Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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.
A resident with significant hearing loss repeatedly kept his TV at a very loud volume and refused headphones, room changes, and other interventions, while multiple neighbors complained that the noise disturbed them and kept them awake. Staff documented repeated redirection and discussions with the resident and family, but the complaints were not resolved and no grievances were found for the issue.
Failure to Hold Required Care Planning Conferences: The facility did not invite and hold care planning conferences for two residents whose care plans were reviewed. One resident with HF, CKD, MDD, dysphagia, epilepsy, and stroke said she had not been invited to or attended a care plan meeting, and the record showed no documented conference after the initial meeting. Another resident with stroke, heart disease, OA, and morbid obesity had prior care plan meetings documented, but there were no additional conferences after the last one, and the SSD confirmed no other meetings were completed.
Failure to assess and monitor a bruise on a resident’s right forearm. The resident had multiple chronic conditions, was receiving Apixaban for DVT prevention, and had orders for geri sleeves and skin checks every shift. Staff observed a reddish purple discoloration on the forearm, but the bruise was not documented in nursing notes or weekly assessments, and the DON confirmed there had been no prior assessment before it was identified.
Failure to ensure fall precautions were in place for a resident at risk for falls. A resident with a recent L hip replacement, difficulty walking, and a care plan calling for non-skid footwear was repeatedly observed in her wheelchair wearing only white socks or fuzzy socks without a non-skid surface while up in her room, bathroom doorway, hall, and dining room. The resident said she could transfer herself and that the socks she wore did not have non-skid surfaces; the DON stated she should have been wearing shoes or non-skid socks when up during the day.
Improper medication labeling and storage were observed for a resident’s eye drops, two insulin pens, and an opened tuberculin vial. An RN prepared eye drops that lacked directions for use and the physician’s name, two Lantus KwikPens were found past the 28-day discard period on medication carts, and an opened TB vial in the med room had no open date; the DON and other staff acknowledged the labeling and dating issues.
An LPN failed to wear an isolation gown while administering and later disconnecting an IV antibiotic for a resident on enhanced barrier precautions, despite knowing PPE was required. In a separate observation, an RN used a multi-functional BP machine for a resident’s vital signs and medications, then returned it without wiping it down or sanitizing it after use; the DON stated the machine was to be cleaned after each use.
Expired CNA Certification: The facility failed to ensure one CNA had a current and valid certificate on file. Record review showed the CNA's certification had expired, yet the CNA continued working on multiple scheduled shifts after expiration. The HR Director acknowledged the expired certification, and the Corporate Administrator stated the monthly certification check system missed the CNA.
A resident dependent on staff for transfers, with severe cognitive impairment and multiple medical conditions, sustained a significant skin tear requiring ER treatment and sutures after a CNA manually transferred the resident from a chair to a bed without using the required mechanical lift. The CNA did not follow the care plan or physician's orders due to the absence of the lift pad and uncertainty about how to proceed, and the Pocket Guide detailing transfer requirements was reportedly unavailable at the time.
A resident with multiple chronic conditions was prescribed Levaquin for a urinary tract infection, but the antibiotic was not administered as ordered on the third day. Documentation indicated the medication was unavailable, though the DON later confirmed it was present in the Pyxis dispensing system, and the reason for the missed dose was unclear.
The facility's main kitchen failed to properly label and date food items, including pickles, mayonnaise, sweet corn nuggets, and a bag of white powder, which were observed during a kitchen sanitation tour. The Assistant Kitchen Manager confirmed the labeling requirements, and the Kitchen Manager began re-educating staff. The facility's policy mandates proper labeling and storage of food items.
The facility failed to implement proper infection control practices, including hand hygiene after glove removal, handling of soiled linens, and adherence to enhanced barrier precautions (EBP) for residents with wounds. An LPN did not sanitize hands before donning PPE, a CNA carried uncontained soiled linens, and staff did not wear isolation gowns during high-contact care for residents requiring EBP.
The facility failed to maintain a sanitary environment on the ICF wing, where a strong urine odor was consistently present. Observations over several days confirmed the issue, and a resident's family member noted the persistent smell. An LPN attempted to address the odor by removing garbage and using air freshener, but the smell remained. The Maintenance Director had noticed the odor for weeks but assumed it was from a resident. The Administrator was informed and planned to investigate further.
