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.
A resident with chronic pain, anxiety, and depression experienced two falls—one during a transfer without a gait belt and another while attempting to toilet independently. Although new interventions were identified, such as using a gait belt and keeping the bed in the lowest position, these were not added to the resident's care plan as required. The DON confirmed the care plan should have been updated to reflect these changes.
A resident with advanced cognitive impairment and end-of-life care needs was repeatedly observed without access to sensory or leisure activities, despite documented preferences for music and religious services. Staff interviews and record reviews confirmed that the resident was not regularly included in activity programs and received sensory activities infrequently, contrary to the facility's policy and the resident's care plan.
A resident with chronic kidney disease and high protein supplementation did not receive the recommended laboratory monitoring after a dietician's assessment. The dietician's recommendation to monitor kidney function was not communicated to the medical provider, and the dietician was unaware of existing lab results. Facility policy requiring interdepartmental communication of such recommendations was not followed.
A medication cart was observed to contain an opened and undated bottle of dorzolamide eye drops without resident identifiers, an unsealed and unlabeled petrolatum gauze dressing, and an open, undated bottle of lactulose. A QMA confirmed these items should have been labeled, dated, and sealed according to facility policy, which was not followed.
A nurse did not perform hand hygiene after removing a dressing and gloves while providing a skin treatment to a resident, and another nurse failed to use a barrier when placing a glucometer on a bedside table during blood glucose monitoring. Both staff acknowledged the lapses in infection control practices during interviews.
The facility failed to ensure proper storage and labeling of food brought in by outside sources in resident nourishment refrigerators. Observations revealed unlabeled food items and ice packs used for residents stored inappropriately, affecting all 67 residents on the units. The Dietary Manager confirmed the lack of adherence to food storage policies and professional standards for food safety.
The facility failed to provide adequate ADL assistance for a resident, specifically in relation to shaving and nail care. The resident was observed with long facial hair and untrimmed fingernails with debris, despite expressing a preference for being clean-shaven and having a care plan indicating the need for maximum assistance with grooming. Staff interviews and documentation revealed inconsistencies in the provision of these services.
The facility failed to provide appropriate care for a central venous catheter for a resident and did not follow physician orders for another resident with skin conditions. The central venous catheter dressing was not changed as required, and the tubigrip for the left lower extremity was not applied as ordered, leading to deficiencies in care.
The facility failed to properly store and clean respiratory equipment for two residents. One resident's CPAP machine and another's nebulizer were found uncovered and uncleaned, with staff showing confusion about cleaning responsibilities and inconsistent practices.
The facility failed to ensure pharmacy recommendations were communicated to the physician for review in a timely manner for a resident with overactive bladder, allergies, and insomnia. Recommendations to reduce dosages of Loratadine, Myrbetriq, and Melatonin were not acted upon promptly due to a communication issue with the new pharmacy representative.
A medication cart in Windsor Hall was left unattended with keys in the drawer for about 8 minutes. The RN left the cart to respond to a call for help and forgot to take the keys. The DON confirmed that the cart should have been locked and the keys taken by the nurse.
The facility failed to keep physician orders current with a resident's advanced directive instructions, resulting in conflicting directives for Resident B, who was receiving hospice services. Despite multiple advanced directive forms with differing instructions, the facility did not ensure that the physician orders were consistent with the resident's current wishes.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was at risk for falls, as required following significant changes in the resident's condition and incidents. The resident, who had diagnoses including chronic pain, anxiety, and depression, experienced two falls. The first fall occurred during a transfer from bed to wheelchair when a staff member did not use a gait belt, resulting in the resident falling onto her right knee. The root cause was identified as the lack of gait belt use, and the staff member involved was counseled on proper transfer technique. The second fall happened when the resident attempted to toilet herself and was found on the bathroom floor. After this incident, a new intervention to keep the resident's bed in the lowest position was identified as necessary. Despite these incidents and the identification of new interventions, the resident's care plan was not updated to include the use of a gait belt during transfers or the intervention to keep the bed in the lowest position. The existing care plan only included general fall prevention measures such as keeping the call light within reach, encouraging the use of assistive devices, and monitoring for changes in gait. The Director of Nursing confirmed that the care plan should have been updated with the new interventions following the falls, in accordance with the facility's policy requiring care plan revisions as changes in the resident's condition dictate.
Failure to Provide Individualized Sensory Activities for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, seizures, aphasia, mood disorder, and altered mental status, who was receiving end-of-life care, was repeatedly observed without access to independent leisure or sensory activities. Over several days, the resident was seen either in bed or in a Broda chair with her eyes closed, and there were no visual or auditory sensory activities present in her environment. The resident's care plan indicated a need for sensory-related activities and noted preferences for music, religious services, and fresh air, but these interventions were not consistently provided. Interviews with staff revealed that the resident was not regularly included in activity programs and typically received sensory activities only once a week due to limited staffing. The facility's policy required daily sensory stimulation for residents with low cognitive function, as well as regular musical and spiritual activities, but these were not implemented as outlined. Documentation and staff accounts confirmed that the resident's activity needs and preferences were not being met according to her care plan and facility policy.
