Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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.
The facility restricted access to resident trust funds to business hours, affecting all residents with such accounts. A resident reported being unable to access funds outside these hours, and staff interviews confirmed this practice. The facility's policy stated funds should be readily available, but it acknowledged limited access during weekends and evenings.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. A resident with multiple diagnoses did not have daily weights recorded as ordered, and another resident received an incorrect dosage of sertraline due to a transcription error. The facility lacked documentation and policy adherence in both cases.
A facility failed to notify a physician of abnormal blood sugar levels for a resident with diabetes, despite care plan and physician orders requiring such notification. The resident's blood sugar levels were consistently below the ordered parameters over several months, yet there was no documentation of physician notification. The DON acknowledged the oversight, which violated the facility's policy on condition change notifications.
A facility failed to provide adequate activities for a resident with severe cognitive impairment and other health issues. Observations showed the resident was often left without visual or auditory stimulation, despite a care plan emphasizing the need for socialization and group activities. The Activity Director acknowledged the resident should have had activities in her room, highlighting a lapse in following the facility's Life Enrichment Program Guidelines.
The facility failed to comply with regulations regarding PRN antianxiety and antipsychotic medication use for two residents. A resident received lorazepam beyond the 14-day limit without proper documentation, and another resident was prescribed Seroquel without a documented medical indication. The DON was unable to provide a rationale for these deficiencies.
The facility failed to properly label and date over-the-counter medications in one of the medication storage areas. During an observation, several medications, including ibuprofen, CoQ10, and Vitamin D3, were found unlabeled or without an opened date. RN 5 acknowledged the oversight, and the DON provided the facility's policy requiring compliance with labeling standards.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a Stage 2 pressure ulcer. Despite a physician's order for wound care, there was no indication of EBP being in place, and a nurse assisted the resident without wearing a gown. Staff interviews revealed a lack of adherence to the facility's EBP policy, as there was no signage or physician's order for EBP, contrary to the facility's guidelines for residents with wounds.
The facility failed to provide staff-directed activities in the evening and on weekends due to staffing limitations, affecting 52 out of 70 residents. The Activity Director confirmed the lack of activities, citing that the last scheduled activity during the week was at 1:30 P.M. or 2 P.M., with limited weekend activities primarily consisting of church services on alternate Saturdays.
The facility failed to maintain a sanitary room environment for a resident, with inconsistent cleaning practices leading to dusty blinds, picture frames, and shelves. The resident reported inadequate cleaning, and observations confirmed the deficiencies. Housekeeping staff had varying cleaning routines, and the facility's policy was not consistently followed.
A resident reported $25.00 missing from her purse, but the facility failed to report the incident to the State Survey Agency within the required time frame. The Social Services Director began an investigation and provided a lock box, but there was no documentation in the resident's progress notes, and the resident was not updated on the investigation. The Administrator only reported the incident to the Indiana Department of Health after the survey team inquired about it, several days later.
The facility failed to thoroughly investigate a resident's missing $25.00, with lapses in communication and documentation. The investigation only began after surveyor inquiries, contrary to the facility's policy on abuse prohibition and reporting.
The facility failed to update the care plan for a resident with functional quadriplegia and contractures, despite physician's orders for the use of splints during nighttime hours. The care plan contained outdated interventions and did not reflect the current orders.
The facility failed to notify the physician of critical blood sugar readings and significant weight changes for a resident with diabetes and heart failure. Despite multiple instances of out-of-range blood sugar levels and notable weight fluctuations, the required notifications were not made, as confirmed by the RN and documented in the resident's care plan.
A facility failed to provide ordered nutritional supplements for a resident with significant weight loss, despite a care plan indicating the need for such supplements. The resident, who had multiple diagnoses including hemiplegia and diabetes, experienced a notable weight loss, and the ordered Glucerna shakes were not consistently administered as documented in the Medication Administration Record.
The facility failed to provide safe side rails and complete an assessment for a resident. The resident's bed had a side rail with an unsafe opening size, and no bed rail screen or assessment was found in the medical record. The Executive Director and Maintenance Director were unaware of safe measurements, and the resident reported previous incidents of getting caught in the side rails. The facility's policy requiring an assessment before using assistive devices was not followed.
The facility failed to ensure it was free of medication errors greater than 5 percent, resulting in a medication error rate of 9.68 percent. An LPN administered insulin to three residents without following physician orders, and the residents did not receive snacks or meals within the required 15 minutes after insulin administration. The facility also lacked a policy for following physician orders.
