MILLER'S MERRY MANOR
For profit - Corporation
137 Beds
MILLER'S MERRY MANOR
Data: November 2025
Trust Grade
85/100
#73 of 505 in IN
Photo by Miller's Merry Manor
Photo by Miller's Merry Manor
Photo by Miller's Merry Manor
1 / 10 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Miller's Merry Manor in Warsaw, Indiana has a Trust Grade of B+, which means it is above average and recommended for care. It ranks #77 out of 505 facilities in Indiana, placing it in the top half, and #2 out of 6 in Kosciusko County, indicating only one local option is better. The facility is improving, with the number of issues decreasing from 7 in 2024 to 5 in 2025. Staffing is rated at 4 out of 5 stars, with a turnover rate of 48%, which is about average for the state, but it also boasts more RN coverage than 78% of Indiana facilities, which is a strong point for resident care. However, there are some concerns to note. The facility has faced issues such as improper food storage, which could potentially affect all residents, and delays in sending out personal fund statements, which were sent every six months instead of the required quarterly basis. Additionally, there was a serious incident where a resident fell during a transfer because a gait belt, which is necessary for safety, was not used, highlighting a need for better adherence to care plans. Overall, while Miller's Merry Manor has many strengths, families should be aware of these weaknesses as they consider care options.
- Trust Score
- B+
- In Indiana
- #73/505
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Indiana facilities.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Indiana. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
85/100
Top 14%
No red flags
7 → 5 violations
★★★★★
5.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 5 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 48%
Near Indiana avg (46%)
Higher turnover may affect care consistency
Chain: MILLER'S MERRY MANOR
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 19 deficiencies on record
Apr 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to update the care plan for 1 of 1 residents reviewed for falls (Resident 1).
Finding includes:
A record review was completed on 4/4/2025 at 1...
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Based on record review and interview, the facility failed to update the care plan for 1 of 1 residents reviewed for falls (Resident 1).
Finding includes:
A record review was completed on 4/4/2025 at 11:40 A.M., for Resident 1. Diagnoses included, but were not limited to: chronic pain, anxiety and depression.
A Fall assessment, dated 1/10/2025, indicated Resident 1 fell in her room while being transferred from her bed to her wheelchair by a staff member. When the staff member assisted the resident to stand, her knees buckled and the resident fell onto her right knee.
A Post IDT (interdisciplinary team) Fall Risk assessment, dated 1/10/2025 indicated the root cause for Resident 1's fall was because a gait belt was not used during the transfer. The assessment indicated the staff member was counseled on the proper use of a gait belt.
A Fall assessment, dated 3/13/2025 indicated Resident 1 fell attempting to toilet herself via her wheelchair. It indicated the resident was found during rounds on the bathroom floor by a staff member. The assessment indicated a new intervention to keep her bed in the lowest position was to be put into place post fall.
A Care Plan, initiated on 6/16/23 indicated Resident 1 was at risk for falls due to her condition and risk factors. Interventions included and were limited to: call light within reach, explain use of assistive device upon admission, encourage and assist with wearing non-skid foot-wear, encourage resident to use handrails or assistive devices properly, evaluate effectiveness and side effects of psychotropic drugs with physician for possible decreasing of dose or elimination of medication, keep most used items in arms length to prevent bending and reaching, monitor for changes in gait and positioning, notify Physician of changes in condition and safety strips on bathroom floor.
The current Care Plan related to falls did not include the new interventions regarding gait belt use and keeping the resident's bed in the lowest position.
During an interview on 4/07/2205 at 11:01 A.M., the DON indicated the residents care plan should have been updated with the new fall interventions.
On 4/7/2025 at 12:00 P.M., the DON provided a policy titled, Care Plan Development and Review, dated 1/24/2020 and indicated it was the policy currently being used by the facility. The policy indicated 3. Care Plan Revision: A. Care plans will be revised daily and PRN as changes in the residents condition dictate. Changes include but are not limited to changes in Physician orders, diet changes, therapy changes, behavior changes, ADL changes, skin changes etc
3.1-35(d)(2)(B)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to provide independent leisure activities for 1 of 2 residents reviewed for activities. (Resident 61)
Finding includes:
During an...
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Based on observation, record review and interview, the facility failed to provide independent leisure activities for 1 of 2 residents reviewed for activities. (Resident 61)
Finding includes:
During an observation, on 4/2/2025 at 9:34 A.M. and 2:40 P.M., Resident 61 was observed in bed with her eyes closed without any visual or hearing sensory activities.
During an observation, on 4/3/2025 at 2:17 P.M., Resident 61 was observed in bed with her eyes closed without any visual or hearing sensory activities.
During an observation, on 4/4/2025 at 10:51 A.M., Resident 61 was observed in her Broda chair at the bedside with her eyes closed. There were no stimulating activities occurring in her room.
During an observation, on 4/7/2025 at 8:56 A.M., Resident 61 was observed sitting in the hallway outside her room in a Broda chair. At 9:41 A.M. and 1:53 P.M., she was observed in her bed with her eyes closed and without any visual or hearing sensory activities.
During an observation, on 4/8/2025 at 10:21 A.M., Resident 61 was observed in her bed with her eyes closed.
A record review for Resident 61 was completed on 4/3/2025 at 1:46 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, seizures, aphasia, mood disorder and altered mental status. Resident 61 received end of life care.
A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/2025, indicated Resident 61 was rarely or never understood and was dependent on staff for wheelchair locomotion.
An Annual MDS assessment, dated 09/25/2024, indicated Resident 61's activity preferences were somewhat important for listening to music, having animals around, participating in activities with groups of people, participating in her favorite activities, getting fresh air when the weather was good and participating in religious services or practices.
A Care Plan, initiated on 8/18/2023, indicated the Resident was considered cognitively impaired, was not capable of making decisions about activity involvement and would benefit from sensory related activities. The interventions included, but were not limited to: at times, Resident 61 preferred to vary her rest periods between morning and afternoon, through past history and/or family/resident interview it had been determined that religion had always been important and staff would provide religious music, opportunities to watch services on the television or special local church tapes, and Resident 61 always enjoyed music.
