Cycle 1
Health 2024-12-06 · Fire 2024-12-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Culver, IN
Miller's Merry Manor
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
730 School St, Culver, IN
(574) 842-3337
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Miller's Merry Manor
Operator or chain grouping
Approved since
1995-11-01
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
0.78
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.46
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
2.89
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.26
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
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,169
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
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
2.24
Baseline 7.56% · Performance 7.16% · Measure score 2.24 · Achievement 2.24 · Improvement 1.06
Total nurse turnover
3.10
Baseline 48.65% · Performance 51.02% · Measure score 3.10 · Achievement 3.10 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 7.18% |
| Discharge to community | 59.2% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 54.55% · Lower 95% interval 48.38% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 26.92% |
53.69%
26.8 pts worse
|
Numerator 7 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 5.02% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 6.25% |
42%
35.8 pts worse
|
Numerator 5 · Denominator 80 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 4.6% |
3.8%
0.8 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 5.1% · Q4 6.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 32.9% |
24.6%
8.3 pts worse
|
11.4%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 25.0% · Q3 42.1% · Q4 46.5% · 4Q avg 32.9% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.6%
3.7 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 5.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
23.5%
14.6 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.5% · Q3 5.6% · Q4 10.0% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
14.8%
1.3 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 18.8% · Q3 18.8% · Q4 13.5% · 4Q avg 16.1% · 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 | 14.3% |
13.3%
1 pts worse
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 21.9% · Q3 7.6% · Q4 18.9% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
11.7%
3.4 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 13.5% · Q3 15.2% · Q4 21.1% · 4Q avg 15.1% · 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 | 4.6% |
1.2%
3.4 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.5% · Q3 5.3% · Q4 4.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.4% |
24.2%
13.8 pts better
|
19.8%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 8.5% · Q3 11.3% · Q4 16.1% · 4Q avg 10.4% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.1%
1.4 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.1% · Q3 5.0% · Q4 2.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
81.6%
17.4 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 98.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.1% |
10.5%
9.6 pts worse
|
12.0%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 20.0% · Expected 11.1% · 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 | 98.1% |
79.0%
19.1 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.4%
1.9 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 22.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-06
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-24
E · Potential for more than minimal harm
2022-12-02
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 2023-03-06
C · Minimal harm
2022-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-11
D · Potential for more than minimal harm
2024-12-06
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 2024-12-26
D · Potential for more than minimal harm
2024-12-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-01-12
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 2024-02-03
E · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-12
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 2024-02-03
D · Potential for more than minimal harm
2022-12-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-24
D · Potential for more than minimal harm
2022-12-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-24
D · Potential for more than minimal harm
2022-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-24
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
Clemons, Craig
Operational/Managerial Control · Individual
Decola, Robert
Operational/Managerial Control · Individual
Dunkle, David
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Haug, Lori
Operational/Managerial Control · Individual
Holm, Byron
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
Robinson, Tina
Operational/Managerial Control · Individual
Theracare Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Miller's Merry Manor
Plymouth, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Pilgrim Manor
Plymouth, IN
2-star overall rating with 1-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Brickyard Healthcare - Knox Care Center
Knox, IN
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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