Created on: 07/25/2025
Posted to the Web on: 08/06/2025
Basic Information
FACILITY CONTACT INFORMATION:
Address: 1705 S MAIN ST
City: CLINTON
Telephone: (765) 832-3573
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 24-000052-1
License effective date: 11/01/2024
License expiration date: 10/31/2025
Administration and Staff
Administrator: MELISSA GUM
Start date: 04/10/1995
Director of Nursing: AMANDA DOWELL
Start date: 10/08/2024
Medical director:
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist: Courtney Creasey
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: BOARD OF TRUSTEES OF FLAVIUS J WITHAM MEMORIAL
2605 NORTH LEBANON STREET
LEBANON IN 46052
Ownership type: OTHER
Officer(s): C ARCHIBALD HAWKINS
JOHN BRAND
KELLY L. P. BRAVERMAN
BRETT BAYSTON
ANDREA CASTETTER
MICHAEL JASON HORNBECKER
DANIEL SELLERS
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: MAGNOLIA HEALTH SYSTEMS XIX LLC
Date of last change of ownership: 11/01/2011
Bed Counts and Census
COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF): 0
Number of Medicare beds (SNF): 0
Number of Medicare/Medicaid beds (SNF/NF): 100
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 100
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 100
CENSUS:
Facility census: 72
As reported by the facility on: 07/16/2025
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 07/16/2025
Residential care beds occupied: 0
As reported by the facility on: 07/16/2025
Alzheimer Beds: 20
Alzheimer Beds Occupied: 11
As reported by the facility on: / /
Ventilator Beds: 0
Ventilator Beds Occupied: 0
As reported by the facility on: / /
Sprinklers and Smoke Detectors
This facility is: FULLY SPRINKLERED
Number of comprehensive care resident rooms: 66
Number of comprehensive care resident rooms with battery
operated smoke detectors: 66
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 0
Person completing form - MELISSA GUM
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. ADMINISTRATOR
Date form completed - 05/11/2025
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 09/11/2023
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2025
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 01/14/2023
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
AREA 30 CAREER CENTER
Approved: 08/05/2002
Terminated: 12/24/2003
ADVANCED HEALTHCARE TRAINING SERVICES
Approved: 05/27/2010
Terminated: 01/04/2016
PARKE-VERMILLION EDUCATION AND TRAINING INTERLOCAL
Approved: N/A
Terminated: 12/24/2003
VERMILLION CONVALESCENT CENTER
Approved: 02/16/2010
Terminated: 01/15/2021
WABASH RIVER CAREER & TECHNICAL EDUCATION
Approved: 07/16/2014
Terminated: 01/15/2021
GRAND VALLEY HEALTH & REHAB
Approved: 01/04/2019
Terminated: 01/15/2021
KEYSTONE NURSING ACADEMY INC
Approved: 02/23/2023
Terminated: N/A
VERMILLION CONVALESCENT CENTER
Approved: 09/11/2023
Terminated: N/A
WABASH RIVER CAREER & TECHNICAL EDUCATION
Approved: 06/16/2023
Terminated: N/A
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 0
Previous year: 0
2 years previous: 0
Facility Report Card
03/01/2020 Current QTR
12/01/2019 Previous QTR
09/01/2019 Previous QTR
06/01/2019 Previous QTR
Report Card Score
263
308
359
341
Rank of Score
80
67
48
55
Average Score
302
296
295
296
*Facility report card scores have not been updated since March 1, 2020 due to changes in the survey process during the ongoing COVID-19 pandemic.
The facility report card score is calculated four times per calendar year
for the two most recent nursing home health surveys. The facility report card score
also includes all complaint surveys, life safety code surveys, emergency preparedness surveys,
and any follow-up surveys that occur within the two most recent nursing home health surveys.
The facility report card score ranges from 500 to 0, with 500 being the best score possible.
View the Scope and Severity gridView the scoring methodology
Overview of Survey findings
The Most Recent Set
2ND Most Recent Set
3RD Most Recent Set
Immediate Jeopardy
No
No
No
Substandard Quality of Care
No
No
No
Administrator Change
No
No
No
Owner Change
No
No
No
Number of Substantiated Complaints With Deficiencies
0
0
0
Deficiency Free Standard Health Survey
No
No
No
The term 'Recent Set' referenced above relates to the referenced annual survey,
and any other surveys performed between it and the previous annual survey.
Enforcement Actions
Federal Certification Actions Imposed
Date terminated from Medicare/Medicaid: N/A
Survey History
The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
The survey report therefore will likely not be posted until four to six weeks after the exit date.
In the grid below click on an event ID that is underlined to see the survey report for that event.
