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)
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
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
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
1.19
Licensed practical nurse staffing
Aide hours / resident day
2.52
Nurse aide staffing
Weekend hours
3.72
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
24%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
Moser, Steven
5% Or Greater Indirect Ownership Interest · Individual
Vanderbur, Sharon
5% Or Greater Indirect Ownership Interest · Individual
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Kaehr, Ellen
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Moser, Steven
Operational/Managerial Control · Individual
Oasis Healthcare Managemet LLC
Operational/Managerial Control · Organization
Oasis Healthcare Services, LLC
Operational/Managerial Control · Organization
Reagan, Bryce
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Vanderbur, Sharon
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
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2-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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1-star overall rating with 1-star inspections with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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