Plymouth, IN

Miller's Merry Manor

4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

635 Oakhill Ave, Plymouth, IN

(574) 936-9981

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

131

Certified beds

Average residents

74

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Miller's Merry Manor

Operator or chain grouping

Approved since

1969-10-16

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

0.95

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.58

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.20

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.62

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.48

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.96

CMS adjusted RN staffing hours

Adjusted total hours

4.23

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

48%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,242

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.39

Composite VBP score used to determine payment impact.

Payment multiplier

0.9845

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.87

Baseline 19.00% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 0

Healthcare-associated infections

3.04

Baseline 6.01% · Performance 6.93% · Measure score 3.04 · Achievement 3.04 · Improvement 0

Total nurse turnover

0

Baseline 63.79% · Performance 66.09% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

4.04

Baseline 3.72 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 1.94

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.11%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 100 · Observed rate 8% · Lower 95% interval 6.61%
Discharge to community	64.31%	50.57% 13.7 pts better	Better than the National Rate · Eligible stays 88 · Observed rate 62.5% · Lower 95% interval 53.21%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 52 · Denominator 52
Falls with major injury	1.92%	0.77% 1.1 pts worse	Numerator 1 · Denominator 52
Discharge self-care score	52.17%	53.69% 1.5 pts worse	Numerator 24 · Denominator 46
Discharge mobility score	47.83%	50.94% 3.1 pts worse	Numerator 22 · Denominator 46
Pressure ulcers or injuries, new or worsened	7.69%	2.29% 5.4 pts worse	Numerator 4 · Denominator 52 · Adjusted rate 7.7%
Healthcare-associated infections requiring hospitalization	6.93%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage	15.04%	8.2% 6.8 pts better	Numerator 17 · Denominator 113
Staff flu vaccination coverage	28.79%	42% 13.2 pts worse	Numerator 38 · Denominator 132
Discharge function score	47.83%	56.45% 8.6 pts worse	Numerator 22 · Denominator 46
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 37 · Denominator 37
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	34.62%	25.2% 9.4 pts better	Numerator 9 · Denominator 26

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.6 0.4 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.7 · Expected 1.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.5 0.3 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.2 · Used in QM five-star
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	98.4%	95.4% 3 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4%
Percentage of long-stay residents experiencing one or more falls with major injury	6.3%	3.8% 2.5 pts worse	3.3% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.7% · Q3 5.2% · Q4 5.1% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	13.7%	24.6% 10.9 pts better	11.4% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.9% · Q3 14.0% · Q4 6.9% · 4Q avg 13.7%
Percentage of long-stay residents who lose too much weight	2.5%	5.6% 3.1 pts better	5.4% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 2.0% · Q3 0.0% · Q4 2.0% · 4Q avg 2.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.4%	23.5% 3.1 pts better	19.6% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.4% · Q3 20.4% · Q4 18.4% · 4Q avg 20.4%
Percentage of long-stay residents who received an antipsychotic medication	5.9%	14.8% 8.9 pts better	16.7% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 9.1% · Q3 2.4% · Q4 4.8% · 4Q avg 5.9% · 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	7.9%	13.3% 5.4 pts better	16.3% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 14.0% · Q4 13.7% · 4Q avg 7.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.1%	11.7% 4.6 pts better	14.9% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 2.3% · Q3 13.3% · Q4 6.5% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.0%	0.4% 1.6 pts worse	1.0% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.5% · Q3 1.8% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.2% 1.2 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	5.3%	24.2% 18.9 pts better	19.8% 14.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 1.7% · Q3 8.2% · Q4 3.2% · 4Q avg 5.3%
Percentage of long-stay residents with pressure ulcers	2.6%	4.1% 1.5 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 1.9% · Q4 5.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	81.6% 17.8 pts better	81.7% 17.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 98.9% · 4Q avg 99.4%
Percentage of short-stay residents who had an outpatient emergency department visit	6.2%	10.5% 4.3 pts better	12.0% 5.8 pts better	Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.6% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.8%	1.3% 0.5 pts worse	1.6% 0.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 3.9% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.5%	79.0% 18.5 pts better	79.7% 17.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.1%	22.4% 1.3 pts better	23.9% 2.8 pts better	Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 16.7% · Expected 18.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-07 · Fire 2025-02-07

7 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-04-23 · Fire 2024-04-23

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-02-24 · Fire 2023-02-24

3 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

11 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-02-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-27

E · Potential for more than minimal harm 2025-02-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-03-27

E · Potential for more than minimal harm 2025-02-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-03-27

C · Minimal harm 2024-04-23

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-20

F · Potential for more than minimal harm 2023-02-24

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-05-08

F · Potential for more than minimal harm 2023-02-24

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-05-08

F · Potential for more than minimal harm 2023-02-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-05-08

F · Potential for more than minimal harm 2023-02-24

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-05-08

F · Potential for more than minimal harm 2023-02-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-02-24

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-02-24

K321 · Smoke Deficiencies

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 2023-05-08

E · Potential for more than minimal harm 2023-02-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-02-24

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-02-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-05-08

D · Potential for more than minimal harm 2023-02-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-05-08

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-07

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2025-03-03

E · Potential for more than minimal harm 2025-02-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-03

D · Potential for more than minimal harm 2025-02-07

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-03

D · Potential for more than minimal harm 2025-02-07

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-03-03

D · Potential for more than minimal harm 2025-02-07

F758 · Pharmacy Service Deficiencies

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 2025-03-03

D · Potential for more than minimal harm 2025-02-07

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 2025-03-03

D · Potential for more than minimal harm 2025-02-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-03

E · Potential for more than minimal harm 2024-04-23