Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
Activities Program Not Directed by Qualified Professional: The Activities Director lacked required training and/or certification before assuming the role and had no evidence of an approved activities training course or other qualifying documentation in the record. The AD stated she had been serving in the role after previously working as the assistant to the AD, was waiting to start online training, and continued scheduling activities while awaiting the program start date; the Administrator confirmed the same.
Infection Control Lapses With Draining Wounds and Foley Catheters: A resident with dementia, peripheral vascular disease, and multiple draining lower-extremity wounds was observed moving around the unit with the wounds exposed, including while entering another resident’s room, and staff noted the wounds should have been covered. Two residents with foley catheters were also observed with tubing or drainage bags touching the floor or dragging during wheelchair transport, despite orders and policy requiring the bag to remain below the waist and not touch the floor.
A resident with severe cognitive impairment and multiple medical conditions experienced repeated falls resulting in serious injuries, including fractures, due to inadequate supervision and ineffective fall prevention interventions. Despite care plans that included a low bed, floor mat, non-skid socks, and frequent checks, the resident continued to attempt self-transfers and ambulation without staff assistance. Staff interviews revealed inconsistent knowledge and communication about fall prevention measures, and the resident's call light was found nonfunctional at times.
The facility failed to maintain sanitary food handling practices, affecting all residents receiving meals. Observations revealed that staff did not change gloves between tasks or wash hands before applying new gloves. A CNA handled food without proper hand hygiene, and the facility's policies on hand washing and glove use were not followed.
A resident's dignity was compromised when their urinary catheter bag was left exposed and visible to others, contrary to physician orders and facility policy. The catheter bag was observed hanging on the right side of the bed, visible from the room and hallway, without a dignity cover. The facility's policy required catheter bags to be covered, but this was not adhered to, as confirmed by the Infection Preventionist.
The facility failed to provide therapeutic pureed diets as ordered for two residents. During a meal observation, both residents received regular gelatin instead of pureed gelatin, and one resident did not receive the required gravy with their meal. The dietary manager was unaware of the need to puree the gelatin, and the facility's policies on food texture alteration were not followed.
A facility failed to follow Enhanced Barrier Precautions during wound care for a resident with antibiotic-resistant bacteria, as a nurse did not wear a gown despite policy requirements. Additionally, a QMA administered eye drops to another resident without performing hand hygiene or wearing gloves, contrary to facility policy.
The facility failed to ensure pneumococcal vaccinations were offered or administered to three residents. One resident, admitted in 2020 with hemiplegia, COPD, and diabetes, had an undated refusal for PCV 13 and PPSV 23 vaccines, with no updated documentation since 2020. Another resident, admitted in 2024 with heart failure and diabetes, had an undated refusal and pending entry for Prevnar 20, with no confirmation of vaccination. A third resident, admitted in 2019 with Alzheimer's, COPD, and anxiety disorder, had an undated refusal for PCV 13, with refusal documentation from 2019 but no updates since.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The Activities Program was not directed by a qualified professional because the Activities Director lacked the required training and/or certification for the position before assuming the role. Review of employee records showed no evidence that the Activities Director had completed an approved activities training course or had documentation showing qualifications consistent with regulatory requirements at the time she was hired into the position. During interview, the Activities Director stated she had been in the position since 12/1/25 and had previously served as the assistant to the Activities Director, a role she said did not require training. She stated that after being hired as the Activities Director, she signed up for online training but was still waiting for a start date from the program and continued to schedule activities in the meantime. The Administrator confirmed the Activities Director's start date and stated they were both awaiting notification from the training program. Facility policy identified required qualifications for the Activity Director or Director of Life, including licensure or registration if applicable, eligibility for certification as a therapeutic recreation specialist or activities professional, two years of experience in a social or recreational program within the last five years with one year full-time in a patient activities program in a health care setting, or qualification as an occupational therapist or occupational therapy assistant.
