0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Carmel, IN
5-star overall rating with 5-star inspections
1335 S Guilford Road, Carmel, IN
(317) 810-1800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
8
Certified beds
Average residents
5
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bhi Senior Living
Operator or chain grouping
Approved since
2014-04-17
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 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
RN hours / resident day
3.43
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
3.25
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.86
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
10.54
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
6.68
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
7.76
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
2.06
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.71
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
3.20
CMS adjusted RN staffing hours
Adjusted total hours
9.83
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 6.85% · Lower 95% interval 6.8% |
| Discharge to community | 53.66% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 51.47% · Lower 95% interval 44.28% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 68.75% |
53.69%
15.1 pts better
|
Numerator 22 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 121 |
| Staff flu vaccination coverage | 24.83% |
42%
17.2 pts worse
|
Numerator 37 · Denominator 149 |
| Discharge function score | 84.38% |
56.45%
27.9 pts better
|
Numerator 27 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 9 · Denominator 24 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
81.6%
13.3 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 90.3% · Q4 89.3% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
10.5%
10.7 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 18.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
79.0%
17.8 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
22.4%
7.7 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 11.6% · Expected 18.8% · Used in QM five-star |
Survey summary
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-26
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-07-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-28
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Nearby options
Carmel, IN
3-star overall rating with 2-star inspections with $15,646 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Carmel, IN
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Carmel, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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