Cycle 1
Health 2026-01-06 · Fire 2026-01-06
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lawrenceburg, IN
Shady Nook Care Center
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
36 Village Drive, Lawrenceburg, IN
(812) 537-0930
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Adams County Memorial Hospital
Operator or chain grouping
Approved since
1994-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.64
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
2.88
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.61
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
25%
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
7,863
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.27
Baseline 17.36% · Performance 19.45% · Measure score 4.27 · Achievement 4.27 · Improvement 0
Healthcare-associated infections
6.54
Baseline 6.90% · Performance 5.88% · Measure score 6.54 · Achievement 6.54 · Improvement 4.85
Total nurse turnover
0
Baseline 51.11% · Performance 63.16% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.62
Baseline 1.75 hours · Performance 2.20 hours · Measure score 0.62 · Achievement 0 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 14.74% · Lower 95% interval 8.53% |
| Discharge to community | 47.53% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 38.6% · Lower 95% interval 37.03% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 35% |
53.69%
18.7 pts worse
|
Numerator 14 · Denominator 40 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 16 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 73.2% |
8.2%
65 pts better
|
Numerator 71 · Denominator 97 |
| Staff flu vaccination coverage | 6.19% |
42%
35.8 pts worse
|
Numerator 7 · Denominator 113 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 15 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 7 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
93.6%
6.3 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 84.6% · Q3 89.9% · Q4 79.8% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.4%
0.1 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.8%
2.4 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.4% · Q3 5.1% · Q4 6.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.1% |
24.6%
4.5 pts better
|
11.4%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 31.5% · Q3 18.4% · Q4 13.9% · 4Q avg 20.1% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.7% · Q3 9.3% · Q4 5.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
23.5%
3.1 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 27.0% · Q3 24.0% · Q4 35.4% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
14.8%
1.7 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 14.0% · Q3 15.2% · Q4 12.3% · 4Q avg 13.1% · 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 | 30.7% |
13.3%
17.4 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 26.9% · Q3 35.7% · Q4 51.5% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
11.7%
10.1 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 22.9% · Q3 25.7% · Q4 29.2% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
24.2%
2.6 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 22.8% · Q3 18.1% · Q4 22.7% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.1%
1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 3.0% · Q4 1.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
81.6%
1.3 pts better
|
81.7%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 83.3% · Q3 81.2% · Q4 76.9% · 4Q avg 82.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
10.5%
3.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 7.9% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.3%
1.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.4% |
79.0%
3.6 pts worse
|
79.7%
4.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
22.4%
5.9 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 18.4% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-13 · Fire 2024-11-13
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-25 · Fire 2023-09-25
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2026-01-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-06
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-06
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 2026-02-13
E · Potential for more than minimal harm
2026-01-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-13
F · Potential for more than minimal harm
2024-11-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-25
F · Potential for more than minimal harm
2023-09-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-09-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-09-25
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 2023-11-02
D · Potential for more than minimal harm
2023-09-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-11-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
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 2026-02-16
D · Potential for more than minimal harm
2026-01-23
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 2026-02-16
D · Potential for more than minimal harm
2026-01-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-20
D · Potential for more than minimal harm
2026-01-06
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 2026-01-20
D · Potential for more than minimal harm
2026-01-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-20
G · Actual harm
2025-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Not marked corrected
D · Potential for more than minimal harm
2025-02-19
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 2025-03-01
F · Potential for more than minimal harm
2024-11-13
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 2024-11-14
D · Potential for more than minimal harm
2024-11-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-11-13
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 2024-11-14
D · Potential for more than minimal harm
2024-11-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-11-13
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 2024-11-14
D · Potential for more than minimal harm
2024-06-05
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 2024-07-04
D · Potential for more than minimal harm
2023-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-25
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 2023-10-16
D · Potential for more than minimal harm
2023-09-25
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 2023-10-16
D · Potential for more than minimal harm
2023-09-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-05-11
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 2023-06-09
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
Boltz, Lindsey
Operational/Managerial Control · Individual
Boltz, Lindsey
Contracted Managing Employee · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Radadiya, Pragneshkumar
Operational/Managerial Control · Individual
Shady Nook Operations LLC
Operational/Managerial Control · Organization
Smith, Scott
Operational/Managerial Control · Individual
Smith, Scott
Corporate Officer · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Sprunger, Kyle
Corporate Officer · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Wheeler, Dane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Envive Of Lawrenceburg
Lawrenceburg, IN
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Ridgewood Health Campus
Lawrenceburg, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Shawneespring Health Care Center
Harrison, OH
3-star overall rating with 2-star inspections with $28,190 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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