Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Community Home during CMS and state inspections, most recent first.
A resident with CKD, renal failure, and other diagnoses had repeated weight gains of 2 pounds or more and did not receive PRN Furosemide on those occasions. The resident also refused a prescribed high-protein supplement many times, but the chart lacked documentation that the MD/NP was notified or that physician guidance was recorded in the Progress Notes.
Failure to Protect Resident Identifiable Information: Unattended med carts and an unattended nurse's station had resident names and personal/medical information left face up in open view, including medication cards and paperwork with identifiable details. Two unidentified people walked past the area while the information was exposed, and an RN stated the paperwork should not have been left out in the open.
Meal consumption was not documented for three residents whose care plans required monitoring and recording of intake. One resident had severe cognitive impairment, aphasia, diabetes, dementia, and a mechanically altered diet, while two others were cognitively intact with multiple medical diagnoses. A CNA stated every meal should be documented, and the facility policy required accurate, timely documentation of resident food intake by direct care staff.
The facility failed to provide ordered meds to one resident and gave another resident the wrong dose. A cognitively intact resident with multiple diagnoses, including seizures and diabetes, missed several prescribed meds because they were unavailable, and the record did not show NP notification or alternative orders. Another resident with severe cognitive impairment received Depakote 250 mg instead of the ordered 125 mg TID for several days after the wrong medication card was placed in the cart and administered by nursing staff.
Improper medication storage and labeling were observed on a hall medication cart and in a medication room. A Lispro insulin pen for a resident was left without an open date after being removed from refrigeration, and an RN's personal coffee cup was stored in the medication cart with clean supplies. In the medication room, cigarettes and a lighter were found on a shelf next to insulin syringes, and the DON stated staff personal items should not be in medication carts and resident cigarettes should have been discarded or sent home.
The facility did not update care plans for two residents: one with repeated behavioral incidents towards others and another who required a roam alert bracelet after an elopement and fall. In both cases, care plans lacked necessary documentation and interventions for behaviors and monitoring of alert systems, despite facility policy and observed incidents.
A facility failed to provide proper perineal care for a resident with a history of UTIs. A CNA did not follow hygiene protocols, using the same washcloths for different body parts and not cleaning the perineal area from front to back. The resident, who was cognitively intact and had frequent UTIs, was uncertain about her antibiotic treatment. The facility's policy requires cleansing from front to back to prevent infection.
A resident with multiple diagnoses, including epilepsy, experienced a significant medication error when the facility failed to administer phenytoin as ordered. The resident was supposed to receive 150 mg at bedtime, but due to an incorrect order entry, received 175 mg. The ADON believed the order was clarified, but there was no documentation to support this, and the facility lacked a policy for ensuring correct order entry.
Failure to Notify Physician of Weight Changes and Supplement Refusals
Penalty
Summary
The facility failed to notify the physician and document physician guidance for Resident 4 when the resident had significant weight changes and repeated refusals of a prescribed nutritional supplement. Resident 4’s record showed an admission MDS dated 10/23/2025 indicating the resident was cognitively intact, with diagnoses including fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The EMAR showed an order for daily weights for chronic kidney disease and an order for Furosemide 40 mg as needed for weight gain of 2 pounds or more in 24 hours and/or bilateral lower extremity swelling. The resident had multiple weight increases of 2 pounds or more, including gains of 9 pounds, 5.2 pounds, and 5.4 pounds, but the record did not show that the PRN Furosemide was given on those occasions. The EMAR also showed an order to offer a chocolate high protein drink twice daily, and the record indicated the resident either drank none of it or refused it 29 times out of 40 offers in November 2025. Progress Notes lacked documentation that the physician was notified about the weight changes or the refusals of the nutritional supplement. During interview, the resident stated she did not like the chocolate supplement because it caused diarrhea and that she had repeatedly refused it; she also said other flavors had been offered but she still did not want it. The Administrator stated physician notifications were documented in Progress Notes, and the DON stated staff were to document the nature of physician notifications and responses in Progress Notes, and that if PRN Furosemide was not given for weight gain, the reason should have been documented.