During an interview, on 4/8/2025 at 8:54 A.M., the Activity Director indicated Resident 61 was not typically taken to the activity programs, but would generally receive a sensory activity once a week since she was the only activity staff working recently. She indicated Resident 61 was generally in bed. She indicated music was available in the resident lounge on the television and she tried to take Resident 61 to church services every other week.
During an interview, on 4/8/2025 at 10:30 A.M., LPN 2 indicated Resident 61 laid down in bed after breakfast and lunch. She indicated Resident 61 sometimes attend a sensory activity a couple times a week.
A policy was provided, on 4/8/2025 at 10:14 A.M., by the director of Nursing (DON). The policy titled, Enrichment Program Guidelines, indicated, .1. Purpose A. To enhance the lives of our residents through activity involvement. Benefits include: decreased behaviors, and increase overall satisfaction, and quality of life .III. Level 1/2 [these are lowest functioning-typically the ones who sleep during activities-they need sensory stem] a. Sensory stem-daily before lunch and supper- this will wake them up and stimulate appetite b. Musical programs c. spiritual activities d. Gross Motor movement active exercises-slow repetitive movements ie repetitively clapping hands to music, etc. at least 2 times a week
3.1-33(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide the recommended laboratory work recommended per the facility dietician for 1 of 3 residents reviewed for nutrition. (Resident 76)
F...
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Based on record review and interview, the facility failed to provide the recommended laboratory work recommended per the facility dietician for 1 of 3 residents reviewed for nutrition. (Resident 76)
Finding includes:
A record review for Resident 76 was completed on 4/3/2025 at 1:09 P.M. Diagnoses included, but were not limited to: fracture of the left femur, mild cognitive impairment and chronic kidney disease stage 3b.
A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/2025, indicated Resident 76 was cognitively intact and had a stage 2 and 3 pressure ulcer that were not present on admission.
A Nursing Progress Note, on 12/2/2024 at 5:47 P.M., indicated Resident 76 had laboratory kidney function values of a blood urea nitrogen of 96 mg/dL (milligrams per deciliters) with a normal range of 7-20 mg/dL and a creatinine of 2.9 mg/dL with a normal range of 0.7-1.3 mg/dL
An Admission/Annual/Significant Change/Other Registered Dietician Assessment, dated 1/2/2025, indicated to nursing a suggestion to monitor kidney function due to high protein supplementation and chronic kidney disease stage 3. The assessment indicated Resident 76 received greater than 107 grams of protein per day with supplementation and dietary recommendations. This was an increase from the recommended supplementation from 12/30/2024 of greater than 80 grams of protein per day.
A Registered Dietician Note, on 1/2/2025 at 3:43 P.M., indicated the registered dietician assessment was completed and suggested lab monitoring for kidney function due to high protein supplementation with a diagnosis of chronic kidney disease stage 3.
A Care Plan, initiated 11/25/2024, indicated Resident 76 was at nutritional risk related to chronic kidney disease stage 3, mild cognitive impairment, hypertension, anemia and pressure injury. Interventions included, but were not limited to: serve 8 ounces of milk and 4 ounces of orange juice at all meals, serve 4 ounces of super cereal at breakfast, serve 1-ounce additional protein at breakfast, oral pharmaceutical supplements as ordered: Ensure 237 milliliters twice daily and protein supplementation: ProHeal 30 milliliters twice daily.
During an interview, on 4/7/2025 at 10:40 A.M., the Director of Nursing (DON) indicated recommendations from the registered dietician should be followed and the registered dietician usually puts a note in the medical record for recommendations.
During an interview, on 4/7/2025 at 11:10 A.M., the DON indicated the registered dietician was not aware of laboratory results available in the medical record from 12/2/2024.
During an interview, on 4/8/2025 at 8:47 A.M, the DON indicated the registered dietician did not know laboratory results were available in the medical record from 12/2/2025 and the nurse practitioner would not have drawn labs until six months after the laboratory results from 12/2/20205.
However, there was no indication the MD or NP were made aware of the increased protein and the dietician's recommendation to closely monitor the resident's kidney function.
A policy was provided, on 4/8/2025 at 10:14 A.M., by the DON. The policy titled, Dietician Clinical Communication, indicated, .The Dietary Manager will communicate clinical information to and from the consultant dietician and interdepartmentally .C. The Consultant Dietician or designee will: Make recommendations as needed. Communicate the recommendations and other comments/concerns to the Dietary Manager. D. The Dietary Manager will: Communicate recommendations, other comments and concerns to other departments for their follow-up.
3.1-46(a)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure medications were stored appropriately and were labeled and dated for 1 of 3 medication carts observed. (Windsor 1)
Find...
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Based on observation, interview and record review, the facility failed to ensure medications were stored appropriately and were labeled and dated for 1 of 3 medication carts observed. (Windsor 1)
Finding includes:
During a medication storage observation, on 4/7/2025 at 2:00 P.M., with QMA 4, the following was observed:
- an opened and undated bottle of dorzolamide eye drops with no resident identifiers.
- an unsealed and unlabeled package of petrolatum gauze dressing.
- an open and undated bottle of lactulose (stool softener).
During an interview, on 4/07/2025 at 2:09 P.M., QMA 4 indicated the eye drops should have been labeled and dated. The lactulose should have been dated and the gauze dressing should have been sealed and labeled.
On 4/8/2025 at 8:39 A.M., the Director of Nursing provided the policy titled, Storage of Medications, dated, 12/26/2024, and indicated the policy was the one currently used by the facility. The policy indicated .3. All medications dispensed by the pharmacy are stored in the container with the pharmacy label . 8.Expiration Dating . 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. A. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration
3.1-25(j)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow general Infection Control Practices for 1 of 1 staff observed providing a skin treatment and failed to use a barrier wh...