Failure to Monitor Kidney Function Following Dietician Recommendation
Penalty
Summary
The facility failed to provide the recommended laboratory monitoring for a resident with chronic kidney disease who was receiving high protein supplementation. The resident had diagnoses including a left femur fracture, mild cognitive impairment, and stage 3b chronic kidney disease, and was noted to have developed stage 2 and 3 pressure ulcers after admission. Laboratory results from an earlier date showed significantly elevated blood urea nitrogen and creatinine levels. The registered dietician assessed the resident and recommended monitoring kidney function due to the increased protein intake, which exceeded 107 grams per day with supplementation. Despite the dietician's recommendation, there was no evidence that the medical provider (MD or NP) was informed of the increased protein supplementation or the need for closer kidney function monitoring. The dietician was also unaware of the available laboratory results in the medical record, and the nurse practitioner would not have ordered new labs until six months after the previous results. Facility policy required communication of dietician recommendations to other departments for follow-up, but this did not occur, resulting in a lack of appropriate monitoring for the resident's kidney function.
Failure to Properly Label and Store Medications
Penalty
Summary
During a medication storage observation, a medication cart was found to contain an opened and undated bottle of dorzolamide eye drops with no resident identifiers, an unsealed and unlabeled package of petrolatum gauze dressing, and an open and undated bottle of lactulose. The Qualified Medication Aide (QMA) present confirmed that 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. The facility's policy requires all medications to be stored in containers with pharmacy labels, and for opened medications to be dated and labeled accordingly. These findings indicate that the facility failed to ensure medications and biologicals were properly labeled, dated, and stored as per policy and professional standards.
Failure to Follow Infection Control Practices During Skin Treatment and Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection control practices during a skin treatment for a resident. The nurse removed a dressing from the resident's inner left gluteal cleft, changed gloves, and applied wound gel and a new dressing. However, the nurse did not perform hand hygiene after removing the old dressing and after removing gloves, as confirmed during an interview. The nurse also assisted with repositioning the resident and applied skin prep to other areas without appropriate hand hygiene between tasks. In a separate incident, another nurse failed to use a barrier when obtaining a blood glucose sample for a resident. The nurse disinfected her hands, donned personal protective equipment, and placed the glucometer directly on the bedside table without a barrier. After obtaining the blood sample, the glucometer was again placed on the table without any protective barrier. The nurse acknowledged during an interview that a barrier should have been used.
Improper Food Storage and Labeling in Resident Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure that food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety. During an observation, the Boulevard unit pantry had an opened container with five slices of cheesecake, an opened package of milk chocolate morsels, and three full containers of Culver's ice cream in the refrigerator without a label. Additionally, the Windsor unit pantry had a large blue ice pack in the freezer compartment, which was used for a resident and should not have been stored there. The Heritage unit freezer also had three ice packs and bags of frozen green beans, with the large blue ice pack placed directly on top of one of the bags of green beans. The Dietary Manager confirmed that all food should be labeled with a date and the resident's name, and that ice packs used for residents should not be in the pantry refrigerators on the units. The Dietary Manager indicated that there was no policy on the storage of residents' ice packs in the nourishment freezers. The facility's policy titled 'Resident Food From Outside Source,' dated 11/28/2023, stated that items for a resident must be labeled with the name, room number, and date the food was brought into the facility. This deficiency had the potential to affect all 67 residents residing on the units, as the improper storage of food and ice packs could lead to food safety issues. The observations and interviews revealed a lack of adherence to the facility's food storage policies and professional standards for food safety.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) assistance for a resident, specifically in relation to shaving and nail care. During multiple observations, the resident was noted to have long facial hair and long fingernails with a brown/black substance underneath them. The resident expressed a preference for not having a beard and indicated that his wife had requested for him to be shaved. Despite this, the resident's beard was only partially shaved by his wife, and his fingernails remained untrimmed with debris underneath them. The resident's medical records indicated that he had moderate cognitive impairment and required partial to moderate assistance for grooming and personal hygiene. The care plan also specified that the resident needed maximum assistance with dressing, grooming, and bathing. However, the documentation showed inconsistencies in the provision of these services, with no record of shaving or nail care on certain shower days. Interviews with staff revealed that male residents were typically shaved on their scheduled shower days or upon request, and nails were evaluated for trimming on shower days. However, the shower sheets reviewed did not consistently document the provision of these services. Additionally, it was noted that CNAs were not permitted to trim the nails of diabetic residents, and the responsibility fell to the nurses, who were to be informed by the CNAs if nail care was needed. The facility's policies on morning care and diabetic nail care were reviewed, indicating that residents should be assisted with shaving and have their nails inspected weekly. Despite these policies, the resident's grooming needs were not adequately met, leading to the observed deficiencies.