A resident developed a venous stasis foot ulcer, and the facility failed to promptly notify the responsible party. The ulcer was first identified and treated on 12/15/24, but the family was not informed until 12/19/24. This delay in communication was contrary to the facility's policy requiring timely notification of condition changes.
A resident reported multiple grievances regarding pain management, inappropriate comments by a nurse, and room arrangements to the Administrator, who failed to document these concerns on a grievance form. Despite the resident being cognitively intact and having a complex medical history, there was no follow-up documentation to indicate resolution, violating the facility's grievance policy.
The facility failed to provide scheduled showers and oral care for residents requiring assistance with ADLs. A resident with a feeding tube did not receive scheduled showers or mouth care, and another resident with hemiplegia also missed scheduled showers and oral care. A third resident reported not receiving showers due to staffing shortages. Observations confirmed their disheveled appearances, and facility records showed missed showers and lack of documentation for mouth care. The DON acknowledged these failures.
A facility failed to manage constipation for a resident with multiple health issues, resulting in ineffective treatment. Another resident missed a medical appointment due to inadequate transportation scheduling, and a third resident's care plan for wound management was not followed, leading to potential skin issues. The facility lacked a backup transportation plan and did not adhere to care plans for effective treatment.
The facility failed to provide adequate nutritional support and monitoring for two residents. One resident with a PEG tube and significant weight fluctuations was not assisted with meals, leading to untouched trays and unmonitored intake. Another resident undergoing dialysis did not consistently receive breakfast before sessions, and post-dialysis weights were not documented. The lack of staff assistance and oversight in providing meals and monitoring nutritional status contributed to the deficiencies.
A resident with chronic respiratory failure and COPD was observed receiving oxygen at an incorrect flow rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Nurse Case Manager and acknowledged by the DON, indicating a failure to adhere to the prescribed care plan.
A resident with a fractured tibia experienced severe pain that was not managed effectively by the facility. Despite the resident's consistent reports of high pain levels, the nursing staff failed to notify the physician until several days later, resulting in inadequate pain management. The facility's pain management policy was not properly implemented, leading to a deficiency in care.
The facility failed to monitor and document blood pressure for two residents prescribed medications with specific parameters. One resident, with dementia and hypertension, was not consistently monitored for blood pressure before receiving Midodrine. Another resident, with dementia and heart conditions, had inconsistent blood pressure documentation while on Metoprolol Tartrate. An LPN cited workload issues, and the DON confirmed the need for proper documentation.
The facility recorded a 12% medication error rate during administration for two residents. An LPN included an extra Potassium Chloride tablet for a resident, while another LPN failed to dilute Potassium Chloride for a resident with a gastrostomy tube, leading to uncertainty about the correct dose after a spill. The DON confirmed the errors and highlighted the need for careful review of medication orders.
A facility failed to document meal consumption for a resident with cognitive impairment and nutritional risk. The resident, diagnosed with stroke, dysphagia, and dementia, required supervision with eating. The Food Consumption Log showed missing entries for several meals, which the DON confirmed should have been documented.
Unresolved Loud TV Complaints Affected Resident Rights
Penalty
Summary
The facility failed to ensure residents’ dignity and rights were maintained when complaints about excessive television volume on the 100 unit were not resolved in a timely manner for three resident council members and one additional resident. During the resident council interview, residents reported that another resident on the unit kept his television very loud and often left his door open, and that they had complained to staff several times without any change. One resident stated the noise kept her up at night, another said he had moved out of the room because of the television volume, and another felt their rights were being infringed upon. No grievances related to the loud television volume were found in the prior six months. Record review showed the resident with the loud television was hard of hearing and had a history of turning the TV up very high, with staff documenting repeated redirection and education because the volume disturbed other residents. Notes also showed the resident refused headphones, rejected room or TV placement changes, and would turn the volume back up after staff left. Social services documented discussions with the resident’s family, attempted contact with the Ombudsman, and behavior monitoring, but staff interviews confirmed the issue remained unresolved and that roommates had moved out because of the television volume. A resident on the unit later stated she continued to hear the television all the time and had complained to staff, but nothing had changed.