Infection Control Lapses With Draining Wounds and Foley Catheters
Penalty
Summary
The facility failed to use infection prevention and control practices for a resident with draining venous wounds. Resident 64 had diagnoses including dementia, lymphedema, peripheral vascular disease, chronic obstructive pulmonary disease, and altered mental status. Her record showed ongoing wound treatment orders for both lower legs and the left third toe, and care plans noted that she frequently removed her dressings and declined some interventions. On observation, she was seen moving around the unit barefoot or with only partial footwear, with her left pant leg pulled up and multiple wounds exposed and draining serosanguineous fluid. During the observations, the resident’s left leg wounds were open to air with drainage trailing down the leg, and the left third toe had swelling, discoloration, and drainage. She entered another resident’s room while the wounds remained exposed. Later, the wound nurse observed the wounds still visible and draining, cleansed and dressed them, and stated the resident should not walk around the unit with draining wounds uncovered. The wound nurse also noted the resident’s feet were dirty and that the left foot should have been washed before putting on a nonskid sock. Staff interviews indicated that residents with open, draining wounds should have their legs and feet wrapped or covered, and the DON stated that if dressings were removed, staff should redirect the resident away from other residents and attempt to place a barrier on the draining wounds. The nursing notes did not document that the resident had removed her dressings or footwear that day. The facility also failed to maintain foley catheter tubing and drainage bags in a sanitary manner for two residents. Resident 82 was observed with catheter tubing lying on the floor beneath her wheelchair, and later her catheter bag was under the wheelchair in a privacy bag with part of the bag touching the floor and dragging as she was moved down the hallway. At another observation, her catheter bag was lying on the floor beside her recliner. Staff then repositioned the bag to the walker or between the recliner and leg rest. Resident 68 was later observed with catheter tubing lying on the floor beneath her wheelchair, and an RN secured it inside the privacy bag. Both residents had orders for catheter care every shift and for the drainage bag to be below the waist and covered, and the facility policy stated that catheter tubing or the bag should not touch the floor.
Failure to Provide Adequate Supervision Resulting in Repeated Falls and Injuries
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent repeated falls for a cognitively impaired resident, resulting in multiple serious injuries. The resident, who had diagnoses including unspecified dementia, mild cognitive impairment, urinary tract infection, and benign prostatic hyperplasia, experienced a series of falls over several weeks. These falls occurred in various locations, such as the bathroom, next to a recliner, and on the floor beside the bed, often when the resident attempted to transfer or ambulate without assistance. The resident's care plan included interventions such as a low bed, floor mat, non-skid socks, 15-minute checks, and staff reminders to use the call light, but these measures did not prevent repeated incidents. The resident was assessed as severely cognitively impaired and required varying levels of staff assistance for activities of daily living, including substantial or maximal assistance for toileting, transfers, and ambulation. Despite this, the resident was frequently found attempting to self-transfer or ambulate without staff help, often due to confusion, urinary urgency, or lack of safety awareness. Several root cause analyses identified issues such as confusion related to a new environment, urinary retention, and discontinued catheter use as contributing factors. In some instances, the resident's call light was found to be nonfunctional, and staff were not always aware of or able to locate the specific fall prevention interventions in place for the resident. Staff interviews revealed inconsistencies in knowledge and communication regarding the resident's fall interventions. Some CNAs were unsure where to find information about fall prevention measures, relying instead on verbal communication or personal familiarity with residents' behaviors. The facility's policy required assessment of fall risk factors and implementation of planned interventions, but the repeated falls and resulting injuries, including multiple fractures and a hospital admission, indicate that adequate supervision and effective interventions were not consistently provided for this resident.
Sanitary Food Handling Deficiency
Penalty
Summary
The facility failed to ensure food was served under sanitary methods, impacting all 73 residents who received meals. During a lunch meal service observation, Cook 5 was seen wearing gloves while touching various items such as meal trays, bread bags, and cheese without changing her gloves. She used the same gloves to prepare bread rolls and cheese, which were then handed to Cook 4, who also did not change her gloves while handling multiple items. Cook 5 left the kitchen with soiled gloves, touched the door and door knob, and upon returning, did not wash her hands before putting on new gloves. In a separate observation in the memory care unit, a CNA was seen delivering trays to residents and handling food without proper hand hygiene. The CNA opened ketchup packets and squeezed the contents onto sandwiches, and when a resident requested their sandwich to be cut, the CNA used her bare hand to grip the bun while cutting it. The Dietary Manager confirmed that food should not be touched with gloved hands and that hand washing is required before applying gloves. The facility's policies on hand washing and glove use were not followed, as gloves were not changed between tasks and hands were not washed before and after glove use.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident by not properly handling the resident's urinary catheter. During observations on two separate occasions, the resident's catheter bag was found hanging on the right side of the bed frame, exposed, and visible to others, with urine clearly seen in the bag. This was contrary to the physician's orders, which specified that the catheter drainage bag should be covered every shift and placed below the waist. The facility's policy on Foley Catheter Care & Maintenance required catheter bags to be placed in dignity bags when residents are in or out of their rooms. However, during a catheter care observation, an RN noted that a device meant to cover the catheter bag was only present on the left side of the bed, which was against the wall, leaving the right side exposed to the room and hallway. The Infection Preventionist confirmed that all catheter bags should be placed in dignity bags, indicating a failure to adhere to the facility's policy.
