Indianapolis, IN

Northwest Manor Health Care Center

3-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

6440 W 34th St, Indianapolis, IN

(317) 293-4930

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 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

126

Certified beds

Average residents

105

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Adams County Memorial Hospital

Operator or chain grouping

Approved since

1967-01-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 3 overall / 3 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

0.65

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.19

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.52

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.37

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.85

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.72

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.55

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.63

CMS adjusted RN staffing hours

Adjusted total hours

4.21

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

24%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,621

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

Performance score

55.23

Composite VBP score used to determine payment impact.

Payment multiplier

1.0102

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

9.47

Baseline 19.92% · Performance 17.04% · Measure score 9.47 · Achievement 9.47 · Improvement 9

Healthcare-associated infections

1.38

Baseline 7.41% · Performance 7.42% · Measure score 1.38 · Achievement 1.38 · Improvement 0

Total nurse turnover

7.74

Baseline 32.58% · Performance 32.04% · Measure score 7.74 · Achievement 7.74 · Improvement 0.20

Adjusted total nurse staffing

3.50

Baseline 3.81 hours · Performance 4.07 hours · Measure score 3.50 · Achievement 3.50 · Improvement 0.84

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.23%
10.72%
1.5 pts better
No Different than the National Rate · Eligible stays 150 · Observed rate 7.33% · Lower 95% interval 6.78%
Discharge to community 57.9%
50.57%
7.3 pts better
No Different than the National Rate · Eligible stays 118 · Observed rate 51.69% · Lower 95% interval 48.7%
Medicare spending per beneficiary 0.78
1.02
0.2 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 59 · Denominator 59
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 59
Discharge self-care score 23.08%
53.69%
30.6 pts worse
Numerator 12 · Denominator 52
Discharge mobility score 34.62%
50.94%
16.3 pts worse
Numerator 18 · Denominator 52
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 59 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 7.42%
7.12%
0.3 pts worse
No Different than the National Rate · Eligible stays 77 · Observed rate 7.79% · Lower 95% interval 4.66%
Staff COVID-19 vaccination coverage 0.65%
8.2%
7.5 pts worse
Numerator 1 · Denominator 154
Staff flu vaccination coverage 50.57%
42%
8.6 pts better
Numerator 89 · Denominator 176
Discharge function score 30.77%
56.45%
25.7 pts worse
Numerator 16 · Denominator 52
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient 96.88%
96.28%
0.6 pts better
Numerator 31 · Denominator 32
Resident COVID-19 vaccinations up to date 48.39%
25.2%
23.2 pts better
Numerator 15 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.3
1.6
0.3 pts better
1.9
0.6 pts better
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.7
1.5
0.8 pts better
1.8
1.1 pts better
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.7 · 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 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 2.5%
3.8%
1.3 pts better
3.3%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.4% · Q3 3.2% · Q4 1.1% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 4.7%
24.6%
19.9 pts better
11.4%
6.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.8% · Q3 2.3% · Q4 4.7% · 4Q avg 4.7%
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 1.3% · Q2 2.6% · Q3 3.6% · Q4 2.5% · 4Q avg 2.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.2%
23.5%
10.3 pts better
19.6%
6.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.2% · Q3 15.7% · Q4 12.2% · 4Q avg 13.2%
Percentage of long-stay residents who received an antipsychotic medication 9.7%
14.8%
5.1 pts better
16.7%
7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 10.0% · Q3 12.9% · Q4 7.1% · 4Q avg 9.7% · 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 21.3%
13.3%
8 pts worse
16.3%
5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 16.1% · Q3 13.8% · Q4 19.6% · 4Q avg 21.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 22.7%
11.7%
11 pts worse
14.9%
7.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 17.4% · Q3 12.5% · Q4 31.5% · 4Q avg 22.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.6%
0.4%
0.2 pts worse
1.0%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.7% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.2%
1.2%
1 pts worse
1.7%
0.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.1% · Q3 0.0% · Q4 4.6% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 21.9%
24.2%
2.3 pts better
19.8%
2.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 26.4% · Q3 13.8% · Q4 20.5% · 4Q avg 21.9%
Percentage of long-stay residents with pressure ulcers 3.5%
4.1%
0.6 pts better
5.1%
1.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 2.6% · Q4 3.7% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 98.3%
81.6%
16.7 pts better
81.7%
16.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 99.3% · Q3 99.2% · Q4 98.4% · 4Q avg 98.3%
Percentage of short-stay residents who had an outpatient emergency department visit 10.8%
10.5%
0.3 pts worse
12.0%
1.2 pts better
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 11.5% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.3%
1.3%
About the same
1.6%
0.3 pts better
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.1% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91.9%
79.0%
12.9 pts better
79.7%
12.2 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 19.6%
22.4%
2.8 pts better
23.9%
4.3 pts better
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 21.2% · Expected 25.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-11 · Fire 2025-06-11

