Cycle 1
Health 2024-12-20 · Fire 2024-12-20
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mooresville, IN
Miller's Merry Manor
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
259 W Harrison St, Mooresville, IN
(317) 831-6272
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
60
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
1.24
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.41
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
3.84
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0010
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.67
Baseline 18.60% · Performance 18.80% · Measure score 5.67 · Achievement 5.67 · Improvement 0
Healthcare-associated infections
2.78
Baseline 6.21% · Performance 7.00% · Measure score 2.78 · Achievement 2.78 · Improvement 0
Total nurse turnover
9.36
Baseline 62.12% · Performance 25.42% · Measure score 9.36 · Achievement 9.36 · Improvement 9
Adjusted total nurse staffing
1.17
Baseline 3.07 hours · Performance 3.41 hours · Measure score 1.17 · Achievement 1.17 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.65% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 14.41% · Lower 95% interval 8.51% |
| Discharge to community | 56.96% |
50.57%
6.4 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 53.77% · Lower 95% interval 46.74% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.06% |
95.27%
3.2 pts worse
|
Numerator 58 · Denominator 63 |
| Falls with major injury | 3.17% |
0.77%
2.4 pts worse
|
Numerator 2 · Denominator 63 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 27 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 2.41% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 6.14% |
8.2%
2.1 pts worse
|
Numerator 7 · Denominator 114 |
| Staff flu vaccination coverage | 26.53% |
42%
15.5 pts worse
|
Numerator 26 · Denominator 98 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 26 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
93.6%
3.9 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.5% |
| 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 | 3.0% |
3.8%
0.8 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.1% · Q3 2.1% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
24.6%
23.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
5.6%
3.8 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.5% · Q4 2.6% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
23.5%
10.6 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.9% · Q3 15.0% · Q4 13.2% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
14.8%
3.2 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 10.8% · Q3 11.1% · Q4 12.5% · 4Q avg 11.6% · 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 | 14.7% |
13.3%
1.4 pts worse
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 20.2% · Q3 16.1% · Q4 9.3% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
11.7%
9 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 29.3% · Q3 21.1% · Q4 2.8% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
1.2%
3.9 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 12.2% · Q3 2.1% · Q4 2.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.1% |
24.2%
20.1 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.3% · Q3 2.0% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.1%
0.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.0% · Q3 3.5% · Q4 1.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
81.6%
11.4 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 92.3% · Q3 92.1% · Q4 92.4% · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
10.5%
2.1 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 11.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
79.0%
6 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
22.4%
5.3 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 15.0% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-18 · Fire 2023-01-18
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-28
F · Potential for more than minimal harm
2024-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-25
F · Potential for more than minimal harm
2023-01-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-01
E · Potential for more than minimal harm
2023-01-18
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 2023-02-01
E · Potential for more than minimal harm
2023-01-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-02-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-26
D · Potential for more than minimal harm
2023-08-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-01-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-01
D · Potential for more than minimal harm
2023-01-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-01
D · Potential for more than minimal harm
2023-01-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-01
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Andres, Anthony
Operational/Managerial Control · Individual
Boyle, Patrick
Operational/Managerial Control · Individual
Boyle, Patrick
Corporate Director · Individual
Decola, Robert
Operational/Managerial Control · 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
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
Miller's Merry Manor Mooresville LLC
5% Or Greater Mortgage Interest · Organization
Mmm-Invest Inc
5% Or Greater Mortgage Interest · Organization
Peterson, Natalie
Operational/Managerial Control · Individual
Robinson, Tina
Operational/Managerial Control · Individual
Robinson, Tina
Corporate Director · Individual
Theracare Inc
Operational/Managerial Control · Organization
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Springs Of Mooresville, The
Mooresville, IN
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Meadow Lakes
Mooresville, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cumberland Trace Health & Living Community
Plainfield, IN
3-star overall rating with 2-star inspections with $33,579 in total fines with 7 recent health deficiencies
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