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Based on observation, interview and record review, the facility failed to follow general Infection Control Practices for 1 of 1 staff observed providing a skin treatment and failed to use a barrier when obtaining a blood sugar sample for 1 of 1 staff observed for insulin administration. (LPN 2 & RN 5)
Findings include:
1. During an observation, on 4/4/2025 at 10:00 A.M., LPN 2 was observed to complete a skin treatment on Resident 145's inner left glueteal cleft. LPN 4 applied gloves and assisted Resident 145 to lay on his right side. LPN 4 removed the dressing from the resident's inner cleft, then removed her right-hand glove and applied a new glove. LPN 4 opened a package of comfort foam dressing. She applied a small amount of Medi-honey (wound gel) to a cotton tipped applicator and then applied the gel to the left gluteal cleft. LPN 4 then placed the foam dressing over the open area. LPN 4 removed the right-hand glove, then used a marker to write the date on the dressing. She applied a new glove to her right hand and assisted the resident to position in the bed. She then applied skin prep (skin barrier) to an area on Resident 145's right heel. LPN 4 then applied skin prep to an area on the resident's left ankle. She then removed both gloves and assisted the aide in placing the bed spread on the bed.
During an interview, on 4/4/2025 at 10:14 A.M., LPN 4 indicated she should have washed her hands after removing the old dressing and after removing her gloves.
2. During a medication observation, on 4/8/2025 at 11:00 A.M., RN 5 was observed to obtain a blood sample. RN 5 disinfected her hands and then applied a gown, mask, and gloves. She entered the residents' room and placed the glucometer (device to monitor blood glucose levels) on the bedside table. She used an alcohol pad and wiped the residents' finger and obtained the blood sample. RN 5 placed the glucometer device back on the table. RN 5 did not place any type of barrier on the table before placing the glucometer on the table.
During an interview, on 4/8/2025 at 11:10 A.M., RN 5 indicated she probably should have placed a barrier on the table.
3.1-18(a)
May 2024
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to identify and clarify a change in advanced directive status related to not keeping physician orders current with a resident's advanced direc...
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Based on record review and interview, the facility failed to identify and clarify a change in advanced directive status related to not keeping physician orders current with a resident's advanced directive instructions for 1 of 1 resident reviewed for hospice. (Resident B)
Finding includes:
A record review for Resident B was completed on 4/30/2024 at 10:38 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, atrial fibrillation, and status post below the knee amputation.
A Significant Change Minimum Data Set (MDS) assessment, dated 3/16/2024, indicated Resident B was cognitively intact and was receiving hospice services.
Advanced Directive forms indicated the following:
- An Out of Hospital Do Not Resuscitate was signed by the Medical Director on 2/9/2024.
- An Indiana Physician Orders for Scope of Treatment (POST) form dated, 3/13/2024, indicated, Do Not Attempt Resuscitation, comfort measures, use of antibiotics for infection only, and no artificial nutrition. The POST was signed by Resident B on 3/13/2024, and the facility Nurse Practitioner signed the form on 3/15/2024.
- A POST form dated, 3/15/2024, indicated, Cardiopulmonary Resuscitation to be provided, comfort measures, use of antibiotics for infection only, and no artificial nutrition. The POST was signed by Resident B on 3/15/2024, and the hospice Medical Director signed the form on 3/27/2024.
A Physician's Order dated, 2/17/2024, indicated, Do Not Resuscitate.
A Care Plan dated, 2/8/2024, indicated the code status was no resuscitate.
During an interview on 5/2/2024 1:06 P.M., LPN 4 indicated should Resident B's heart stop beating, or she stopped breathing, she would keep Resident B comfortable and follow her advanced directives. LPN 4 indicated Resident B had a do not resuscitate order.
A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Advanced Directives, indicated, .[company name] will honor all advanced care planning decisions in accordance with the resident and/or representative wishes .5 .If the resident's preference changes, the medical record documentation will reflect this change
This citation relates to Complaint IN00431936.
3.1-4(f)(4)(A)(ii)
3.1-4(f)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance related to shaving and nail care, for 1 of 2 residents reviewed for activ...
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Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance related to shaving and nail care, for 1 of 2 residents reviewed for activities of daily living. (Resident 234)
Finding includes:
During an observation on 4/29/2024 at 10:01 A.M., Resident 234 was observed to have long facial hair and long fingernails with a brown/black substance underneath them. Resident 234 indicated he did not normally have a beard, and preferred to not have a beard. He indicated his wife had requested for him to be shaved.
During an observation on 5/1/2024 at 10:52 A.M., Resident 234 was observed to not have the longer beard hair, but still had significant stubble on his face. Resident 234 indicated his wife shaved him yesterday. Resident E continued to have long fingernails with the black/brown substance under the nails.
A record review for Resident 234 was completed on 5/1/2024 at 12:49 P.M. Diagnoses included, but were not limited to: urinary tract infection, sepsis, quadriplegia, and diabetes mellitus type 2.
An admission Minimum Data Set (MDS) assessment dated , 4/24/2024, indicated Resident 234 had moderate cognitive impairment with impairment on both the upper and lower extremities. He required partial to moderate assistance for grooming and personal hygiene.
The CNA documentation of showers in the electronic health record, dated 4/19/2024-5/1/2024, indicated Resident 234 received showers on 4/21/2024, 4/25/2024, and 4/29/2025.
A Care Plan for late loss activities of daily living, dated 4/21/2024, indicated Resident 234 needed maximum assistance with dressing, grooming, and bathing.
During an observation on 5/2/2024 at 10:36 A.M., Resident 234's fingernails remained long with black/brown debris under the nails and longer beard stubble.
During an interview on 5/2/2024 at 1:13 P.M., CNA 6 indicated male residents were shaved on their scheduled shower days or when the resident requested to be shaved, and nails were evaluated for trimming on shower days. CNA 6 indicated the staff used shower sheets which indicated if shaving and nail care was provided, or a refusal occurred.
The Shower Sheets were reviewed on 5/2/2024 at 2:06 P.M. Two shower sheets for Resident 234 were provided. On 4/21/2024, the shower sheet indicated Resident 234 was shaved and nail care was provided. The shower sheet on 4/25/2024 indicated no documentation of shaving or nail care.
During an interview on 5/2/2024 at 2:29 P.M., LPN 3 indicated CNAs cannot trim the nails of diabetic residents. She indicated nails were evaluated when the resident was assessed daily, or when the resident was showered, the CNA would inform the nurses of the need for the nails to be trimmed.