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

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

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

17 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 3 Health 2023-01-20 · Fire 2023-01-20

10 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-11

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-08-12

F · Potential for more than minimal harm 2025-06-11

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-08-13

F · Potential for more than minimal harm 2025-06-11

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-08-31

E · Potential for more than minimal harm 2025-06-11

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2025-08-14

E · Potential for more than minimal harm 2025-06-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-08-18

E · Potential for more than minimal harm 2025-06-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-08-15

F · Potential for more than minimal harm 2024-04-04

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-07-06

F · Potential for more than minimal harm 2024-04-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-01

F · Potential for more than minimal harm 2024-04-04

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 2024-07-06

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

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-07-06

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

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-07-06

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

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-07-06

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

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 2024-07-06

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

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-07-06

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

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2024-07-06

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

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-06

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

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-06

D · Potential for more than minimal harm 2024-04-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-06

F · Potential for more than minimal harm 2023-01-20

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-02-26

F · Potential for more than minimal harm 2023-01-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-02-24

F · Potential for more than minimal harm 2023-01-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-02-26

E · Potential for more than minimal harm 2023-01-20

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 2023-02-24

E · Potential for more than minimal harm 2023-01-20

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-02-24

D · Potential for more than minimal harm 2023-01-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-02-26

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-22

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-07-22

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-06-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-07-07

D · Potential for more than minimal harm 2025-06-11

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-07-07

D · Potential for more than minimal harm 2025-06-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-07

D · Potential for more than minimal harm 2025-06-11

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 2025-07-07

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

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 2024-05-06

D · Potential for more than minimal harm 2024-04-04

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 2024-05-06

D · Potential for more than minimal harm 2024-04-04

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-05-06

E · Potential for more than minimal harm 2023-01-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-02-20

E · Potential for more than minimal harm 2023-01-20

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-02-20

E · Potential for more than minimal harm 2023-01-20

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-02-20

E · Potential for more than minimal harm 2023-01-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-02-20

E · Potential for more than minimal harm 2023-01-20

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-02-20

E · Potential for more than minimal harm 2023-01-20

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 2023-02-20

D · Potential for more than minimal harm 2023-01-20

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2023-02-20

D · Potential for more than minimal harm 2023-01-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-02-20

D · Potential for more than minimal harm 2023-01-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-02-20

D · Potential for more than minimal harm 2023-01-20

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 2023-02-20

Penalties and ownership

What sits behind the stars

Ownership

Adams County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 52 facilities 2012-07-01
Moser, Steven

5% Or Greater Indirect Ownership Interest · Individual

50% 1 facilities 2012-07-01
Vanderbur, Sharon

5% Or Greater Indirect Ownership Interest · Individual

50% 1 facilities 2012-07-01
Adams County Memorial Hospital

Operational/Managerial Control · Organization

0% 52 facilities 2012-07-01
Borne-Bauman, Candice

Operational/Managerial Control · Individual

0% 45 facilities 2019-01-01
Flueckiger, Russell

Operational/Managerial Control · Individual

0% 46 facilities 2012-07-01
Forvis Mazars Llp

Operational/Managerial Control · Organization

0% 80 facilities 2023-06-01
Kaehr, Ellen

Operational/Managerial Control · Individual

0% 1 facilities 2020-09-15
Lehman, Scott

Operational/Managerial Control · Individual

0% 45 facilities 2020-07-14
Lument Real Estate Capital LLC

5% Or Greater Mortgage Interest · Organization

0% 36 facilities 2012-07-01
Macklin, Larry

Operational/Managerial Control · Individual

0% 45 facilities 2012-07-01
Mcintire, David

Operational/Managerial Control · Individual

0% 44 facilities 2019-01-01
Moser, Steven

Operational/Managerial Control · Individual

0% 1 facilities 2012-07-01
Oasis Healthcare Managemet LLC

Operational/Managerial Control · Organization

0% 1 facilities 2012-07-01
Oasis Healthcare Services, LLC

Operational/Managerial Control · Organization

0% 1 facilities 2012-07-01
Reagan, Bryce

Operational/Managerial Control · Individual

0% 1 facilities 2019-04-03
Smith, Scott

Operational/Managerial Control · Individual

0% 54 facilities 2020-01-01
Sprunger, Kyle

Operational/Managerial Control · Individual

0% 53 facilities 2018-01-01
Vanderbur, Sharon

Operational/Managerial Control · Individual

0% 1 facilities 2012-07-01
Wheeler, Dane

Operational/Managerial Control · Individual

0% 53 facilities 2012-07-01

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Staffing
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