The facility failed to follow proper infection control practices during blood glucose monitoring for two residents. An LPN used an alcohol prep pad instead of a commercial disinfectant wipe to clean the glucometer between uses, contrary to the facility's policy. The DON confirmed the improper cleaning method and provided the correct procedure.
Resident Trust Fund Access Limited to Business Hours
Penalty
Summary
The facility failed to ensure that resident funds were immediately available during non-business hours, affecting all 24 residents with trust funds. Resident 12 reported being informed that funds could only be accessed when the business office was open. Observations confirmed that a sign at the front desk indicated limited availability of funds, with access restricted to business hours on weekdays and a short window on weekends. Interviews with staff, including the Business Office Manager, Executive Director, CNA, and RN, revealed a consistent practice of restricting access to resident trust funds outside of designated hours. The facility's policy, provided by the Director of Nursing, stated that funds should be readily available but acknowledged that money was not accessible when the business office was closed, including weekends and evenings. This practice contradicted the policy's intent and led to the deficiency.
Failure to Follow Physician Orders and Transcribe Medication Accurately
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident 55, who had diagnoses including diabetes, dementia, depression, and anxiety, the facility did not consistently record daily weights as ordered by the physician. The resident's care plan highlighted the importance of monitoring weights due to nutritional risks and fluid shifts. However, there were multiple instances in November, December, and January where daily weights were not documented, nor was there any explanation provided for these omissions. The Director of Nursing acknowledged the oversight and confirmed the absence of a facility policy regarding weight documentation. For Resident 267, who had conditions such as depression, end-stage renal disease, dysphagia, and diabetes mellitus type two, there was a failure in accurately transcribing a medication order. The discharge medication order from the hospital specified sertraline 25 mg, but the facility's records incorrectly listed it as 50 mg. This error led to the resident receiving the incorrect dosage for six consecutive days. Although the Nurse Practitioner had clarified other medication orders, there was no documentation of a review or change in the sertraline dosage. The Assistant Director of Nursing mentioned a conversation with the Nurse Practitioner about the dosage but did not document it in the medical record.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of abnormal blood sugar results for a resident with multiple diagnoses, including diabetes. The resident's care plan and physician orders required notification if blood sugar levels were outside specified parameters. Despite this, the facility did not document any physician notification for numerous low blood sugar readings recorded in November, December, and January. The Director of Nursing confirmed that the physician should have been notified of these abnormal results. The facility's policy mandates notifying the physician of any condition changes or monitored values outside ordered parameters. However, the nursing progress notes lacked documentation of such notifications, indicating a failure to adhere to the policy.
Failure to Provide Adequate Activities for a Resident
Penalty
Summary
The facility failed to provide adequate activities for a dependent resident, identified as Resident 40, who was reviewed for activities. Observations over several days revealed that Resident 40 was frequently left in her room without visual or auditory stimulation. Specifically, on multiple occasions, she was seen in her room either in a reclined position in her Broda chair or sleeping, without any engagement in activities. This lack of stimulation occurred despite the resident's care plan, which emphasized the importance of socialization and involvement in group activities to enhance her quality of life. Resident 40 had a history of severe cognitive impairment, cerebral infarction, hemiplegia, dementia, and delirium, and was receiving hospice care. Her care plan, initiated in November 2022 and updated in May 2024, outlined various interventions to prevent loneliness and isolation, such as attending sensory activities, receiving invitations to readings, and being encouraged to participate in group activities. However, these interventions were not observed to be implemented during the survey period. The Activity Director confirmed that Resident 40 should have had visual or auditory activities in her room, indicating a failure to adhere to the facility's Life Enrichment Program Guidelines.