A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Morning Care, indicated, .To cleanse and refresh resident, while stimulating circulation and providing comfort and preparing resident for the day .7. Remind or assist male residents to shave
A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Diabetic Nail Care, indicated, .1. Purpose: To promote cleanliness, prevent infection and skin irritation, and to promote a positive self image. To assure that each resident will have a weekly inspection of nails at the time of shower and/or complete bed bath and as needed
3.1-38(a)(3)(D)
3.1-38(a)(3)(E)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to provide care for a central venous catheter (a long, flexible tube inserted into a large vein that leads to the heart) for 1 o...
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Based on observation, record review, and interview, the facility failed to provide care for a central venous catheter (a long, flexible tube inserted into a large vein that leads to the heart) for 1 of 3 residents reviewed for antibiotics (Resident 234) and failed to follow physician orders for 1 of 2 residents reviewed for skin conditions non-pressure related. (Resident 236)
Findings include:
1. During an observation on, 4/29/2024 at 10:01 A.M., Resident 234's central venous catheter to the right chest had a transparent dressing dated 4/19.
A record review was completed on 5/1/2024 at 12:49 P.M. Diagnoses included, but were not limited to: urinary tract infection, sepsis, quadriplegia, and diabetes mellitus type 2.
An admission Minimum Data Set (MDS) assessment, dated 4/24/2024, indicated Resident 234 had intravenous access with medications administered.
A Physician Order dated, 4/25/2024, indicated to change the transparent dressing to the intravenous line every 7 days and as needed if soiled or loose.
A Care Plan dated 4/19/2024, indicated Resident 234 had an intravenous infusion with the potential of infection to the central line site in the right chest.
On 5/2/2024 at 10:38 A.M., Resident 234's central venous catheter continued to be dated 4/19, and the transparent dressing was not adhered to the skin in the 6 o'clock position.
During an interview on, 5/2/2024 at 2:30 P.M., LPN 3 indicated the central venous catheter dressing was to be changed every 7 days. She indicated the Treatment Administration Record (TAR) had been signed by the nurse on 4/25/2024 as being completed, but the facility didn't have a new bio-patch (a dressing that surrounds the central venous catheter entrance to prevent infection) in house to replace the current bio-patch when the dressing change was to be completed, so the dressing was not changed.
During an observation with LPN 3 on, 5/2/2024 at 2:31 P.M., LPN 3 observed Resident 234's central venous catheter dressing and indicated the dressing was dated 4/19, and was not adhered to the skin in the 6 o'clock position.
A policy was provided on, 5/3/2024 at 8:02 A.M. by the Director of Nursing. The policy titled, VADs: [Vascular Access Devices] Ongoing Assessment, Site Care, and Dressing Changes was dated, 10/2/2017. The policy indicated, .Central vascular device and Midline catheter site care and dressing changes are performed every 7 days and when the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment if site infection or inflammation is suspected
2. A record review for Resident 236 was completed on 5/1/2024 at 9:37 A.M. Diagnoses included, but were not limited to: cellulitis of right and left lower limb, chronic venous hypertension with ulcer and inflammation of bilateral lower extremity, peripheral vascular disease, and lymphedema.
Physician Orders, dated 4/25/2024, indicated to apply single tubigrip (an elasticated tubular bandage that provides support and reduces swelling) to left lower extremity daily, on in the morning and off in the evening for wound care and lymphedema.
During an observation on 5/1/2024 at 10:51 A.M., Resident 236's right lower extremity was wrapped with a compression wrap, and the left lower extremity was bare, and appeared very swollen and tight in appearance.
During an observation on 5/2/2024 at 9:45 A.M., and 10:40 A.M., Resident 236's right lower extremity was wrapped with a compression wrap, and the left lower extremity was bare. The compression wrap to the right lower extremity was to remain intact.
An Outpatient/emergency room Services Return Assessment on 4/25/2024 at 4:00 P.M., indicated Resident 236 had an appointment at the wound clinic. The assessment indicated the lymphedema had improved from the prior week, and to start the single tubigrip to the left lower extremity on the morning and off in the evening.
During an interview on 5/2/2024 at 2:40 P.M., RN 5 indicated Resident 236's right lower extremity was wrapped, and those wraps were not removed. The left lower extremity had a single tubigrip placed in the morning and removed in the evening.
During an observation with RN 5 on 5/2/2024 2:42 P.M., RN 5 indicated the tubigrip was on the left lower extremity. RN 5 indicated maybe the staff thought it was evening and removed the tubigrip. Resident 236 interjected and indicated the tubigrip had not been placed all day.
A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, New Order Transcription, indicated, .It is the policy of [facility name] to ensure that physician orders are transcribed and maintained in a manner that ensures safety upon administration
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure respiratory equipment/tubing was properly stored when not in use and cleaned, for 2 of 4 residents reviewed for respir...
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Based on observation, interview, and record review, the facility failed to ensure respiratory equipment/tubing was properly stored when not in use and cleaned, for 2 of 4 residents reviewed for respiratory care. (Residents 46 & 62)
Findings include:
1. During an observation and interview on 4/29/2024 at 9:50 A.M., Resident 42 indicated he slept in his recliner, so the continuous positive airway pressure (CPAP) machine was on top of his bed. The tubing and mask were on top of the machine uncovered. The staff had not cleaned the mask or the tubing for the past 3 months.
During an observation on 4/30/2024 at 9:42 A.M., the mask and tubing were lying on the bed not covered.
During an observation and interview on 5/1/2024 at 2:30 P.M., he indicated no one had cleaned his CPAP tubing or mask yesterday, it was sitting on his bed uncovered.
A record review was completed for Resident 42, on 5/1/2024 at 2:16 P.M. Diagnoses included, but were not limited to: Parkinson's Disease with dyskinesia, and obstructive sleep apnea.
A Physician's Order, dated 3/31/2023, indicated to disinfect tubing, mask and humidifier basin by soaking for 30 minutes in 1 part white vinegar and 4 parts water and air dry monthly, every day shift, on the last day of the month.
The Treatment Administration Record (TAR), dated 4/1/2024 to 4/30/2024, indicated on 4/30/2024 during day shift the task was signed as completed.
During an interview on 5/2/2024 at 8:54 A.M., QMA 7 indicated she had never washed any type of respiratory equipment, the nurses do it. She worked on 4/30/2024 with LPN 8 and LPN 8 would have cleaned the equipment for Resident 42.
