Johnson Memorial Hospital
An acute care hospital in Franklin, Indiana 46131
1125 W Jefferson St, Franklin, Indiana 46131. (317) 736-3300.
Watch and the shortlist are kept with a free account, on every device. Your watch list. CMS’s own record is on Care Compare.
The short answer
Record last released by CMS on Oct 20, 2026.
- 5of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 5 deficiencies cited in the last three years (needs attention)
- 125 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Jun 16, 2026: a complaint inspection.
5 deficiencies cited in the last three years, 1 of them at condition level, the most serious, 2 of them under EMTALA, the law requiring an emergency department to examine and stabilise anyone who comes to it.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
5 deficiencies in 2 months of the last 36. Last cited Aug 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Aug 22, 2024: complaint inspection3 deficiencies
-
Patient Rights
“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48704 Based on document review, observation, and interview, the facility failed to provide a safe environment for 1 of 1 patients (Patient 11). The cumulative effect of this systemic problem resulted in the hospitals inability to promote Patient Rights in a safe setting.”
-
Patient Rights: Care In Safe Setting
The inspectors’ words, 240 words
“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48704 Based on document review, interview, and observation, the facility failed to provide a safe care setting for 1 of 1 patients (Patient 11) medical records reviewed. Findings include: 1. Facility Policy titled, Patient Rights and Responsibilities, Code RI.10.25, last Reviewed/Revised on 05/2024, indicated under Policy Statement: The patient has: f. The right to receive care in a safe setting. 2. Review of Patient 11’s medical record indicated on 08/18/2024 at approximately 2:02 p.m. the patient was taken from the facility by Family Member #1 (Father of Patient 11). Patient 11’s medical record indicated on 08/18/2024 day shift nursing assessment and on 08/19/2024 day shift nursing assessment, lacked documentation of infant security tag. 3. Review of the Root Cause Analysis dated 08/20/2024 indicated that Family Member #1 was able to walk off the unit with Patient 11 and the Maternity Care Unit doors failed to lock. 4. Observation of video footage on 08/21/2024 at approximately 4:40 p.m. confirmed Family Member #1 was able to open secure doors and exit the Maternity Care Unit and leave the facility with Patient 11. 5. Interview with S4 (Registered Nurse) on 08/22/2024 at approximately 4:38 p.m. confirmed that Family Member #1 exited the Maternity Care Unit with Patient 11 and left the facility with Patient 11.”
-
Rn Supervision Of Nursing Care
The inspectors’ words, 111 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on documentation review and interview, nursing failed to complete and document 2 out of 6 infant security checks in 1 of 1 (Patient 11) patient medical records reviewed. Findings include: 1. Review of Patient 11’s medical record indicated on 08/18/2024 day shift nursing assessment and on 08/19/2024 day shift nursing assessment, lacked completion and documentation of infant security tag checks. 2. Interview with S5 (Clinical Analyst) on 08/21/2024 at approximately 3:40 p.m. confirmed Patient 11’s medical record lacked the above documentation.”
Jun 18, 2024: complaint inspection2 deficiencies
-
Compliance With 489.24
The inspectors’ words, 108 words
“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41134 Based on document review and interview, the facility on call provider failed to return an emergency contact request while “on call” at 0453 hours on 04/15/2024, and the facility “on call” policy failed to identify a specific timing requirement in minutes that a provider must respond to a request while “on call” in the review of 1 of 27 medical records and EMTALA policies. Findings Include: 1. See findings cited at 42 CFR 489.20(r)(2) and 489.24(i)(1-2), A2404.”
-
On Call Physicians
The inspectors’ words, 454 words
“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 41134 Based on document review and interview, F1 (Acute Care Facility) failed to ensure MD1, Medical Doctor, Obstetrician Gynecologist who was the primary service contact on the facility “on call” list, failed to respond to an emergency request for service at 0453 hours on 04/15/2024. Findings Include: 1. Facility policy titled “EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) POLICY”, 8395.MS 2014, last approved 09/2021, indicated under Policy: 3. F1 expected on call practitioners to make reasonable efforts to respond timely to requests from the F1 Emergency Department. 2. Review of P1’s medical record indicated that MD1, Medical Doctor, Obstetrician Gynecologist was called at 0454 hours on 04/15/2024 as the listed primary provider “on call” for the facility Obstetrics Service. MD1 did not respond, and an alternate provider had to be contacted. 3. Review of F1’s “on call” list indicated MD1 was listed as being on call 04/15/2024. 4. On 06/18/2024 at 1200 hours, S1, Director of Quality and Safety, confirmed that MD1 was called at 0454 hours on 04/15/2024 as the primary “on call” Obstetrics Service provider, no call back was subsequently received from MD1. S1 also confirmed that the facility policy for Emergency Medical Treatment And Labor ACT (EMTALA) only specifies that “on call” providers will make “reasonable efforts” to respond in a timely manner. S1 confirmed no definitive numeric time requirement exists. S1 confirmed there are no definitive instructions for staff on what to do if contingencies or difficulties occur when attempting to reach the provider who is on the “on call” listing.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jun 16, 2026 | Complaint inspection | No deficiencies cited |
| Aug 22, 2024 | Complaint inspection | 3 deficiencies cited |
| Jun 18, 2024 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 5 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 5; safety of care, 1 better and 0 worse of 3; readmission, 0 better and 0 worse of 6.
- Patients rate it 4 of 5 in CMS’s patient survey (343 surveys completed, Oct 1, 2024 to Sep 30, 2025): 70% rated it 9 or 10 out of 10, and 73% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 12.2%, pneumonia 17%, COPD 9.3%, stroke 14.1%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 21.5%, pneumonia 16.4%, COPD 19.1%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 139 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
- 85% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.96 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 5 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: government - local.
- It is accredited by the Accreditation Commission for Health Care (ACHC), whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Government - Local.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 5 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 83% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 8 owners or officers are people: David H Dunkle (corporate officer, 100%); David H Dunkle (corporate director, 100%); David H Dunkle (runs it (operational or managerial control), 100%); Heather Armstrong (corporate director, 100%); Heather Armstrong (runs it (operational or managerial control), 100%); Adam B Putvin (corporate officer, 100%); Adam B Putvin (corporate director, 100%); Adam B Putvin (runs it (operational or managerial control), 100%).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 3 hospitals CMS lists in Johnson County, 1 has an overall star rating from CMS: 1 rated 5 of 5.
- CMS rates this one 5 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Valle Vista Health System | Not given |
| Medical Behavioral Hospital of Indianapolis | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
-
Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.