Failure to Document Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN antianxiety medications and the documentation of antipsychotic medication use for two residents. For Resident 19, a PRN order for lorazepam, an antianxiety medication, was initiated and continued beyond the 14-day limit without proper documentation justifying its extended use. The nurse practitioner noted terminal agitation as a reason for continuation, but there was no supporting documentation in the medical record to substantiate this claim. Additionally, nursing progress notes did not indicate any behaviors or symptoms that would warrant the use of lorazepam, and the Director of Nursing was unable to provide a rationale for the extended use of the medication. For Resident 39, the facility failed to document a medical indication for the use of Seroquel, an antipsychotic medication, which was prescribed for anxiety and combative behaviors. The resident's record lacked documentation to support the use of this medication, and during an interview, the Director of Nursing acknowledged the absence of an appropriate diagnosis for its use. The facility's policy on psychotropic medication use requires documentation of the supporting diagnosis at the time the order is received, which was not adhered to in this case.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that over-the-counter medications were properly labeled and that opened medications were dated when opened in one of the four medication storage areas observed. During an observation of the ICF 3 medication cart, several medications were found to be either unlabeled or lacking an opened date. These included a bottle of ibuprofen, CoQ10, Vitamin D3, aspirin, Ferrosol, Milk of Magnesia (MOM), Men's multivitamins, daily probiotic pills, and Guaifenesin liquid. RN 5 confirmed that these medications should have been labeled and dated according to the facility's policy. The Director of Nursing provided the facility's medication labeling policy, which mandates compliance with facility requirements and state and federal laws.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure ulcer, identified as Resident 46. The resident, who was cognitively intact, had a Stage 2 pressure ulcer on the left mid-buttock, as noted in a Pressure Injury Note dated 1/2/2025. Despite a physician's order to cover the wound with Duoderm every Tuesday and as needed, there was no indication of EBP being in place. During an observation, a registered nurse (RN 5) assisted the resident without wearing a gown, although gloves were used. This was contrary to the facility's policy, which required EBP for residents with wounds to prevent the spread of multi-drug resistant organisms (MDROs). Interviews with staff revealed a lack of adherence to the facility's EBP policy. A certified nursing assistant (CNA 4) and RN 5 both acknowledged that EBP should be in place for residents with wounds beyond Stage 1. However, there was no signage on Resident 46's door to indicate the need for EBP, nor was there a physician's order for such precautions. The Director of Nursing provided a current policy that emphasized the use of gowns and gloves during high-contact care activities for residents with wounds and indwelling devices, which was not followed in this case.
Lack of Evening and Weekend Activities
Penalty
Summary
The facility failed to ensure staff-directed activities were provided in the evening and on the weekends for residents. This deficiency was identified during an interview with a resident who expressed a desire for evening and weekend activities, noting that such activities were only available on holidays like Easter and Christmas. A review of the activity calendar for March and April 2024 confirmed that the last scheduled activity during the week was at 1:30 P.M. or 2 P.M., with limited activities on weekends, primarily church services on alternate Saturdays. No activities were scheduled for several weekend days in both months for the long-term care and rehab units, although two activities were provided in the dementia unit on Sundays. The Activity Director (AD) confirmed the lack of evening and weekend activities, citing staffing limitations as the primary reason. The AD had one full-time assistant working Monday through Friday and a part-time assistant working Tuesday, Wednesday, and Thursday. The AD herself came in on Saturdays for church services but did not schedule other activities unless it was a holiday. The facility's policy, dated 10/13/2010, required at least two activities daily for each of three resident groups, but this was not being met due to the staffing constraints. This deficiency had the potential to affect 52 out of 70 residents residing in the facility.
Failure to Maintain Sanitary Room Environment
Penalty
Summary
The facility failed to ensure housekeeping maintained a sanitary room environment for Resident 42. The resident reported that her room was not being cleaned adequately, with housekeepers only cleaning the toilet, bathroom sink, and taking out the trash. The resident noted that the floors were seldom swept or mopped, and dusting was not performed regularly. Observations confirmed that the blinds, picture frames, and shelves in the bathroom were dusty over multiple days. The resident's medical history includes chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and major depressive disorder. Interviews with housekeeping staff revealed inconsistencies in cleaning practices. One housekeeper indicated that she dusted twice a week, while another stated she only dusted when a resident discharged, died, or switched rooms. The Environmental Supervisor expected daily cleaning, including sweeping and mopping, with a more thorough cleaning once a week. The facility's policy outlined daily and monthly cleaning procedures, but these were not being followed consistently, leading to the observed deficiencies in maintaining a clean and sanitary environment for Resident 42.