During an interview on 5/2/2024 at 8:59 A.M., LPN 7 indicated when she worked with a QMA, she would do the insulin injections, G-tube feedings, breathing treatments, assessments for pain, treatments for open areas, and contact the physician. She did not clean the CPAP equipment for Resident 42 on 4/30/2024.
2. During an observation on 4/29/2024 at 11:26 A.M., Resident 62's nebulizer machine was on the bed with the mask/tubing sitting on the machine uncovered.
During an observation on 4/30/2024 at 9:06 A.M., the nebulizer machine was on Resident 62's bed with mask/tubing sitting on the machine uncovered.
During an observation and interview on 5/2/2024 at 9:47 A.M., Resident 62 indicated she did the breathing treatments 4 times a day, the staff rinsed the equipment out once every other day. She had never had a bag for the mask before, but yesterday the nurse washed it out and said it needed to be in a plastic bag after she used it.
A record review was completed for Resident 62 on 4/30/2024 at 2:33 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease with exacerbation, chronic respiratory disease with hypoxia, and bronchitis.
During an interview on 5/2/2024 at 10:29 A.M., RN 2 indicated after a breathing treatment was completed, she assessed the resident, then wiped the mask with a wet wash cloth, dried it and placed it in a bag, then washed the resident's face.
During an interview on 5/2/2024 at 10:36 A.M., LPN 8 indicated after a breathing treatment, she would reassess the resident, listened to the lungs, and the door needed to be shut for an hour.
During an interview on 5/2/2024 at 2:58 P.M., the DON indicated she would assess the patient then clean the equipment with soap and water, let it air day and place in a plastic bag. The CPAP is cleaned with vinegar and water weekly.
On 5/3/2024 at 8:02 A.M., the DON provided a policy titled, CPAP'/BiPAP. dated 4/4/2024, and indicated the policy was the one currently used by the facility. The policy indicated, .6. Circuits are to be cleaned every week and PRN with sterile water and soap. Hang to dry. Disinfect monthly by soaking for 30 minutes in 1 part white vinegar to 4 parts sterile water. Hang to dry .
On 5/3/2024 at 8:02 A.M., the DON provided a policy titled, High Mist Nebulizer or Oxygen Tank, dated 8/23/2012, and indicated the policy was the one currently used by the facility. The policy indicated . 20. If desired, have the resident rinse mouth with tap water after using nebulizer. Place the nebulizer set into a plastic bag between uses. Do not rinse. Neb set is changed weekly per facility schedule .
3.1-47(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure pharmacy recommendations were given to the physician for review, for 1 of 7 residents reviewed for unnecessary medications. (Residen...
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Based on record review and interview, the facility failed to ensure pharmacy recommendations were given to the physician for review, for 1 of 7 residents reviewed for unnecessary medications. (Resident 47)
Finding includes:
A record review for Resident 47 was completed on 5/1/24 at 3:17 P.M. Diagnoses included, but were not limited to: overactive bladder, allergies and insomnia.
A Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident had intact cognition.
Physician's Orders, dated 4/30/24, indicated the following:
Loratidine (used for allergies) 10mg daily.
Myrbetriq (used for urinary urgency/frequency) 50mg daily.
Melatonin (used for insomnia) 6mg at bedtime.
A Pharmacy Recommendation, dated 2/14/24, indicated Loratadine 10mg to be reduced to every other day. The recommendation lacked documentation it was acted upon in a timely manner.
A Pharmacy Recommendation, dated 3/13/24, indicated Myrbetriq 50mg to be reduced to 25mg daily. The recommendation lacked documentation it was acted upon in a timely manner.
A Pharmacy Recommendation, dated 3/13/24, indicated Melatonin 6mg to be reduced to 5mg at bedtime. The recommendation lacked documentation it was acted upon in a timely manner.
During an interview on 5/2/24 at 11:24 A.M., the Director of Nursing (DON) indicated the new pharmacy representative for the facility was sending communication through a different portal and she was not aware, so she did not complete the recommendations in a timely manner.
On 5/2/24 at 3:20 P.M., the DON provided the policy titled, Response to Pharmacist Recommendations, dated 4/11/17, and indicated the policy was the one currently used by the facility. The policy indicated .3. DON or designee will monitor for physician response and will re-submit to practitioner within 7 days .4. If after resending there is no response within 72 hours, the DON or designee will telephone the physician for verification the physician has reviewed the recommendation and for any new orders
3.1-48(a)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications were kept in a locked cart when unattended for a random observation of 1 of 3 facility medication carts. (Windsor Hall car...
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Based on observation and interview, the facility failed to ensure medications were kept in a locked cart when unattended for a random observation of 1 of 3 facility medication carts. (Windsor Hall cart)
Finding includes:
On 5/2/24 at 10:48 A.M., the medication cart for Windsor Hall was observed with the keys in the drawer and with no licensed nursing staff within sight of the cart. The nurse left the medication cart at 10:48 A.M. and returned to the cart at 10:56 A.M.
During an interview on 5/2/24 at 10:57 A.M., RN 2 indicated she heard a staff member call for help and she left the cart without taking the keys out of the lock. She was not to leave her cart unattended while unlocked and should have taken the cart keys with her.
During an interview on 5/2/24 at 3:25 P.M., the Director of Nursing (DON) indicated the employee should have locked the cart and taken the keys with her, they are not to be left in the medication cart.
On 5/3/24 at 8:00 A.M., The DON provided the policy titled, Storage of Medications, dated 4/24/19, and indicated the policy was the one currently used by the facility. The policy indicated Medications and biological's are stored safely, securely, and properly, following manufacturers recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications
3.1-25(m)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standar...
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Based on observation and interview, the facility failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only, for 3 out of 4 pantry rooms reviewed. This deficient practice had the potential to affect 67 of 67 residents who reside on the units.
Findings include:
1. During an observation on 5/2/2024 at 1:32 P.M., the Boulevard unit pantry had an opened container with 5 slices of cheesecake, an opened package of milk chocolate morsels, and 3 full containers of Culver's ice cream in the refrigerator without a label.
