Created on: 07/25/2025
Posted to the Web on: 08/06/2025
Basic Information
FACILITY CONTACT INFORMATION:
Address: 101 POTTERS LN
City: CLARKSVILLE
Telephone: (812) 948-0808
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 24-000166-1
License effective date: 12/01/2024
License expiration date: 11/30/2025
Administration and Staff
Administrator: ALICIA WELLS
Start date: 01/31/2025
Director of Nursing: DANNIELLE PELUCHETTE
Start date: 04/23/2025
Medical director:
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: ADAMS COUNTY MEMORIAL HOSPITAL
1100 MERCER AVENUE
DECATUR IN 46733
Ownership type: OTHER
Officer(s): RUSSELL FLUECKIGER
DANE WHEELER
SCOTT SMITH
LARRY MACKLIN
DAVID MCINTIRE
SCOTT LEHMAN
KYLE SPRUNGER
TIFFANY WILLIAMS
ELIZABETH FISHER
ADAM MILLER, J.D.
AMBER LAUTZENHEISE
CANDICE BORNE-BAUMAN
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: COLUMBUS REGIONAL HOSPITAL
Date of last change of ownership: 12/01/2023
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): 124
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 124
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 124
CENSUS:
Facility census: 78
As reported by the facility on: 07/13/2022
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 07/13/2022
Residential care beds occupied: 0
As reported by the facility on: 07/13/2022
Alzheimer Beds: 0
Alzheimer Beds Occupied: 0
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: 62
Number of comprehensive care resident rooms with battery
operated smoke detectors: 50
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 12
If hard wired and/or wireless smoke detectors are provided in resident's room, do they:
(A) Provide a visual and audible signal at the nurses'stations that attend each room? - Yes
(B) Transmit to a central station service - Yes
(C) Connect to the health facility's fire alarm system - Yes
Person completing form - ALICIA KLEES
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. HFA
Date form completed - 04/12/2025
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/10/1998
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2000
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 06/20/2025
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
NURSES ON CALL NURSING AGENCY
Approved: 12/02/2003
Terminated: 08/14/2004
HOOSIER HILLS HOME HEALTH SERV
Approved: N/A
Terminated: 08/14/2004
INDIANA HEALTH CAREERS VOCATIONAL TRAINING & TEST
Approved: 08/20/2009
Terminated: 11/05/2020
NURSE AIDE TRAINING CENTER LLC
Approved: 03/03/1998
Terminated: 08/14/2004
IVY TECH STATE COLLEGE
Approved: 03/17/1997
Terminated: 08/14/2004
NORTON ACADEMY
Approved: 12/19/2012
Terminated: 11/05/2020
NURSE TECH
Approved: 07/27/2011
Terminated: 11/05/2020
WEDGEWOOD HEALTHCARE CENTER
Approved: N/A
Terminated: 08/14/2004
EXCEL FIVE STAR TRAINING FOR CERTIFIED NURSE AIDES
Approved: 07/03/2013
Terminated: 11/05/2020
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
237
278
284
264
Rank of Score
85
78
76
79
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
Yes
No
Substandard Quality of Care
No
Yes
No
Administrator Change
Yes
No
Yes
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
Civil Money Penalty
Date Imposed: 06/14/2023 Date Ended: 07/16/2023
Amount proposed per day: 11030
Amount proposed per day: 360
Directed Plan of Correction
Date Imposed: 08/20/2022 Date Ended: 08/18/2022
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.