Failure to Timely Report Missing Property
Penalty
Summary
The facility failed to ensure an allegation of a resident's missing property was reported immediately or within 2 hours after the allegation was made to the State Survey Agency. Resident 42 reported $25.00 missing from her purse, which she last saw the previous Friday. She informed the Social Services Director, who began an investigation and provided her with a lock box. However, there was no documentation of the missing money in the resident's progress notes, and the resident had not been updated on the investigation's progress. The Administrator only reported the missing money to the Indiana Department of Health (IDOH) after the survey team inquired about it, several days after the initial report by the resident. The facility's policy required immediate reporting, but the Administrator was unsure of the exact time frame and believed it should have been reported within 24-48 hours. The Social Worker acknowledged that the missing money could be considered misappropriation and should have been reported immediately, with a follow-up investigation. The Administrator eventually reported the incident to IDOH and initiated an investigation, but this was done only after the survey team raised questions about the incident. The facility's policy, dated 11/29/2017, clearly stated that incidents involving suspicion of a crime or abuse should be reported immediately, but no later than 2 hours, and misappropriation of resident property should be reported within 24 hours.
Failure to Investigate Missing Property
Penalty
Summary
The facility failed to ensure a thorough investigation was initiated for an allegation of a resident's missing property. Resident 42 reported $25.00 missing from her purse, which she last saw the previous Friday. Despite informing the Social Services Director and receiving a lock box, the resident had not been updated on the investigation's progress. The Administrator only began investigating after the survey team inquired about the incident, and there was no documentation of the missing money in the resident's progress notes. The Social Worker admitted to not completing the investigation or interviewing other residents, and the Administrator reported the incident to the Indiana Department of Health and local law enforcement only after the survey team raised concerns. Resident 42, who is cognitively intact and has diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and major depressive disorder, expressed frustration over the lack of communication regarding the investigation. The facility's policy on abuse prohibition, reporting, and investigation mandates thorough investigations and reporting of reasonable suspicions of crime, which was not adhered to in this case. The Administrator and Social Worker both acknowledged lapses in the investigation process, highlighting a failure to follow established protocols for handling allegations of missing property.
Failure to Update Care Plan for Splint Use
Penalty
Summary
The facility failed to update the care plan for a resident regarding the use of splints. The resident, who has diagnoses including functional quadriplegia, lobster-claw hand, contracture of muscle right hand, and muscle weakness, was observed to have contractures on both hands and indicated that he wears splints during nighttime hours. Despite a physician's order for the resident to wear a left palm protector with finger separators and a right-handed splint during sleeping hours, the care plan had not been updated to reflect these orders. The care plan, dated 6/2/2020, included outdated interventions for the application of the left-hand brace and right-hand splint, which did not align with the current physician's orders. During an interview, the MDS Coordinator confirmed that care plans should be updated at least quarterly and with any new medication or change in the resident's status. The facility's policy on care plan development and review, provided by the Director of Nursing, indicated that care plans should be revised daily and as needed based on changes in the resident's condition, including changes in physician orders. However, the care plan for this resident had not been updated to reflect the new orders, leading to a deficiency in the care provided.
Failure to Notify Physician of Critical Health Changes
Penalty
Summary
The facility failed to notify the physician of blood sugars outside the ordered parameters for a resident with diabetes and heart failure. The resident had multiple instances of blood sugar readings below 70 mg/dL and above 400 mg/dL, but there was no documentation of physician notification for these out-of-range readings. Additionally, the resident experienced significant weight changes, which were not reported to the physician as required by the care plan. The resident's weight fluctuated significantly, with a five-pound gain over five days and a two-pound gain in one day, but these changes were not communicated to the physician. The resident was readmitted to the facility after a hospitalization for acute on chronic combined systolic and diastolic congestive heart failure. Despite the care plan's requirement to notify the physician of significant weight changes, the facility failed to do so on multiple occasions. Interviews with the RN confirmed that the physician should have been notified of both the blood sugar readings and the weight changes, but this did not occur. The facility's policies on blood glucose monitoring and weight management were not adequately followed, leading to the deficiencies noted in the report.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide ordered nutritional supplements for a resident with significant weight loss. Resident 10, who had diagnoses including hemiplegia, diabetes mellitus type 2, and dysphagia, was observed lying in bed with a note indicating to see the nurse before giving fluids. The resident's care plan, dated 8/1/2019, indicated that she was at nutritional risk due to a stroke and anemia, with interventions including offering replacement foods/beverages if meal consumption was less than 50 percent and monitoring weights and intakes. The weight record showed a decrease from 154.8 pounds on 3/5/2025 to 146.2 pounds on 4/8/2024. A Nurse's Note on 4/8/2024 indicated a Nurse Practitioner ordered a Glucerna shake 237 milliliters twice daily due to the weight loss, which was also noted in a Progress Note on 4/12/2024. However, the Medication Administration Record for April 2024 indicated multiple instances where the resident did not receive the Glucerna shake as ordered. During an interview on 4/23/2024, RN 3 confirmed that Resident 10 should be receiving the Glucerna shake twice a day and that the shake had not been out of stock, nor had the resident refused it. The RN indicated that she would notify the physician or nurse practitioner if the resident did not receive or refused the shake. The facility's policy on Weight Management Program, provided by the Director of Nursing, indicated that residents' weight status would be monitored and that interventions, including nutritional oral supplements, would be assessed for residents experiencing unplanned weight changes. Despite this policy, the facility failed to ensure that Resident 10 received the ordered nutritional supplements consistently, leading to a deficiency in providing adequate nutrition to maintain the resident's health.