2. During an observation on 5/3/3035 at 1:36 P.M., the Windsor unit pantry had a large blue ice pack in the freezer compartment only. The Dietary Manager did not know why it was in there.
During an interview on 5/2/2024 at 1:38 P.M., CNA 9 indicated the ice pack was used for a resident and had been placed on her hip when she asked for it. LPN 8 then indicated that was where she had always seen it placed, but it should not be in a resident refrigerator.
3. During an observation on 5/2/2024 at 1:49 P.M., the Heritage unit freezer had 3 ice packs: one large blue pack, medium size and a small one. The large blue ice pack had a bag of frozen green beans underneath it and another bag of green beans in the door shelf.
During an interview on 5/2/2024 at 1:50 P.M., the Dietary Manager indicated that all food should be labeled with a date and the resident's name, and ice packs used for the Residents should not be in the pantry refrigerators on the units.
On 5/2/2024 at 2:00 P.M., the Dietary Manager indicated she did not have a policy on the storage of residents' ice pack in the nourishment freezers.
On 5/2/2024 at 2:00 P.M., the Dietary Manager provided a policy titled, Resident Food From Outside Source, dated 11/28/2023, and indicated the policy was the one currently used by the facility. The policy indicated .1. Family and friends are welcomes to bring food from outside source into facility for a resident. 2. Items for a resident must be labeled with name and room number and date food brought into the facility .
3.1-21(i)(3)
Mar 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents are able to withdrawal their money during the evening hours Monday through Thursday for 1 of 21 residents reviewed for per...
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Based on record review and interview, the facility failed to ensure residents are able to withdrawal their money during the evening hours Monday through Thursday for 1 of 21 residents reviewed for personal funds. (Resident 36)
Finding includes:
During an interview, on 3/01/2023 at 10:49 A.M., Resident 36 indicated she could not get her money at any time.
A clinical record review was completed on, 3/6/2023 at 10:39 A.M. Resident 36's diagnoses included, but were not limited to: anemia, diabetes, anxiety, and depression.
An Annual MDS (Minimum Data Set) Assessment, dated 12/14/2022, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15, cognition intact.
During an interview, on 3/3/2023 at 1:43 P.M., business office staff 6 indicated the residents could get money on Monday through Friday from 8:00 A.M. to 4:30 P.M., and all hours on the weekends. Business office staff 6 indicated the nurse on the rehab unit would be given the cash bag on Friday afternoon until Monday morning when the bag would be reconciled then given back to the receptionist.
During an interview, on 3/3/2023 at 3:07 P.M., the Administrator indicated the residents should be able to get their money during the evenings also.
On 3/6/2023 at 4:10 P.M., the Administrator provided the policy titled,Resident Fund Procedures with PCC, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Funds should be readily available for residents. It is suggested that at the time of admission, the family and /or the resident be advised of the business office hours. 03/25/11 Petty Cash is available to residents as they request it even on weekends.9. A minimum balance of $50.00 should be kept in the resident fund petty cash box at all times. Federal and State laws require that we be able to supply a resident with $50.00 cash upon demand
3.1-6(f)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to prevent verbal abuse to 1 of 2 resident reviewed for abuse. (Resident 176)
Finding includes:
On 3/02/2023 at 8:02 A.M., the Administrator ...
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Based on record review and interview, the facility failed to prevent verbal abuse to 1 of 2 resident reviewed for abuse. (Resident 176)
Finding includes:
On 3/02/2023 at 8:02 A.M., the Administrator indicated there was an allegation of abuse. It was between the night nurse and Resident 176. She provided a copy of the reportable that was submitted on 3/2/2023.
The reportable indicated: Incident Time: 11:35 P.M. Brief Description of Incident: Other nurse on the unit overheard LPN 8 call resident 176 an a-- h---. No injury noted to the resident. Immediate Action Taken: LPN 8 left residents room as she made the a-- h--- comment. CNA 9 went into the residents' room to checked on resident. Resident 176 indicated he was alright and that he had a rough day and apologized for having also called LPN 8 an a--h--- and wanted to apologize to her. CNA 9 told Resident 176 he could speak to LPN 8 shortly, she wanted to give the nurse time to cool off from the situation. Preventative Measures Taken: Other Nurse on the unit called the Director of Nursing, who then called the Administrator to alert of the incident. The Director of Nursing and the Administrator arrived at the building and interviewed LPN 8. LPN 8 was then sent home from her shift pending investigation. The NP (Nurse Practitioner) also notified of event.
A clinical record review was completed on, 3/3/2023 at 5:30 A.M. Resident 176's diagnoses included, but were not limited to, obesity, end stage renal disease, diabetes, respiratory failure, congestive heart failure and anxiety.
A 5 day MDS (Minimum Data Set) Assessment, dated 2/25/2023, indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15, cognition intact, had no mood issues or behaviors.
The Follow up report, dated 3/6/2023, indicated: Investigation of the occurrence, from 3/1/2023, revealed that Resident 176 was disgruntled when the LPN 8 indicated that he had a fluid restriction and that was why there was no water pitcher at his bedside. LPN 8 provided education on fluid restriction and provided the resident with a cup of water. Resident 176 continued to express his desire to have a water pitcher and LPN 8 confirmed as she was exiting the residents' room, she mumbled a-- h---. Resident 176 was interviewed and indicated that he yelled at the nurse over not having a water pitcher at bedside, and that LPN 8 did call him an a-- h---. Other residents on the unit were interviewed and voiced no concerns of care or verbal exchanges with staff, specifically LPN 8. Following suspension and investigation of the occurrence, LPN 8 was terminated.
During an interview, on 3/7/2023 at 9:35 A.M., the Administrator indicated the resident was not free from abuse by what the staff nurse had said to the resident.
On 3/2/2023 at 11:50 A.M., the Administrator provided the policy titled,Abuse Prohibition, Reporting, and Investigation, dated 12/4/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Policy: .all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion . C. Verbal Abuse- The use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. I. Staff to Resident -any episode . Investigating and Reporting To Correct Authority .11. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until the investigation is completed
3.1-27(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report to state agencies an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 34)
Finding includes:
During an intervie...
