Cycle 1
Health 2025-06-26 · Fire 2025-06-26
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Miller's Merry Manor
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1651 N Campbell St, Indianapolis, IN
(317) 357-8040
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Miller's Merry Manor
Operator or chain grouping
Approved since
1995-04-01
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
0.90
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,265
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.04
Baseline 63.29% · Performance 59.42% · Measure score 1.04 · Achievement 1.04 · Improvement 0.51
Adjusted total nurse staffing
0.36
Baseline 2.95 hours · Performance 3.19 hours · Measure score 0.36 · Achievement 0 · Improvement 0.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 6.49% |
| Discharge to community | 54.85% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 52% · Lower 95% interval 38.24% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 24.39% |
42%
17.6 pts worse
|
Numerator 20 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
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 | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.8%
2.3 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.5% · Q3 4.5% · Q4 4.7% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.0% |
24.6%
2.4 pts worse
|
11.4%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 25.0% · Q3 24.4% · Q4 27.0% · 4Q avg 27.0% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.6%
1.6 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.3% · Q3 10.3% · Q4 5.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
23.5%
2.7 pts better
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.1% · Q3 25.6% · Q4 23.7% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
14.8%
3.1 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 17.6% · Q3 19.4% · Q4 15.6% · 4Q avg 17.9% · 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 | 19.4% |
13.3%
6.1 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 22.6% · Q3 22.3% · Q4 17.8% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
11.7%
5 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.5% · Q3 10.5% · Q4 8.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · 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 | 3.2% |
24.2%
21 pts better
|
19.8%
16.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 2.0% · Q3 4.1% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.1%
0.8 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.2% · Q3 3.9% · Q4 10.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
81.6%
17.5 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
10.5%
0.6 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 9.1% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
79.0%
15.3 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.0% |
22.4%
11.4 pts better
|
23.9%
12.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.1% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-14 · Fire 2024-06-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-05-19 · Fire 2023-05-19
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-06-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-20
F · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-20
E · Potential for more than minimal harm
2025-06-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-20
E · Potential for more than minimal harm
2025-06-26
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-06-26
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-08-20
F · Potential for more than minimal harm
2024-06-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-14
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-08
E · Potential for more than minimal harm
2023-05-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-15
C · Minimal harm
2023-05-19
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-16
G · Actual harm
2024-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
D · Potential for more than minimal harm
2023-05-19
F585 · Resident Rights Deficiencies
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 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-06-05
B · Minimal harm
2023-05-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Boyle, Patrick
Operational/Managerial Control · Individual
Decola, Robert
Operational/Managerial Control · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Officer · Individual
Durham-Boring, Tammy
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Haug, Lori
Operational/Managerial Control · Individual
Johnson Memorial Hospital
Operational/Managerial Control · Organization
Lument Finance Trust Inc
5% Or Greater Mortgage Interest · Organization
Miller's Health Systems Inc
Operational/Managerial Control · Organization
Peterson, Jance
Operational/Managerial Control · Individual
Robinson, Tina
Operational/Managerial Control · Individual
Theracare Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Arlington Place Health Campus
Indianapolis, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Community Nursing And Rehabilitation Center
Indianapolis, IN
2-star overall rating with 1-star inspections with Special Focus status with 24 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Rosewalk Village
Indianapolis, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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