Failure to Protect Resident Identifiable Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when medication carts and the nurse's station were left unattended with resident-identifying information in open view. On the 200 Hall on 12/04/2025 at 10:23 A.M., two medication carts were observed sitting in the hallway across from the nurse's station without staff present. One cart had an empty medication card on top labeled with Resident 32's name for Losartan Potassium 100 mg, and the other had an empty medication card labeled with Resident 40's name for Losartan HCTZ. Two unidentified people walked past the carts before a staff member later removed and discarded the card for Resident 40. On 12/05/2025 at 9:04 A.M., the medication cart was again unattended, and a paper on top of the cart was face up with a list of resident names and personal information. The nurse's station was also unattended, and a paper on the desk was face up with a list of resident names and personal health information while several unidentified people walked past. During interview at 9:06 A.M., RN 6 stated paperwork with residents' information should not be left out in the open and turned the papers face down. The facility policy titled Safeguarding of Resident Identifiable Information stated that medical records shall not be left in open areas where unauthorized persons could access identifiable resident information and that paper notes or reminders with resident personal or medical information shall not be left unattended or viewable by unauthorized persons.
Meal Consumption Documentation Missing for Multiple Residents
Penalty
Summary
The facility failed to document meal consumption for 3 of 4 residents reviewed for nutrition. Resident 84 had severe cognitive impairment and diagnoses including expressive language disorder, aphasia, diabetes, and dementia, and was on a mechanically altered diet with complaints of pain or difficulty swallowing or eating. Her Nutritional Status Care Plan directed staff to monitor and record meal intakes, but the Meal Consumption Record lacked documentation for multiple meals across November and early December 2025, including breakfast, lunch, and dinner entries on several dates. Resident 4 was cognitively intact and had diagnoses including fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. Her care plan also directed staff to monitor and record meal intakes, but the Meal Consumption Record lacked documentation for numerous meals across November and December 2025. Resident 72 was cognitively intact with diagnoses including peripheral vascular disease and hypertension, and his Meal Consumption Record also lacked documentation for many meals over the same period. During interview, a CNA stated meal consumptions were documented in the computer charting system and that every meal should be documented, and the facility policy stated resident documentation would occur accurately and timely and that direct care staff would monitor and record food intake.
Missed Medications and Wrong Dose Administration
Penalty
Summary
The facility failed to provide physician-prescribed medications to one resident and failed to ensure the correct dosage was administered to another resident. For Resident 4, who was cognitively intact and admitted with diagnoses including tibia fractures, hypertension, renal failure, seizure disorder, anxiety, and depression, the EMAR showed multiple missed doses of ordered medications because the medications were unavailable. These included Lacosamide 100 mg for seizures, Sitagliptin 50 mg for diabetes with chronic kidney disease, Enoxaparin 30 mg/0.3 ml subcutaneous for fracture, Amitriptyline 30 mg for depression, Desvenlafaxine ER for depression, Esomeprazole magnesium 40 mg for gastro-esophageal disease, Glimepiride 2 mg for diabetes, and Tizanidine 4 mg for muscle spasms. The record for Resident 4 also lacked documentation that the NP was notified of the medication delays or that any alternative treatment orders or monitoring orders were obtained. A progress note stated medications had not been ordered until 11/17/2025, and the pharmacy reported a system glitch that delayed delivery until the night of 11/18/2025. During interviews, the NP stated medications could be ordered the same day and the DON stated medications should be available, that staff could use local pharmacies or an EDK, and that the NP should be notified if medications were not available, with the notification documented in the progress notes. The facility policy stated staff should notify the physician immediately when medication is unavailable and obtain alternative treatment orders and/or monitoring orders. For Resident 3, who was severely cognitively impaired and had diagnoses including fractures, anemia, hypertension, depression, and dementia, the record showed a physician order for Depakote 125 mg three times daily. However, a medication card for Depakote 250 mg was found in the medication cart, and the resident received 250 mg three times daily for 4 and a half days, which was double the ordered dose. A progress note identified the medication card as a medication error, and the DON stated the pharmacy sent the wrong medication card but nursing staff administered the 250 mg tablets. Facility policy required medications to be administered according to the physician's order and for staff to verify the right dosage by comparing the medication source with the MAR.
