Created on: 07/25/2025
Posted to the Web on: 08/06/2025
Basic Information
FACILITY CONTACT INFORMATION:
Address: 5480 E 25TH STREET
City: COLUMBUS
Telephone: (812) 372-6136
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 24-000284-1
License effective date: 08/01/2024
License expiration date: 07/31/2025
Administration and Staff
Administrator: LISA TETRICK
Start date: 02/19/2025
Director of Nursing: KIMBERLY MILLER
Start date: 05/08/2023
Medical director: Marwan Mustaklem
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: HENRY COUNTY MEMORIAL HOSPITAL
798 NORTH 16TH ST
NEW CASTLE IN 47362
Ownership type: OTHER
Officer(s): JOHN PIDGEON
SHELDON DYNES
DEBI WARE
BUD SHORE
BRIAN RING
MARK DICE
DAVID BARR
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: HICKORY CREEK HEALTHCARE FOUNDATION INC
Date of last change of ownership: 08/01/2013
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): 36
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 36
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 36
CENSUS:
Facility census: 34
As reported by the facility on: 09/14/2022
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 09/14/2022
Residential care beds occupied: 0
As reported by the facility on: 09/14/2022
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: 18
Number of comprehensive care resident rooms with battery
operated smoke detectors: 18
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 0
Person completing form - SABRINA MORIO-HALE
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. AIT
Date form completed - 06/10/2025
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/09/2005
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2007
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 07/27/2025
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
MCDOWELL ADULT EDUCATION CENTER
Approved: 12/21/2005
Terminated: 04/01/2010
HICKORY CREEK AT FRANKLIN
Approved: 07/28/1999
Terminated: 12/26/2013
HICKORY CREEK AT NEW CASTLE
Approved: 01/27/2000
Terminated: 02/26/2013
HICKORY CREEK AT SCOTTSBURG
Approved: 03/13/2001
Terminated: 07/07/2004
Approved: 04/24/1998
Terminated: 09/09/2021
CENTRAL NINE CAREER CENTER
Approved: 05/21/1999
Terminated: 09/09/2021
COLUMBUS AREA CAREER CONNECTION
Approved: N/A
Terminated: 09/09/2021
HICKORY CREEK AT COLUMBUS
Approved: 09/27/1999
Terminated: 04/01/2007
CERTIFIED HEALTHCARE TRAINING
Approved: 03/01/2018
Terminated: 09/09/2021
ASC TRAINING CENTER
Approved: 10/01/2021
Terminated: 09/09/2021
ASC TRAINING CENTER
Approved: 10/01/2021
Terminated: 09/09/2021
IVY TECH COMMUNITY COLLEGE
Approved: 03/20/2024
Terminated: 07/28/2023
ASC TRAINING CENTER
Approved: 07/15/2025
Terminated: N/A
ASC TRAINING CENTER
Approved: 09/15/2023
Terminated: 09/09/2021
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
357
399
431
425
Rank of Score
48
28
13
15
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
Yes
Substandard Quality of Care
No
No
Yes
Administrator Change
Yes
Yes
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
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.