Failure to Serve Therapeutic Pureed Diets as Ordered
Penalty
Summary
The facility failed to serve a therapeutic pureed diet as ordered by a physician for two residents who required pureed diets. During a lunch meal observation, both residents were served regular gelatin dessert with whipped topping, which was not pureed as required. The gelatin was cubed and solid, contrary to the facility's recipe for pureed diet gelatin, which specified that the gelatin should be blended until smooth. Additionally, one resident's meal ticket indicated that gravy should be served with their meat and potatoes, but no gravy was provided, and the resident consumed the meal without it. The dietary manager admitted to not realizing that the gelatin was supposed to be pureed before service. Resident 42 had a diagnosis of vascular dementia, anxiety, and dysphagia, with a current order for a pureed diet due to dysphagia. The resident's care plan highlighted the need for a therapeutic diet and mechanically altered food due to a history of weight loss. Resident 43 had diagnoses of dementia, depression, and anxiety, with a current order for a pureed diet with extra butter, sauce, or gravy. The resident was on hospice care and had a history of pneumonia related to food inhalation. The facility's policies required food to be altered to meet individual needs and served according to therapeutic diet spreadsheets, which was not followed in these instances.
Infection Control and Sanitary Practices Deficiencies
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple health conditions, including antibiotic-resistant bacteria in their urine and current wounds. The resident's care plan required the use of personal protective equipment (PPE) during high-contact care, such as wound care. However, during an observation, a registered nurse performed wound care on the resident's left heel without wearing a gown, despite being aware of the EBP requirements. The facility's policy clearly stated that gowns and gloves should be used during high-contact care activities, including wound care, to prevent the spread of multidrug-resistant organisms. Additionally, the facility failed to ensure sanitary medication administration practices. During an observation, a Qualified Medication Aide (QMA) administered eye drops to another resident without performing hand hygiene or wearing gloves. The QMA used her bare hand to lift the resident's eyelid, contrary to the facility's policy, which required hand hygiene and glove use during eye drop administration. The QMA was unaware of the policy, and the facility administrator confirmed that the expectation was for staff to follow the established procedures.
Failure to Ensure Pneumococcal Vaccinations Offered or Administered
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were offered or administered to three residents reviewed for immunizations. Resident 32, who was admitted in 2020 and had diagnoses including hemiplegia, COPD, and diabetes, had an undated refusal for the PCV 13 and PPSV 23 vaccines. The Infection Preventionist provided a consent form indicating a refusal dated back to 2020 but could not provide additional documentation for consent or refusal in subsequent years, including 2024. Resident 53, admitted in 2024 with diagnoses including heart failure and diabetes, had an immunization record showing an undated refusal and a pending entry for the Prevnar 20 vaccine. The Infection Preventionist could not explain the refusal or confirm if the resident received the vaccine. Resident 14, admitted in 2019 with Alzheimer's, COPD, and anxiety disorder, had an undated refusal for the PCV 13 vaccine, with documentation of refusal from 2019. The Infection Preventionist discussed vaccines during care plan meetings but lacked documentation for consents or refusals in the years following 2019, including 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 210 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Marion Llc | 1.6 mi | ★★★★★ | 13 | 0 |
| Wesleyan Health Care Center | 2.8 mi | ★★★★★ | 9 | 0 |
| Colonial Oaks Health Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Twin City Health Care | 6.5 mi | ★★★★★ | 2 | 0 |
| Rolling Meadows Health Care Center | 8.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Miller's Merry Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.