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Based on record review and interview, the facility failed to report to state agencies an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 34)
Finding includes:
During an interview, on 3/01/2023 at 9:59 A.M., Resident 34 indicated about a month ago a nurse on evenings yelled at her.
On 3/2/2023 at 9:00 A.M., the Administrator provided a concern report for Resident 34, dated 2/14/2023. The concern report indicated the resident had reported to the Director of Nursing about the nurse telling her to get back to her room and she would come later to give her the medications.
The concern report indicated the nurse was heard telling the resident to go back to her room and was not demeaning in any way. The Administrator interviewed 4 other residents on the unit and had no negative responses. The Staff member was educated.
A clinical record review was completed on, 3/3/2023 at 2:27 P.M. Resident 34's diagnoses included, but were not limited to: renal failure, diabetes, and depression.
A Quarterly MDS (Minimum Data Set) Assessment, dated 2/15/2023, indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15, cognition intact and had no behaviors.
During an interview, on 3/2/2023 at 3:53 P.M., the Administrator indicated she did not report the concern to the state. She stated they determined that the nurse was not willful in her response to the residents request and the resident did not have any emotional outcome and the resident did not allege any abuse of any kind.
On 3/2/2023 at 11:50 A.M., the Administrator provided the policy titled,Abuse Prohibition, Reporting, and Investigation, dated 12/4/2017, and indicated the policy was the one currently used by the facility. The policy indicated . 3 . {Name of Facility} has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) . Investigating and Reporting to Correct Authority: 1. All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately . 2. Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures as outlined in the Incident Reporting to the ISDH procedure
3.1-28(c)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and interview, the facility failed to develop a person-centered care plan for 1 of 25 residents reviewed. (Resident 19)
Finding includes:
During an interv...
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Based on observation, clinical record review, and interview, the facility failed to develop a person-centered care plan for 1 of 25 residents reviewed. (Resident 19)
Finding includes:
During an interview on 3/6/2023 at 11:04 A.M., LPN 3 indicated Resident 19 had a skin tear on her left outer arm but could not find the skin tear on the care plan. LPN 3 indicated that current skin issues should be on the care plan.
During a clinical record review conducted on 3/3/2023 at 2:13 P.M., a Significant Change MDS (Minimum Data Set) Assessment for Resident 19, dated 12/14/2022, included, but was not limited to, a BIMS (Brief Interview for Mental Status) of 3, severe impairment and no behaviors. She required limited assist of 1 staff person for bed mobility, extensive assist of 2 staff persons for transfers and toileting, and extensive assist of 1 staff person for dressing. Skin condition indicated skin tears present.
Diagnoses for Resident 19 included, but were not limited to: unspecified dementia with other behavioral disturbances.
Physician orders for Resident 19 included, but were not limited to: on 2/3/2023 cleanse area on left outer arm with soap and water apply ABD pad cover the site of concern with dressing and wrap with kerlix. On 2/8/2023 geri-sleeves to both upper extremities at all times to prevent further skin tears and abrasions.
A care plan for Resident 19, dated 1/2/2023, included, but was not limited to: a problem for chronic bruises and skin tears. Interventions included, but not limited to, apply geri-legs, apply geri-sleeves, apply lotion to skin as needed, keep fingernails trimmed and filed, and be aware that resident picks at geri-sleeves as well as skin at times.
A policy provided by the Executive Director on 3/6/2023 at 4:10 P.M., included, but was not limited to: .Care plans will be revised daily and as needed as changes in the resident's condition dictate. Changes include but are not limited to, changes in physician orders, diet changes, therapy changes, behavior changes, ADL (Activities of Daily Living) changes, skin changes etc
3.1-35(d)(1)(2)(A)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to follow physicians orders for fluid restriction for 1 of 1 resident receiving dialysis. (Resident 176)
Finding includes:
During an interview...
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Based on record review and interview, the facility failed to follow physicians orders for fluid restriction for 1 of 1 resident receiving dialysis. (Resident 176)
Finding includes:
During an interview, on 3/1/2023 at 9:16 A.M., Resident 176 indicated he received dialysis three times a week on Monday, Wednesday and Friday and was on a fluid restriction.
A clinical record review was completed, on 3/3/2023 at 5:30 AM. Resident 176's diagnoses included, but were not limited to: obesity, end stage renal disease, diabetes, respiratory failure, congestive heart failure and anxiety.
Resident 176'2 current Physician Orders included: 2000 cc fluid restriction ordered on 2/22/2023, carbohydrate controlled diet, daily weights after voiding (urination) and before breakfast/medications with the same clothes each day every evening shift on Monday, Wednesday and Friday, and Notify the physician of a 2 Lb. gain in 1 day and 4 Lb. gain in 5 days.
A current care plan, dated 3/1/2023, indicated the resident had the potential for alteration in fluid balance related to: end stage renal disease, congestive heart failure, and often drinks more fluids beyond the ordered restricted amount of 2000 daily. Interventions included, but were not limited to fluid restriction as ordered.
A Nutritional Risk Assessment, dated 3/1/2023, indicated Resident 176 was at nutritional risk related to: recent hospitalization, diagnosis of End Stage Renal Disease with dialysis, diabetes, congestive heart failure, and fluid restriction. Monitor weights and intakes. Provide fluid restriction of ml (milliliters). Nursing to provide 920 ml's and dietary 1080 ml's.
A Physician's Order, dated 3/1/2023, indicated the resident was allowed 300 cc fluids per shift from nursing.
The Fluid Intakes, dated from 2/22/2023 to 3/6/2023, indicated Resident 176 had received the following extra fluids from the aides:
2/23/2023 a total of 1840 ml.
2/24/2023 a total of 1580 ml.
2/25/2023 a total of 2040 ml.
2/26/2023 a total of 1990 ml.
2/27/2023 a total of 1840 ml.
2/28/2023 a total of 2170 ml.
3/2/2023 a total of 2020 ml.
3/3/2023 a total of 1380 ml.
3/4/2023 a total of 2020 ml.
3/5/2023 a total of 2030 ml.
3/6/2023 a total of 1500 ml.
During an interview, on 3/6/2023 at 1:54 P.M., the Director of Nursing indicated the aides should not have given him more fluids.
