Cycle 1
Health 2024-09-13 · Fire 2024-09-13
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Seymour, IN
Lutheran Community Home
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
111 W Church Ave, Seymour, IN
(812) 522-5927
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-02-07
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
0.88
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,484
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.86
Baseline 16.16% · Performance 20.57% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Healthcare-associated infections
2.03
Baseline 5.16% · Performance 7.23% · Measure score 2.03 · Achievement 2.03 · Improvement 0
Total nurse turnover
5.88
Baseline 39.00% · Performance 39.64% · Measure score 5.88 · Achievement 5.88 · Improvement 0
Adjusted total nurse staffing
4.64
Baseline 4.69 hours · Performance 4.40 hours · Measure score 4.64 · Achievement 4.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 8.14% · Lower 95% interval 6.94% |
| Discharge to community | 65.49% |
50.57%
14.9 pts better
|
Better than the National Rate · Eligible stays 75 · Observed rate 68% · Lower 95% interval 57.58% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.18% |
95.27%
2.1 pts worse
|
Numerator 41 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 64.1% |
53.69%
10.4 pts better
|
Numerator 25 · Denominator 39 |
| Discharge mobility score | 69.23% |
50.94%
18.3 pts better
|
Numerator 27 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 6.82% |
2.29%
4.5 pts worse
|
Numerator 3 · Denominator 44 · Adjusted rate 7.28% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 6 · Denominator 162 |
| Staff flu vaccination coverage | 49.22% |
42%
7.2 pts better
|
Numerator 95 · Denominator 193 |
| Discharge function score | 71.79% |
56.45%
15.3 pts better
|
Numerator 28 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
93.6%
4.6 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 97.1% · Q3 98.5% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.4%
2.1 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.8%
1.7 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 4.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
24.6%
23.8 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.6%
2.4 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.2% · Q3 1.7% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
23.5%
0.2 pts better
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 28.1% · Q3 23.3% · Q4 15.9% · 4Q avg 23.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
14.8%
0.7 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 15.4% · Q3 16.4% · Q4 11.9% · 4Q avg 14.1% · 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 | 25.4% |
13.3%
12.1 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 38.4% · Q3 40.8% · Q4 15.0% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
11.7%
17.2 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 39.7% · Q3 44.8% · Q4 21.7% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.4%
1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.4% · Q3 1.3% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
1.2%
4.5 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.8% · Q3 4.5% · Q4 9.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
24.2%
0.3 pts better
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 27.1% · Q3 28.1% · Q4 16.8% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.1%
2.4 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 3.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
81.6%
13.5 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 93.2% · Q3 100.0% · Q4 100.0% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
10.5%
1.3 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.1% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.5% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.5% |
79.0%
9.5 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
22.4%
2.8 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 13.5% · Expected 16.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-25 · Fire 2023-07-25
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-07-25 · Fire 2022-07-25
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-08
E · Potential for more than minimal harm
2023-07-25
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-25
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 2023-08-18
D · Potential for more than minimal harm
2023-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-18
F · Potential for more than minimal harm
2022-07-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-09-08
F · Potential for more than minimal harm
2022-07-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-08
F · Potential for more than minimal harm
2022-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-08
F · Potential for more than minimal harm
2022-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
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 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-08
C · Minimal harm
2022-07-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-09-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-23
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 2025-11-28
D · Potential for more than minimal harm
2024-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-04
D · Potential for more than minimal harm
2023-07-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-25
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 2023-08-23
D · Potential for more than minimal harm
2023-07-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-25
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 2023-08-23
D · Potential for more than minimal harm
2023-07-25
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-03-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-17
D · Potential for more than minimal harm
2022-07-25
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 2022-08-31
D · Potential for more than minimal harm
2022-07-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-25
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 2022-08-31
D · Potential for more than minimal harm
2022-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
Penalties and ownership
What sits behind the stars
Ownership
Carter, Anita
Operational/Managerial Control · Individual
Fish, Eric
Operational/Managerial Control · Individual
Fleetwood, Karyn
Operational/Managerial Control · Individual
Hill, Neil
Operational/Managerial Control · Individual
Jackson County Schneck Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Jackson County Schneck Memorial Hospital
Operational/Managerial Control · Organization
Jung, Matthew
Operational/Managerial Control · Individual
Krumme, Galen
Operational/Managerial Control · Individual
Lutheran Community Home, Inc.
5% Or Greater Direct Ownership Interest · Organization
Lutheran Community Home, Inc.
Operational/Managerial Control · Organization
Mann, Deborah
Operational/Managerial Control · Individual
Meyer, Gary
Operational/Managerial Control · Individual
Nolting, John
Operational/Managerial Control · Individual
Pollert, Max
Operational/Managerial Control · Individual
Pollert, Roger
Operational/Managerial Control · Individual
Rothert, Erin
Operational/Managerial Control · Individual
Schnitker, Susan
Operational/Managerial Control · Individual
Voelker, Louis
Operational/Managerial Control · Individual
Wischmeier, Henry
Operational/Managerial Control · Individual
Wischmeier, Priscilla
Operational/Managerial Control · Individual
Wischmeier, Roger
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Seymour Crossing
Seymour, IN
3-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Covered Bridge Health Campus
Seymour, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hoosier Health & Living Community
Brownstown, IN
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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