Cycle 1
Health 2024-09-13 · Fire 2024-09-13
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Leo, IN
Cedars The
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
14409 Sunrise Ct, Leo, IN
(260) 627-2191
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Adams County Memorial Hospital
Operator or chain grouping
Approved since
2012-03-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
73%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
93.6%
1.7 pts better
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.5% |
95.4%
14.9 pts worse
|
95.5%
15 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.8%
0.9 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.6%
2.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
23.5%
4.3 pts better
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
14.8%
10.8 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.1% |
13.3%
21.8 pts worse
|
16.3%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
11.7%
12.4 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.4%
1.9 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
24.2%
5.2 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
4.1%
8.9 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
81.6%
1.1 pts better
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
10.5%
10.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 45.8% |
22.4%
23.4 pts worse
|
23.9%
21.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-10
F · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-10
C · Minimal harm
2024-09-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-10
C · Minimal harm
2024-09-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-10
F · Potential for more than minimal harm
2023-09-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-09-08
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-09-08
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-09-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-09-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-08
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-08
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 2023-11-20
E · Potential for more than minimal harm
2023-09-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-20
F · Potential for more than minimal harm
2022-11-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-28
E · Potential for more than minimal harm
2022-11-09
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 2023-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-30
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-02-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-09-13
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 2024-10-01
D · Potential for more than minimal harm
2024-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-08-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-09-08
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 2023-09-28
E · Potential for more than minimal harm
2023-09-08
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-08
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-08
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 2023-09-28
D · Potential for more than minimal harm
2023-09-08
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 2023-09-28
D · Potential for more than minimal harm
2023-08-09
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 2023-08-27
D · Potential for more than minimal harm
2023-05-08
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 2023-06-02
D · Potential for more than minimal harm
2023-03-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-13
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 2023-04-11
D · Potential for more than minimal harm
2022-11-09
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 2022-12-16
D · Potential for more than minimal harm
2022-11-09
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 2022-12-16
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
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Broguard, Duane
Operational/Managerial Control · Individual
Brune, Scott
Operational/Managerial Control · Individual
Cedar Creek Retirement Home Inc
Operational/Managerial Control · Organization
Duggan, Amanda
Operational/Managerial Control · Individual
Fischer, Paul
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Healthcare Therapy Services Inc
Operational/Managerial Control · Organization
Klopfenstein, John
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Lepley, William
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Proactive Medical Review And Consultants LLC
Operational/Managerial Control · Organization
Schlatter, Lowell
Operational/Managerial Control · Individual
Schlatter, Mitch
Operational/Managerial Control · Individual
Schlie, Austin
Operational/Managerial Control · Individual
Schrenk, Steven
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Yoder, Thomas
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Grey Stone Health & Rehabilitation Center
Fort Wayne, IN
1-star overall rating with 1-star inspections with $165,757 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Ashton Creek Health And Rehabilitation Center
Fort Wayne, IN
4-star overall rating with 4-star inspections
#3
Heritage Pointe Of Fort Wayne
Fort Wayne, IN
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
Jump out