Failure to Hold Required Care Planning Conferences
Penalty
Summary
The facility failed to invite and hold care planning conferences for 2 of 16 residents whose care plans were reviewed. Resident 34, who had diagnoses including heart failure, high blood pressure, chronic kidney disease, major depressive disorder, dysphagia, epilepsy, and stroke, was admitted to the facility and had a 1/22/26 Quarterly MDS showing moderate impairment in daily decision making. During interview, the resident stated she had not been invited to or attended a care plan meeting. The record showed a Facility Pre-Discharge Planning Assessment dated 10/6/25 documenting the resident’s first care planning conference, but there was no documentation of any care plan conference after that date. Resident 6, who had diagnoses including stroke, heart disease, osteoarthritis, and morbid obesity, had a 12/11/25 Quarterly MDS indicating cognitive intactness for daily decision making. The Long Term Resident Care Plan Meeting Template documented care planning conferences on 1/7/25, 3/25/25, and 10/3/25, and the resident attended all three. However, there were no care plan meetings held between 3/25/25 and 10/3/25, and no care plan meetings held after 10/3/25. During interview, the resident stated she was not aware of being invited to or attending a care plan meeting, and the Social Service Director confirmed there were no other care planning conferences completed for the resident.
Failure to Assess and Monitor Bruise on Right Forearm
Penalty
Summary
The facility failed to ensure a bruise on Resident 34’s right forearm was assessed and monitored. The resident had diagnoses including heart failure, hypertension, chronic kidney disease, and stroke, and the 1/22/26 MDS indicated moderate impairment in daily decision making. The care plan noted the resident was on anticoagulant therapy for DVT prevention and included monitoring for signs and symptoms of bleeding such as bruising. A physician’s order dated 10/4/25 directed Apixaban 2.5 mg twice daily, and a later order dated 12/22/25 directed geri sleeves to be worn at all times except bathing and hygiene, with skin checks every shift. A care plan dated 2/18/26 also identified the resident as at risk for bruises and skin tears and directed application of geri sleeves. During observation, the resident was seen with a reddish purple discoloration to the right forearm, and staff were observed removing both geri sleeves during morning care. The resident stated staff did not always put the geri sleeves on her arms. The record contained no nursing note documenting the bruise, and the Nursing Weekly Assessments dated 2/12, 2/19, and 2/25/26 did not document any new bruising to the arm. The DON confirmed there was a bruise on the right forearm and stated there had been no prior assessment of the bruise before 3/5/26. The facility policy provided by the DON stated that non-wound skin alterations were to be completed on the nursing-new skin alteration assessment and monitored at least daily until healed.
Failure to Use Non-Skid Footwear for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 2 had diagnoses including aftercare following joint replacement surgery, left artificial hip joint, and difficulty walking. The resident’s Significant Change MDS, dated 1/29/26, indicated she was cognitively intact and required partial to moderate assistance with sit to stand transfers and toilet transfers. Her care plan, dated 12/26/25, identified her as at risk for falls due to a recent left hip replacement and generalized weakness and included interventions to encourage and assist with wearing non-skid footwear. During observations, Resident 2 was repeatedly seen in her wheelchair without shoes or non-skid socks, including while seated in the doorway of her bathroom, in her room, propelling herself down the hall, and eating breakfast in the dining room. She was observed wearing white tube socks, tan fuzzy socks over white socks, and green fuzzy socks over white socks, and the fuzzy socks did not have a non-skid surface. During interview, the resident stated she needed to go to the bathroom and was able to transfer herself, and later stated the tan socks were her own and did not have a non-skid surface. The DON stated the resident should have been wearing either shoes or non-skid socks when up during the day.