Failure to Provide Appropriate Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate care for a central venous catheter for one resident and did not follow physician orders for another resident with skin conditions. For Resident 234, the central venous catheter dressing was observed to be dated 4/19 and was not adhered to the skin in the 6 o'clock position, despite a physician order to change the dressing every 7 days. The LPN indicated that the dressing was not changed on 4/25 as required because the facility did not have a new bio-patch in stock. This was confirmed during an observation on 5/2, where the dressing was still dated 4/19 and not properly adhered. The facility's policy required dressing changes every 7 days or when the integrity of the dressing was compromised, which was not followed in this case. For Resident 236, who had diagnoses including cellulitis, chronic venous hypertension with ulcer, peripheral vascular disease, and lymphedema, the physician ordered a single tubigrip to be applied to the left lower extremity daily. However, during multiple observations, the left lower extremity was found bare and swollen, indicating that the tubigrip was not applied as ordered. The RN confirmed that the tubigrip was supposed to be placed in the morning and removed in the evening, but the resident indicated it had not been placed all day. The facility's policy required that physician orders be transcribed and maintained to ensure safety, which was not adhered to in this instance.
Failure to Properly Store and Clean Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and cleaning of respiratory equipment for two residents. Resident 42's CPAP machine, tubing, and mask were observed uncovered and uncleaned on multiple occasions. Despite a physician's order to disinfect the equipment monthly, the task was not completed as documented. Interviews with staff revealed confusion about responsibilities for cleaning the equipment, with both QMAs and LPNs indicating it was not their duty to clean the CPAP equipment for Resident 42. Similarly, Resident 62's nebulizer machine and mask were found uncovered and not properly stored. The resident reported that the equipment was rinsed every other day, but it was not placed in a plastic bag as required. Staff interviews indicated inconsistent practices in cleaning and storing the nebulizer equipment. The facility's policies for CPAP and nebulizer care were not followed, leading to the observed deficiencies.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure pharmacy recommendations were communicated to the physician for review in a timely manner for one resident. Resident 47, who had diagnoses including overactive bladder, allergies, and insomnia, was prescribed Loratadine, Myrbetriq, and Melatonin. Pharmacy recommendations to reduce the dosages of these medications were made on three separate occasions but were not acted upon promptly. Specifically, recommendations to reduce Loratadine to every other day, Myrbetriq to 25mg daily, and Melatonin to 5mg at bedtime were not documented as being addressed in a timely manner. During an interview, the Director of Nursing (DON) indicated that the new pharmacy representative was using a different communication portal, which she was unaware of, leading to the delay in addressing the recommendations. The facility's policy on responding to pharmacist recommendations, which includes monitoring for physician response and resubmitting recommendations within specified timeframes, was not followed. This lapse resulted in the failure to ensure the resident's drug regimen was free from unnecessary medications.
Unattended Medication Cart with Keys Left in Drawer
Penalty
Summary
The facility failed to ensure medications were kept in a locked cart when unattended. During an observation, the medication cart for Windsor Hall was found with the keys in the drawer and no licensed nursing staff in sight. The nurse left the cart unattended for approximately 8 minutes. In an interview, the RN indicated she left the cart to respond to a call for help and forgot to take the keys with her. The Director of Nursing confirmed that the cart should have been locked and the keys taken by the nurse. The facility's policy on the storage of medications, dated 4/24/19, states that medications should be stored securely and only accessible to authorized personnel.
Failure to Update and Clarify Advanced Directive Status
Penalty
Summary
The facility failed to keep physician orders current with a resident's advanced directive instructions. Resident B, who was cognitively intact and receiving hospice services, had multiple advanced directive forms with conflicting instructions. An Out of Hospital Do Not Resuscitate (DNR) was signed by the Medical Director on 2/9/2024. A POST form dated 3/13/2024 indicated Do Not Attempt Resuscitation, comfort measures, use of antibiotics for infection only, and no artificial nutrition, signed by Resident B and the facility Nurse Practitioner. However, another POST form dated 3/15/2024 indicated Cardiopulmonary Resuscitation (CPR) to be provided, comfort measures, use of antibiotics for infection only, and no artificial nutrition, signed by Resident B and the hospice Medical Director. Despite these conflicting directives, a physician's order dated 2/17/2024 indicated Do Not Resuscitate, and the care plan dated 2/8/2024 also indicated no resuscitation. During an interview, an LPN indicated that if Resident B's heart stopped beating or she stopped breathing, she would follow the advanced directives and keep Resident B comfortable, believing Resident B had a DNR order. The facility's policy on advanced directives stated that any changes in the resident's preferences should be reflected in the medical record documentation. The failure to update and clarify the advanced directive status led to the deficiency, as the facility did not ensure that the physician orders were consistent with Resident B's current advanced directive instructions.
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Illustrative
What surveyors actually found near you
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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.
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 Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warsaw Meadows | 1.1 mi | ★★★★★ | 16 | 0 |
| Paddock Springs | 1.4 mi | ★★★★★ | 4 | 0 |
| Mason Health Care Center | 2.6 mi | ★★★★★ | 31 | 0 |
| Grace Village Health Care Facility | 2.9 mi | ★★★★★ | 0 | 0 |
| Timbercrest Church Of The Brethren Home | 14.3 mi | ★★★★★ | 12 | 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.