On 3/ 7/2023 at 9:36 A.M., the Social Service staff provided the policy titled, Nursing Fluid Restriction Procedure, dated 3/13/2012. The policy indicated .Purpose: To plan and schedule fluid amounts to be offered to any resident on a fluid restriction in an effort to follow the prescribed order.4. Place amount of fluids in ml/cc to be given with each meal on the Medication Administration Record so all nurses are aware of the amount allotted at each meal . 7. Indicate the allotted fluid amounts and times on the nurse aide assignment sheet. 8. Resident should not be provided with a water pitcher or be given water when passes unless a part of the fluid restriction plan of care
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide a routine ordered medication for 1 of 9 residents whose medications were reviewed. (Resident 18)
Finding includes:
During an interv...
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Based on record review and interview, the facility failed to provide a routine ordered medication for 1 of 9 residents whose medications were reviewed. (Resident 18)
Finding includes:
During an interview, on 3/01/2023 at 9:40 A.M., Resident 18 indicated she had been without the inhaler for awhile they said I used it too much.
A clinical record review was completed on, 3/7/2023 at 10:00 A.M. Resident 18's diagnoses included, but were not limited to:+ diabetes, depression, chronic obstructive pulmonary disease, respiratory failure and dementia.
A Quarterly MDS (Minimum Data Set) Assessment, dated 12/7/2022, indicated the resident BIMS (Brief Interview for Mental Status) score of 14, cognition intact and received oxygen.
The January MAR (Medication Administration Record) indicated Resident 18 had an order for Breo Ellipta aerosol powder inhaler 1 puff inhale orally one time a day COPD (chronic obstructive pulmonary disease) with a start date of 2/7/2022 and a discontinued date of 1/30/2023. The MAR was coded as a 3 (hold see progress notes) on 1/27, 1/28, 1/29 and 1/30/2023 for the Breo inhaler.
A Progress Note, dated 1/27/2023 at 10:08 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, called pharmacy will provide on the 24 th.
A Progress Note, dated 1/28/2023 at 8:53 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, NP notified.
A Progress Note, dated 1/29/2023 at 8:21 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, NP aware.
A Progress Note, dated 1/30/2023 7:06 A.M., indicated the inhaler was unavailable, insurance to refill on 2/14/2023.
A Physician's Order, dated 1/30/2023 at 3:41 A.M., indicated to give Resident 18 Torsemide (diuretic) 20 mg STAT (immediately) for COPD exacerbation.
A NP (Nurse Practitioner) Progress Note, dated 1/30/2023, indicated the resident was seen by the NP and new orders included; stop the Breo inhaler; start Anoro inhaler 1 puff daily for COPD; and Prednisone (steroid/anti inflammatory) 40 mg (milligrams) one time a day for COPD exacerbation (acute increase) for 3 days starting on 1/30/2023.
A current care plan, dated 7/30/2021, indicated the resident had chronic respiratory disease, and had the potential for exacerbation of: COPD, chronic respiratory failure. Interventions included, but were not limited to: administer medications as ordered and monitor vital signs at least weekly.
During an interview, on 3/7/2023 at 3:05 P.M., the Director of Nursing indicated there was an issue with the inhaler due to a prior authorization was needed. The NP knew about it and was working on it, so she started a new inhaler for the resident. The Director of Nursing indicated that the nurses did not chart in the nurses notes about not having the medication and or the fact that it needed a prior authorization. She also indicated the nurses did not inform or call the NP about the inhaler not available or to get another medication out of the emergency drug kit (Pyxis).
On 3/7/2023 at 3:45 P.M., the Director of Nursing provided the policy titled,Use of the PYXIS Specialty Station dated 11/3 2022. The policy indicated . Other Information: 1. Medications needed, but not available in the Pyxis machine, contact the pharmacy for delivery arrangements
3.1-25(a)
3.1-25(g)(2)
3.1-25(g)(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents fund statements were sent out timely for 21 of 21 residents with a personal funds account at the facility.
Finding includ...
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Based on record review and interview, the facility failed to ensure residents fund statements were sent out timely for 21 of 21 residents with a personal funds account at the facility.
Finding includes:
During an interview, on 3/3/2023 at 1:43 P.M., Business office staff 6 indicated resident statements were sent out every 6 months.
During an interview on, 3/320/23 at 3:07 P.M., the Administrator indicated the business office staff had only worked a year and was not aware that the statements should have been sent out quarterly and not every 6 months.
On 3/6/2023 at 4:10 P.M., the Administrator provided the policy titled, Resident Fund Procedures with PCC, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 21. Send quarterly statements of account activity to the resident and /or responsible party and have them return with proper signature. These statements should be mailed within 30 days of the end of the quarter
3.1-6(g)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (85/100). Above average facility, better than most options in Indiana.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Indiana facilities.
Concerns
- • 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Miller'S Merry Manor's CMS Rating?
CMS assigns MILLER'S MERRY MANOR an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Indiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Miller'S Merry Manor Staffed?
CMS rates MILLER'S MERRY MANOR's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 48%, compared to the Indiana average of 46%.
What Have Inspectors Found at Miller'S Merry Manor?
State health inspectors documented 19 deficiencies at MILLER'S MERRY MANOR during 2023 to 2025. These included: 19 with potential for harm.
Who Owns and Operates Miller'S Merry Manor?
MILLER'S MERRY MANOR is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MILLER'S MERRY MANOR, a chain that manages multiple nursing homes. With 137 certified beds and approximately 89 residents (about 65% occupancy), it is a mid-sized facility located in WARSAW, Indiana.
How Does Miller'S Merry Manor Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, MILLER'S MERRY MANOR's overall rating (5 stars) is above the state average of 3.1, staff turnover (48%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Miller'S Merry Manor?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Miller'S Merry Manor Safe?
Based on CMS inspection data, MILLER'S MERRY MANOR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Miller'S Merry Manor Stick Around?
MILLER'S MERRY MANOR has a staff turnover rate of 48%, which is about average for Indiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Miller'S Merry Manor Ever Fined?
MILLER'S MERRY MANOR has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Miller'S Merry Manor on Any Federal Watch List?
MILLER'S MERRY MANOR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.