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper medication storage and labeling for drugs and biologicals used in the facility. During medication administration for one resident, an RN prepared Brimonidine ophthalmic 0.1% eye drops that had only a small resident-name label on the bottle and no directions for use or physician name, and there was no original pharmacy-prepared bag with a label available. The RN stated the pharmacy-labeled package was not available and may have been discarded, and the DON had no additional information regarding the labeling of the eye drops. The facility’s Medication Labels policy indicated each prescription medication label included directions for use. The facility also had insulin pens and a tuberculin vial stored improperly. On the ICF medication cart, a Lantus insulin KwikPen had an open date of 1/26/26 and was still present even though the sticker indicated it should be discarded after 28 days. On the Rosewood medication cart, another Lantus insulin KwikPen had an open date of 2/3/25 and was also still present past the 28-day discard timeframe. In the medication room, an opened multi-use vial of Tuberculin had no date showing when it was opened. Staff who observed these items, including an LPN, an RN, and the DON, stated the insulin pens should have been discarded after 28 days and the tuberculin vial should have been dated after opening.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented during care for Resident 57 and Resident 39. During an IV antibiotic administration for Resident 57, an LPN entered the room, performed hand hygiene, and donned clean gloves to access the resident’s single lumen PICC line, but did not wear an isolation gown while administering the IV antibiotic. The LPN flushed the line, connected the antibiotic, helped reposition the resident in bed by placing pillows under the resident’s leg, removed her gloves, and washed her hands. When she later returned to disconnect the IV antibiotic, she again performed hand hygiene and donned clean gloves, removed the tubing, flushed the port with saline and Heparin, removed her gloves, and performed hand hygiene, but did not don an isolation gown. The LPN stated she was aware the resident was in enhanced barrier precautions and that she was supposed to wear an isolation gown while administering and removing the IV antibiotic. During a medication administration observation for Resident 39, an RN brought a multi-functional blood pressure machine into the room, applied the cuff and pulse oximeter, administered medications, and then returned the machine to the wall area and plugged it in without wiping it down or sanitizing it after use. The RN stated she did not clean the multi-function blood pressure machine after use. The DON stated the blood pressure machine was to be wiped down and sanitized after each use, and there was no facility policy for cleaning the multi-function blood pressure machine.
Expired CNA Certification
Penalty
Summary
The facility failed to ensure that 1 of 15 CNA records reviewed had a current and valid certificate to work in the facility. Record review showed CNA 1's certification had expired, yet the staff schedule indicated CNA 1 continued to work on multiple days after the expiration date. During interview, the Human Resources Director stated CNA 1's certification had expired and that she was going to help her fix it. The Corporate Administrator stated there was a system in place to check certifications monthly, but CNA 1 was missed.
Failure to Use Mechanical Lift Results in Resident Injury During Transfer
Penalty
Summary
A resident with diagnoses including rheumatoid arthritis and osteoporosis, and who was dependent on staff for activities of daily living, was injured during a transfer from a chair to a bed. The resident's care plan and physician's orders specified that a mechanical lift was to be used for all transfers, and this requirement was also documented in the Nurse Aide Pocket Guide. However, on the day of the incident, a CNA transferred the resident without using the mechanical lift because the lift pad was not under the resident and the CNA was unsure how to place it while the resident was in the chair. The CNA proceeded to manually transfer the resident, resulting in the resident's left lower leg being snagged on a piece of the wheelchair, causing a significant skin tear. The injury was severe, with a 14 cm by 5.5 cm skin tear on the left lower leg, continuous bleeding, and a pool of blood on the floor. The resident required emergency medical attention, including a visit to the ER and 19 sutures to close the wound. Documentation indicated that the CNA was aware the resident required a mechanical lift for transfers but did not follow the care plan due to the absence of the lift pad and uncertainty about how to proceed. The CNA also reported that the Pocket Guides, which inform staff of required care, were not available that night due to updates, and she had previously been told by other staff that the resident could be manually lifted. Interviews with other staff indicated that the mechanical lift requirement was consistently listed in the Pocket Guide and that these guides were supposed to be always available. The resident's assessment confirmed severe cognitive impairment and total dependence on staff for transfers. The failure to follow the established care plan and use the mechanical lift directly led to the resident's injury during the transfer.
