-05-19 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-19 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Past Non-Compliance · 2025-04-282025-05-19 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Past Non-Compliance · 2025-02-132025-05-19 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-19 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Past Non-Compliance · 2025-05-102025-05-19 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-19 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-19 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-06-162025-05-19 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-162025-05-19 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-06-162024-11-14 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Past Non-Compliance · 2024-06-10 · complaint2024-11-14 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Past Non-Compliance · 2024-06-10 · complaint2024-04-29 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-312024-04-29 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-05-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- WITHAM MEMORIAL HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/01/2014
- TRILOGY HEALTHCARE HOLDINGS INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/01/2015
- KEYBANK NATIONAL ASSOCIATIONOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 04/27/2017
- BAYSTON, BRETTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- BRAND, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- CASTETTER, ANDREAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- HAWKINS, CLAUDEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2013
- HORNBECKER, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- REAGAN, JULIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/25/2024
- BARDOCZI, STEPHENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/03/2013
- BRAVERMAN, KELLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2021
- SELLERS, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/20/2024
- TRILOGY HEALTHCARE OF LAKE, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2014
- GRENARD, HOLLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/07/2022
- THOMAS, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/15/2025
- BARNEY, LEIGHIndividual · LIMITED PARTNERSHIP INTERESTNOT APPLICABLE · since 12/01/2015
- DAVIS, DAVIDIndividual · LIMITED PARTNERSHIP INTERESTNOT APPLICABLE · since 12/31/2019
- AMERICAN HEALTHCARE REIT HOLDINGS LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2015
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.47per resident day
RN hours0.63per resident day
Weekend nurse hours2.97per resident day
Staff turnover29.2%CMS reported field
06 / LOCAL RECORDS
Open the Lafayette ledger →Other published facilities nearby
Creasy Springs Health Campus71 beds · CMS overall 3/535 citation rowsMajestic Care Of Lafayette122 beds · CMS overall 1/548 citation rowsRosewalk Village At Lafayette141 beds · CMS overall 3/514 citation rowsSaint Anthony Rehab And Nursing Center120 beds · CMS overall 4/517 citation rowsSprings At Lafayette, The70 beds · CMS overall 5/525 citation rows