Improper Medication Storage and Labeling
Penalty
Summary
Medication storage areas on the 300 Hall were found to be improperly maintained during observation with an RN. In the 300 Hall medication cart, a Lispro insulin pen for Resident 92 was present without an open date label. The RN stated the pen had not yet been opened, had been out of the refrigerator since Friday, 11/28/2025, and would be dated when opened, although she also stated it was usually dated the same day it was removed from the refrigerator. An insulated coffee cup with a lid, identified by the RN as her own, was also stored in a drawer of the medication cart next to clean health care supplies. In the 300 Hall medication room, a cabinet labeled Wound Supplies contained a pack of cigarettes, two loose cigarettes, and a lighter on a shelf next to a box of insulin safety syringes. RN 2 stated she thought the cigarettes had been confiscated from a resident. During interview, the DON stated staff personal items should not be stored in medication carts and the resident's cigarettes should have been discarded or sent home with the family. The facility's Medication Storage policy stated medications must be stored according to the manufacturer's recommendations and with proper sanitation, temperature, segregation, and security.
Failure to Update Care Plans for Behaviors and Monitoring Alert Systems
Penalty
Summary
The facility failed to update and implement comprehensive care plans for two residents with significant needs. For one resident with severe cognitive impairment and diagnoses including dementia, anemia, and hypertension, there were multiple documented incidents of physical and verbal behaviors towards another resident, including slapping. Despite these repeated behavioral incidents, the resident's care plan did not include any interventions or documentation addressing behaviors towards other residents. Interviews with facility management confirmed that care plans should be updated for behaviors, but this was not done for this resident. In another case, a resident with severe cognitive impairment and a history of heart disease, hypertension, and stroke exited through an exterior door, resulting in a fall and injuries. Following the incident, a roam alert bracelet was placed on the resident, but the care plan was not updated to include the use of the device, nor were there orders for monitoring the device or the resident's skin. Facility policy required care plans and monitoring for such devices, but these steps were not documented or implemented for this resident.
Improper Perineal Care for Resident with History of UTIs
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident with a history of urinary tract infections (UTIs). During an observation, a CNA was seen assisting the resident with morning care. The CNA did not follow proper hygiene protocols, as she used the same washcloths for different parts of the resident's body without changing them, and did not clean the perineal area from front to back as required. The washcloths used were left in the sink and were visibly soiled, indicating improper cleaning procedures. The resident, who was cognitively intact and had a history of frequent UTIs, expressed uncertainty about whether she was receiving antibiotics for a recent UTI. The resident's medical history included peripheral vascular disease, hypertension, and glaucoma. The facility's perineal care policy, which was not adhered to, requires cleansing from front to back to prevent infection. The resident had been receiving various antibiotics due to her frequent UTIs and allergies to certain medications.
Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a significant medication error for a resident. The resident, who was cognitively intact and diagnosed with Parkinson's disease, psychotic disorder, epilepsy, and dementia, had a physician's order to receive 100 mg of phenytoin in the morning and 125 mg at bedtime. However, due to low medication levels identified in bloodwork, the Nurse Practitioner increased the bedtime dose to 150 mg. Despite this, the resident received 175 mg at bedtime instead of the prescribed 150 mg due to an error in the medication order entry. The Assistant Director of Nursing (ADON) believed the order was clarified when received and that the pharmacy had placed a sticker on the medication card to ensure the correct dose was administered. However, there was no documentation to support this, and the EMAR indicated that 75 mg was administered instead of the correct 50 mg. The facility lacked a policy to ensure physician's orders were input correctly or to obtain clarification if there were questions, relying instead on standard nursing practice to ensure accurate implementation of orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Seymour
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seymour Crossing | 1.2 mi | ★★★★★ | 10 | 0 |
| Covered Bridge Health Campus | 1.6 mi | ★★★★★ | 8 | 0 |
| Hoosier Health & Living Community | 9.6 mi | ★★★★★ | 3 | 0 |
| Majestic Care Of North Vernon | 14 mi | ★★★★★ | 5 | 0 |
| Hampton Oaks Health Campus | 17 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.