Antibiotic Not Administered as Ordered for UTI
Penalty
Summary
A resident with diagnoses including hypertension, type 2 diabetes mellitus, and atrial fibrillation was admitted to the facility and had a physician's order to receive Levaquin 500 mg by mouth every 24 hours for three days to treat a urinary tract infection. The Medication Administration Record showed that the antibiotic was administered on the first two days, but on the third day, the medication was not given, with documentation indicating it was unavailable and had been ordered from the pharmacy. However, the Director of Nursing later confirmed that the medication was actually available in the Pyxis dispensing machine at the time, and could not explain why the nurse did not administer the antibiotic as ordered. There was no documentation of further administrations of the medication after the missed dose.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to maintain proper labeling and dating of food items in the main kitchen, which could potentially affect all residents receiving food from this kitchen. During an initial kitchen sanitation tour, surveyors observed several issues: a tray of individual cups of pickles and mayonnaise in the refrigerator was not labeled, an opened bag of sweet corn nuggets in the freezer was undated, and an opened bag of white powder in a cabinet was unlabeled. The Assistant Kitchen Manager confirmed that all items should be labeled with the date they were received, the date they were opened, and the contents if removed from their original container. The unlabeled items were discarded, and the white powder was identified as food thickener taken from a larger container. The Kitchen Manager acknowledged the labeling requirements and indicated that re-education of staff had begun. The facility's policy on food protection and storage mandates that open boxes and containers of food should be securely enclosed, labeled, and dated, and that food not in original containers should be clearly labeled for contents, dated, and stored in food-rated containers with tight-fitting lids.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. An LPN was observed preparing medications and placing them into cups while wearing gloves. After removing the gloves, the LPN did not perform hand hygiene before donning personal protective equipment (PPE) to administer medication via a gastrostomy tube. The Director of Nursing confirmed that the LPN should have sanitized his hands after glove removal and before donning PPE. In another instance, a CNA was observed leaving a resident's room with uncontained soiled linens while wearing gloves. The CNA responded to another resident's call for help while still carrying the soiled linens, which is against the facility's linen handling policy. The Director of Nursing acknowledged that the CNA should not have left the room with uncontained soiled linens, as it could contribute to the spread of infection. Additionally, the facility did not adhere to enhanced barrier precautions (EBP) for residents requiring such measures. During a wound treatment, the ADON and an RN did not wear isolation gowns as required for a resident with a venous ulcer. Similarly, an agency CNA and an RN failed to don isolation gowns while providing incontinence care to a resident with a pressure ulcer. The Infection Control Nurse and the Director of Nursing confirmed that the residents were on EBP, and staff were expected to wear gowns and gloves during high-contact care activities.
Persistent Urine Odor on ICF Wing
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment on the ICF wing, as evidenced by a persistent strong odor of urine detected on one of the three halls. This issue was observed during multiple random checks over several days. A resident's family member confirmed that the entire ICF wing consistently smelled of urine. An LPN suggested the odor might be emanating from garbage in the dirty utility room and attempted to mitigate it by removing garbage bags and using air freshener. Despite these efforts, the odor persisted. The Maintenance Director acknowledged noticing the odor for weeks but assumed it was related to a resident. The Administrator was informed of the situation and indicated plans to investigate the source and clean the carpets.
Failure to Notify Family of Resident's Wound Development
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident's change in condition, specifically the development of a venous stasis foot ulcer. During a wound treatment observation, it was noted that the resident had an open area on the left great toe and a new non-blanchable area on the bottom of the foot. The resident's medical record indicated that the ulcer was first identified on 12/15/24, and a physician's order was given to monitor and treat the wound. However, there was no documentation that the resident's family was notified of the ulcer's development on that date. The Director of Nursing confirmed that the staff nurse assessed the resident's wound on 12/15/24 but failed to document family notification. The Assistant Director of Nursing, who was also the Wound Nurse, only notified the family on 12/19/24 when she assessed the wound and obtained new orders. The facility's policy requires notifying the resident and responsible party of any condition changes, but this protocol was not followed in a timely manner for this resident.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to properly document and address grievances reported by a resident, identified as Resident 32, who had multiple complaints upon arrival at the facility. These complaints included issues with pain medication, inappropriate comments made by a nurse, and concerns about room arrangements. Despite the resident reporting these concerns to the Administrator, there was no official grievance form filed, and no follow-up documentation was provided to indicate that the issues were resolved. Resident 32, who was cognitively intact according to the Admission Minimum Data Set assessment, had a medical history that included a fracture of the right tibia, end-stage renal disease, dependence on renal dialysis, heart failure, high blood pressure, type 2 diabetes, diabetic neuropathy, major depressive disorder, and anxiety. The Administrator acknowledged writing down the resident's concerns on yellow ledger paper but admitted to not documenting them on a grievance form as required by the facility's grievance procedure policy. This lack of documentation and follow-up represents a failure to adhere to the established grievance policy, which mandates prompt investigation and resolution of resident complaints.
