Cycle 1
Health 2025-08-11 · Fire 2025-08-11
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Franklin, IN
Compass Park
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
800 Freemason Parkway, Franklin, IN
(317) 736-6141
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
167
Certified beds
Average residents
145
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,979
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.37% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.21
Baseline 4.84% · Performance 6.87% · Measure score 3.21 · Achievement 3.21 · Improvement 0
Total nurse turnover
2.62
Baseline 61.54% · Performance 52.98% · Measure score 2.62 · Achievement 2.62 · Improvement 1.83
Adjusted total nurse staffing
2.91
Baseline 3.67 hours · Performance 3.91 hours · Measure score 2.91 · Achievement 2.91 · Improvement 0.60
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 194 · Observed rate 11.34% · Lower 95% interval 8.46% |
| Discharge to community | 43.7% |
50.57%
6.9 pts worse
|
Worse than the National Rate · Eligible stays 177 · Observed rate 41.24% · Lower 95% interval 36.58% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 90.43% |
95.27%
4.8 pts worse
|
Numerator 104 · Denominator 115 |
| Falls with major injury | 0.87% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 115 |
| Discharge self-care score | 48.94% |
53.69%
4.8 pts worse
|
Numerator 46 · Denominator 94 |
| Discharge mobility score | 38.3% |
50.94%
12.6 pts worse
|
Numerator 36 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 115 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 5.5% · Lower 95% interval 4.11% |
| Staff COVID-19 vaccination coverage | 15.56% |
8.2%
7.4 pts better
|
Numerator 28 · Denominator 180 |
| Staff flu vaccination coverage | 21.76% |
42%
20.2 pts worse
|
Numerator 42 · Denominator 193 |
| Discharge function score | 41.49% |
56.45%
15 pts worse
|
Numerator 39 · Denominator 94 |
| Transfer of health information to provider | 71.79% |
95.95%
24.2 pts worse
|
Numerator 28 · Denominator 39 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 30 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 50.88% |
25.2%
25.7 pts better
|
Numerator 29 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| 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 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
93.6%
6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 99.2% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.4%
2.4 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.8%
2.8 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.6% · Q3 6.3% · Q4 5.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
24.6%
20.2 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.2% · Q3 2.8% · Q4 3.5% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.6%
2.9 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.2% · Q3 8.1% · Q4 9.1% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
23.5%
5.3 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 31.0% · Q3 27.9% · Q4 28.8% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
14.8%
3.4 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.1% · Q3 12.9% · Q4 13.2% · 4Q avg 11.4% · 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 | 27.7% |
13.3%
14.4 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 27.4% · Q3 30.7% · Q4 27.0% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
11.7%
13.4 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 26.7% · Q3 22.1% · Q4 30.1% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.4%
0.7 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
24.2%
4.3 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 29.7% · Q3 28.1% · Q4 25.8% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.1%
1.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.3% · Q3 7.8% · Q4 0.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
81.6%
12.5 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 94.4% · Q3 94.5% · Q4 97.7% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
10.5%
0.7 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 1.3% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
79.0%
7 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
22.4%
2.4 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 20.4% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-20 · Fire 2024-09-20
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-11-08 · Fire 2023-11-08
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-08-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-08-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-08-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-08-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-09-26
F · Potential for more than minimal harm
2024-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-09-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-16
C · Minimal harm
2024-09-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-16
E · Potential for more than minimal harm
2023-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-09-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
E · Potential for more than minimal harm
2023-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-11-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-21
C · Minimal harm
2023-11-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-15
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bates, Steven
Operational/Managerial Control · Individual
Branigan, Constance
Operational/Managerial Control · Individual
Clark, Cynthia
Operational/Managerial Control · Individual
Davis, Chad
Operational/Managerial Control · Individual
Douglas, Steven
Operational/Managerial Control · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Officer · Individual
Everett, April
Operational/Managerial Control · Individual
Gilpatrick, Michael
Operational/Managerial Control · Individual
Hughes, Mark
Operational/Managerial Control · Individual
Indiana Masonic Home, Inc.
Operational/Managerial Control · Organization
Johnson Memorial Hospital
Operational/Managerial Control · Organization
Lentz, Richard
Operational/Managerial Control · Individual
Maple, Jerry
Operational/Managerial Control · Individual
Meahl, Marissa
Operational/Managerial Control · Individual
Pierce, William
Operational/Managerial Control · Individual
Reynolds, Don
Operational/Managerial Control · Individual
Seipel, Randolph
Operational/Managerial Control · Individual
Spencer, Charles
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Homeview Center Of Franklin
Franklin, IN
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Otterbein Franklin Seniorlife Comm Res & Com Care
Franklin, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Hickory Creek At Franklin
Franklin, IN
5-star overall rating with 5-star inspections with $7,446 in total fines with 10 fire-safety deficiencies in the latest cycle
Jump out