9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Carmel, IN
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
118 Medical Dr, Carmel, IN
(317) 844-4211
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
188
Certified beds
Average residents
131
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
1978-04-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.59
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
11,198
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.71
Baseline 19.05% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Healthcare-associated infections
0
Baseline 5.95% · Performance 9.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.42
Baseline 76.19% · Performance 61.19% · Measure score 2.42 · Achievement 0.61 · Improvement 2.42
Adjusted total nurse staffing
0.95
Baseline 2.96 hours · Performance 3.35 hours · Measure score 0.95 · Achievement 0.95 · Improvement 0.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 15.09% · Lower 95% interval 8.49% |
| Discharge to community | 50.87% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 38.71% · Lower 95% interval 38.6% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.11% |
95.27%
3.2 pts worse
|
Numerator 70 · Denominator 76 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 76 |
| Discharge self-care score | 47.27% |
53.69%
6.4 pts worse
|
Numerator 26 · Denominator 55 |
| Discharge mobility score | 50.91% |
50.94%
About the same
|
Numerator 28 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 9.21% |
2.29%
6.9 pts worse
|
Numerator 7 · Denominator 76 · Adjusted rate 8.18% |
| Healthcare-associated infections requiring hospitalization | 9.93% |
7.12%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 14.81% · Lower 95% interval 6.09% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 158 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 65.45% |
56.45%
9 pts better
|
Numerator 36 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 35.9% |
25.2%
10.7 pts better
|
Numerator 14 · Denominator 39 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
93.6%
2.6 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 96.7% · Q3 93.9% · Q4 96.6% · 4Q avg 96.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.4%
1.4 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.8%
0.2 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.2% · Q3 3.5% · Q4 2.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
24.6%
21.9 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 2.8% · Q4 2.8% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.6%
0.4 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.9% · Q3 6.6% · Q4 5.5% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
23.5%
0.8 pts better
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.4% · Q3 20.8% · Q4 26.4% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
14.8%
4.3 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 18.7% · Q3 19.8% · Q4 16.5% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.2% |
13.3%
0.9 pts worse
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 23.4% · Q3 13.2% · Q4 0.0% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
11.7%
2.8 pts worse
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 11.8% · Q3 9.2% · Q4 11.0% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.2%
1.5 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.5% · Q3 2.6% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
24.2%
1.6 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 23.8% · Q3 25.4% · Q4 24.1% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.1%
1.5 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.7% · Q3 6.7% · Q4 4.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
81.6%
4.2 pts better
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 83.1% · Q3 87.3% · Q4 87.2% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
10.5%
2.1 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 9.6% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.2% · Q3 0.0% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.2% |
79.0%
3.2 pts better
|
79.7%
2.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
22.4%
1 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 30.1% · Expected 30.7% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-15
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-15
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-15
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-12-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-31
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-13
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-09
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-11-27
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2023-11-27
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-27
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-10-24
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-24
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-24
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-22
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-22
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-22
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-22
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-22
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-22
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-10
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-10
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-10
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-10
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-11-10
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-12
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-12
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Nearby options
Carmel, IN
5-star overall rating with 5-star inspections
Carmel, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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
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