Failure to Provide Scheduled Showers and Oral Care
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in providing showers and oral care. Resident 24, who had a feeding tube and required assistance with ADLs, reported not receiving showers twice a week as scheduled and not having her dentures or mouth cleaned since admission. Observations confirmed her disheveled appearance over several days, and the facility's records indicated missed showers and lack of documented mouth care. Interviews with staff revealed a misunderstanding of responsibilities regarding oral care, with the LPN assuming CNAs would brush the residents' teeth. Resident 40, also with a feeding tube, reported not receiving scheduled showers or mouth care. Observations over multiple days showed her in the same clothing and unkempt, with crumbs on her shirt. She confirmed that she was finally assisted with mouth care after several days. Her care plan required maximum assistance with ADLs due to hemiplegia following a stroke, but the facility's records showed missed showers and no documentation of mouth care. The DON acknowledged the failure to provide scheduled showers and mouth care. Resident 8 reported not receiving showers as frequently as scheduled, citing staffing shortages as a reason. Her care plan indicated she required moderate assistance with ADLs due to heart failure and other conditions. Facility records showed multiple missed showers, and a nurse's note confirmed she was not on the shower schedule. The DON was unaware of the resident's complaints about missed showers. Overall, the facility's failure to adhere to care plans and schedules for showers and oral care resulted in deficiencies in meeting the residents' ADL needs.
Deficiencies in Constipation Management, Transportation, and Wound Care
Penalty
Summary
The facility failed to address signs and symptoms of constipation for Resident 7, who had a history of stroke, chronic kidney disease, Alzheimer's disease, high blood pressure, anxiety, and constipation. Despite being on a care plan for potential constipation, the resident experienced multiple episodes without documented bowel movements and received Polyethylene Glycol Powder as needed. However, the effectiveness of the treatment was often unknown or ineffective, and the facility did not follow its bowel elimination policy, which required further intervention if the initial treatment was ineffective. Resident 32 missed an orthopedic surgeon appointment due to late arrival, as the facility's transportation plan was inadequate. The maintenance associate, responsible for driving residents to appointments, failed to manage the schedule effectively, resulting in the resident arriving 20 minutes late and missing the appointment. The facility did not have a backup transportation plan in place, and the Director of Nursing was aware of the missed appointment but did not provide additional information. Resident 51, who had atrial fibrillation, high blood pressure, and high cholesterol, was observed with her heels not floated as required by her care plan for an arterial wound on her left great toe. Despite multiple observations and wound treatment, the resident's heels remained flat on the bed, contrary to the care plan's instructions to float the heels. A new non-blanchable red area was identified on the resident's foot, indicating a failure to adhere to the care plan and potentially contributing to the development of new skin issues.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for two residents, leading to deficiencies in their care. Resident 19, who had a history of stroke, hemiplegia, aphasia, dysphagia, and a PEG tube, was observed multiple times with untouched meal trays and no staff assistance. Despite her inability to feed herself, staff did not assist her, and her nutritional intake was not monitored. Her weight fluctuated significantly, and there were no readmission weights documented after hospital returns, nor were there recent assessments by a registered dietitian. Resident 32, who was undergoing dialysis and had end-stage renal disease and type 2 diabetes, reported not consistently receiving breakfast before his dialysis sessions. He left for dialysis without a meal and returned very hungry. Despite a care plan indicating the need for double protein at breakfast and monitoring of weights and intakes, there were no post-dialysis weights documented, and meal consumption logs were incomplete. The dietary food manager prepared early breakfasts, but CNAs did not pick them up, and the Director of Nursing was unaware of the missed meals. The facility's failure to assist residents with eating, monitor nutritional intake, and ensure proper documentation and communication regarding residents' nutritional needs and weights contributed to the deficiencies observed. The lack of staff assistance and oversight in providing meals and monitoring residents' nutritional status highlights significant gaps in the facility's care processes.
