Cycle 1
Health 2025-09-19 · Fire 2025-09-19
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Decatur, IN
Adams Woodcrest
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
1300 Mercer Ave, Decatur, IN
(260) 724-3311
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
105
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.50
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.40
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
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,694
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.58
Baseline 17.62% · Performance 20.23% · Measure score 2.58 · Achievement 2.58 · Improvement 0
Healthcare-associated infections
1.31
Baseline 6.17% · Performance 7.44% · Measure score 1.31 · Achievement 1.31 · Improvement 0
Total nurse turnover
6.25
Baseline 55.65% · Performance 38.14% · Measure score 6.25 · Achievement 6.25 · Improvement 5.19
Adjusted total nurse staffing
1.46
Baseline 3.61 hours · Performance 3.49 hours · Measure score 1.46 · Achievement 1.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 8.73% · Lower 95% interval 7.5% |
| Discharge to community | 58.03% |
50.57%
7.5 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 60.36% · Lower 95% interval 49.53% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 2.67% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 75 |
| Discharge self-care score | 59.32% |
53.69%
5.6 pts better
|
Numerator 35 · Denominator 59 |
| Discharge mobility score | 50.85% |
50.94%
0.1 pts worse
|
Numerator 30 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 75 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.44% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 239 |
| Staff flu vaccination coverage | 37.67% |
42%
4.3 pts worse
|
Numerator 81 · Denominator 215 |
| Discharge function score | 61.02% |
56.45%
4.6 pts better
|
Numerator 36 · Denominator 59 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 9.76% |
25.2%
15.4 pts worse
|
Numerator 4 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
93.6%
2.6 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 91.3% · Q3 83.7% · Q4 89.8% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
95.4%
0.9 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.8%
1.4 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.9% · Q3 5.1% · Q4 7.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
24.6%
20.2 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.0% · Q3 7.4% · Q4 5.4% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.6%
2.4 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.4% · Q3 7.9% · Q4 5.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
23.5%
6.5 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 17.5% · Q3 19.8% · Q4 18.0% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
14.8%
9.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.2% · Q3 5.0% · Q4 6.3% · 4Q avg 5.7% · 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 | 20.4% |
13.3%
7.1 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 12.6% · Q3 19.6% · Q4 14.9% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
11.7%
5.7 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 14.0% · Q3 15.7% · Q4 14.1% · 4Q avg 17.4% · 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 | 36.4% |
24.2%
12.2 pts worse
|
19.8%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.6% · Q2 39.8% · Q3 24.1% · Q4 44.1% · 4Q avg 36.4% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
4.1%
3.3 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.6% |
81.6%
37 pts worse
|
81.7%
37.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.2% · Q2 52.3% · Q3 44.3% · Q4 33.7% · 4Q avg 44.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
10.5%
4.3 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.4% · Expected 9.6% · 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 | 47.2% |
79.0%
31.8 pts worse
|
79.7%
32.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
22.4%
0.9 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.3% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-27 · Fire 2024-11-27
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-12-21 · Fire 2023-12-21
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-01
E · Potential for more than minimal harm
2025-09-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-01
E · Potential for more than minimal harm
2024-11-27
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-11-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-11-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-31
E · Potential for more than minimal harm
2023-12-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-12-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-27
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 2024-12-27
D · Potential for more than minimal harm
2024-11-27
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 2024-12-27
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Ahmetovic, Alma
Operational/Managerial Control · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Gresla, Mark
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Adams Heritage
Monroeville, IN
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Swiss Village
Berne, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Envive Of Berne
Berne, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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