Cycle 1
Health 2024-11-14 · Fire 2024-11-14
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Columbia City, IN
Miller's At Oak Pointe
4-star overall rating with 4-star inspections with 3 recent health deficiencies
411 N Wolf Rd, Columbia City, IN
(260) 248-8141
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Miller's Merry Manor
Operator or chain grouping
Approved since
1972-07-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 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
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.43
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
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,046
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.53% · Performance 21.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.11
Baseline 6.57% · Performance 6.91% · Measure score 3.11 · Achievement 3.11 · Improvement 0
Total nurse turnover
4.80
Baseline 44.74% · Performance 44.07% · Measure score 4.80 · Achievement 4.80 · Improvement 0
Adjusted total nurse staffing
3.28
Baseline 2.88 hours · Performance 3.98 hours · Measure score 3.28 · Achievement 3.17 · Improvement 3.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 8.33% · Lower 95% interval 6.62% |
| Discharge to community | 62.2% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 63 · Observed rate 65.08% · Lower 95% interval 50.71% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 43.24% |
53.69%
10.4 pts worse
|
Numerator 16 · Denominator 37 |
| Discharge mobility score | 27.03% |
50.94%
23.9 pts worse
|
Numerator 10 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 1.32% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 76 |
| Staff flu vaccination coverage | 24.05% |
42%
17.9 pts worse
|
Numerator 19 · Denominator 79 |
| Discharge function score | 32.43% |
56.45%
24 pts worse
|
Numerator 12 · Denominator 37 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 34 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.93% |
25.2%
0.7 pts better
|
Numerator 7 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
95.4%
2.5 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.8%
0.8 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.0% · Q4 4.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 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 who lose too much weight | 2.2% |
5.6%
3.4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.8% · Q4 2.6% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
23.5%
8.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.2% · Q3 13.9% · Q4 10.5% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
14.8%
9.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 6.7% · Q3 3.3% · Q4 2.9% · 4Q avg 5.7% · 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 | 13.9% |
13.3%
0.6 pts worse
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 13.7% · Q3 11.4% · Q4 17.2% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
11.7%
1.3 pts worse
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.5% · Q3 8.3% · Q4 18.4% · 4Q avg 13.0% · 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 | 6.0% |
1.2%
4.8 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.1% · Q3 4.7% · Q4 7.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
24.2%
3 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 13.2% · Q3 28.3% · Q4 43.7% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.1%
0.5 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 7.8% · Q3 4.4% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
81.6%
18.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
10.5%
3.7 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.0% · Expected 9.9% · 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 · Q1 0.0% · 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 | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.4%
5.5 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 24.0% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-17 · Fire 2024-01-17
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-17 · Fire 2023-01-17
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-07-30
F · Potential for more than minimal harm
2024-11-14
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 2024-11-20
E · Potential for more than minimal harm
2024-11-14
F761 · Pharmacy Service Deficiencies
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 2024-11-20
F · Potential for more than minimal harm
2023-01-17
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 2023-02-09
D · Potential for more than minimal harm
2023-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Baker, Stephen
Operational/Managerial Control · Individual
Berkhouse, Steven
Corporate Director · Individual
Berkhouse, Steven
Corporate Officer · Individual
Boyle, Patrick
Operational/Managerial Control · Individual
Boyle, Patrick
Corporate Director · Individual
Decola, Robert
Operational/Managerial Control · Individual
Decola, Robert
Corporate Officer · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Director · Individual
Dunkle, David
Corporate Officer · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Haug, Lori
Operational/Managerial Control · Individual
Haug, Lori
Corporate Director · Individual
Lake City Bank
5% Or Greater Mortgage Interest · Organization
Mhs Columbia City, LLC
5% Or Greater Mortgage Interest · Organization
Miller's Health Systems Inc
Operational/Managerial Control · Organization
Robinson, Tina
Operational/Managerial Control · Individual
Robinson, Tina
Corporate Director · Individual
Theracare Inc
Operational/Managerial Control · Organization
Van Den Driessche, Thomas
Operational/Managerial Control · Individual
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#3
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