Incorrect Oxygen Flow Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate. The resident, who was diagnosed with chronic respiratory failure and COPD, was observed multiple times with an oxygen concentrator set at 3 liters per minute, despite a physician's order specifying a flow rate of 2 liters per minute. This discrepancy was confirmed by the Nurse Case Manager and acknowledged by the Director of Nursing. The resident's care plan included administering oxygen as ordered, but the facility did not adhere to the prescribed flow rate, leading to the deficiency.
Failure to Manage Resident's Pain Effectively
Penalty
Summary
The facility failed to manage and monitor the pain of a resident, identified as Resident 32, who was admitted with a fracture of the right tibia, among other diagnoses. Upon admission, the resident experienced severe pain, consistently rating it between 6 and 10 on a scale of 1 to 10, with 10 being the worst pain imaginable. Despite the resident's complaints and the ineffectiveness of the prescribed Acetaminophen, there was no communication with the physician regarding the resident's severe pain levels from December 7 to December 10, 2024. The resident's pain was not adequately addressed until December 10, 2024, when the Director of Nursing was informed by the resident and his sons, leading to a new prescription for Norco. The resident's care plan included monitoring for pain and administering medications as ordered, but these measures were not effectively implemented. The facility's Pain Management Program policy aimed to assist residents in achieving optimal comfort, yet the nursing staff failed to notify the physician about the resident's severe pain over the weekend or before December 10, 2024. This oversight resulted in the resident enduring significant pain without appropriate intervention for several days, highlighting a deficiency in the facility's pain management practices.
Failure to Monitor Blood Pressure for Medications with Parameters
Penalty
Summary
The facility failed to ensure proper management and monitoring of medication regimens for two residents, leading to a deficiency in medication administration. Resident 21, who had diagnoses including dementia and hypertension, was prescribed Midodrine with specific blood pressure parameters. However, the resident's blood pressure was not consistently monitored before each dose as required, with documentation missing for several days. An LPN admitted to not always documenting the blood pressure unless the medication was held, citing a heavy workload as the reason. Similarly, Resident 29, with diagnoses including dementia, heart attack, and atrial fibrillation, was prescribed Metoprolol Tartrate with parameters to hold the medication if the blood pressure was below a certain threshold. The resident's blood pressure was not consistently documented, with several days lacking any records of monitoring. The Director of Nursing confirmed that vitals should be taken and documented with each scheduled dose of medication with parameters, indicating a lapse in adherence to this protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12% error rate during medication administration for two residents. The first incident involved an LPN who prepared medications for a resident and mistakenly included an extra Potassium Chloride tablet in the medication cup, totaling 12 pills instead of the prescribed 11. The LPN acknowledged the error upon review of the resident's medication order, which specified only one Potassium Chloride tablet was to be administered. In the second incident, another LPN prepared medications for a resident with a gastrostomy tube, including Potassium Chloride, which was not diluted as required. During the administration, one of the medication cups was knocked over, and the LPN was unable to determine which medication was spilled due to all medications being diluted. The Director of Nursing later confirmed that the Potassium Chloride should have been diluted and expressed concern about ensuring the correct dose was administered. Additionally, the Director noted that medication rolls should be checked to prevent extra pills from being included.
Incomplete Documentation of Meal Consumption for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records related to meal consumption for a resident experiencing a decline in activities of daily living (ADL). The resident, who had diagnoses including stroke, dysphagia, and dementia without behavior disturbance, was cognitively impaired and required supervision with eating. The care plan indicated the resident was at nutritional risk and required monitoring of weights and intakes. However, the Food Consumption Log for December 2024 and January 2025 showed missing documentation of the resident's meal intake on several occasions. The Director of Nursing confirmed that the resident's food consumption should have been documented for each meal.
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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.
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Nursing homes near Portage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Portage Care Center | 0.5 mi | ★★★★★ | 23 | 0 |
| Waters Of Hobart Skilled Nursing Facility, The | 5.1 mi | ★★★★★ | 0 | 0 |
| Casa Of Hobart | 6.7 mi | ★★★★★ | 27 | 0 |
| Life Care Center Of Valparaiso | 7.5 mi | ★★★★★ | 15 | 0 |
| Chesterton Manor | 7.7 mi | ★★★★★ | 0 | 0 |
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