Failure to Provide Safe Side Rails and Complete Assessment
Penalty
Summary
The facility failed to provide safe side rails and complete an assessment for Resident 19. During an observation, it was noted that Resident 19's bed had a side rail with an opening larger than the recommended dimensions for safety. The resident's medical record indicated various diagnoses, including bipolar disorder, functional quadriplegia, and unspecified dementia. Despite a physician's order and care plan indicating the need for side rails, no bed rail screen or assessment was found in the medical record. Additionally, the Nurse's Note lacked documentation for the need for side rails. The Executive Director and Maintenance Director were unaware of the safe measurements for side rails, and the Maintenance Director confirmed that the side rail opening measured 7 inches by 7.5 inches. Resident 19 reported that his arms had been caught in the side rails during jerking movements. Both the Director of Nursing and the Clinical Service Coordinator confirmed that no side rail assessment had been completed. The facility's policy required an assessment before the initiation of an assistive device, which was not followed in this case.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure it was free of medication errors greater than 5 percent, resulting in a medication error rate of 9.68 percent. During an observation, LPN 7 administered insulin to three residents (Residents 24, 56, and 60) without following the physician's orders. Resident 56 received 8 units of Novolog for a blood sugar result of 313 but did not receive a snack or lunch 15 minutes after the insulin injection. Similarly, Resident 60 received 2 units of Flasp for a blood sugar result of 154 but also did not receive a snack or lunch 15 minutes after the insulin injection. Resident 24 received 8 units of Novolin R for a blood sugar of 340, and LPN 7 failed to sign off on the electronic medical record that the insulin was administered. Resident 24 also did not receive a snack after the insulin injection. During interviews, the residents confirmed they had not received snacks or meals within the required 15 minutes after insulin administration. LPN 7 admitted to not offering snacks to the residents and indicated that the meal did not start until 11:30 A.M. The Director of Nursing confirmed that the facility did not have a policy for following physician orders. This lack of adherence to physician orders and the absence of a relevant policy contributed to the observed medication errors.
Inadequate Infection Control During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control practices during blood glucose monitoring for two residents. During an observation, an LPN checked the blood sugar of Resident 56 and cleaned the glucometer with a single alcohol prep pad before placing it back on the medication cart. The same glucometer was then used to check the blood sugar of Resident 60, again cleaned with only one alcohol prep pad. The LPN admitted to not knowing the facility's policy for cleaning the glucometer. The Director of Nursing (DON) confirmed that using an alcohol prep pad was not appropriate for cleaning the glucometer and provided the facility's policy, which required the use of a commercial disinfectant wipe and specific procedures to ensure proper disinfection. The policy detailed steps such as ensuring the glucometer is visibly wet with the disinfectant, avoiding the screen, and allowing the device to air dry for the manufacturer's recommended contact time. The DON also noted that none of the residents requiring glucometer use had any communicable diseases.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 249 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Manor | 1.5 mi | ★★★★★ | 21 | 0 |
| Miller's Merry Manor | 9.3 mi | ★★★★★ | 15 | 0 |
| Signature Healthcare Of Bremen | 12.1 mi | ★★★★★ | 18 | 1 |
| Miller's Merry Manor | 12.8 mi | ★★★★★ | 24 | 0 |
| Brickyard Healthcare - Knox Care Center | 16.1 mi | ★★★★★ | 0 | 0 |
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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.