Miller's Merry Manor

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Activities Program was directed by a qualified professional who met required training and certification standards prior to assuming the role of Activities Director. This failure had the potential to affect 69 of 69 residents who relied on the activities program to meet their psychosocial, emotional, and social needs. Findings include:During a review of employee records on 12/31/25 at 8:40 a.m., records indicated the Activities Director (AD) lacked the required training and/or certification for the position. The records lacked evidence of completion of an approved activities training course or documentation demonstrating qualifications consistent with regulatory requirements at the time the individual was hired into the position.During an interview with the AD on 1/6/25 at 9:52 a.m., she indicated she had been in the position since 12/1/25. Prior to becoming the AD, she was the assistant to the AD. There was no training required to be the assistant. After being hired as the AD, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

A. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies for draining venous wounds to mitigate risk of contamination to the wounds and the risk of exposure to bodily fluids for others for 1 of 4 residents reviewed for pressure injuries. (Resident 64) B. Based on observation, interview and record review, the facility failed to maintain foley catheter tubing and drainage bags in a sanitary manner for 2 of 2 residents reviewed for foley catheters. (Residents 68 and 82) Findings include:A. During an observation, on 12/29/25 at 11:09 a.m., Resident 64 shuffled out of her room, using a two-wheel walker and wearing nonskid socks. Resident 64's clinical record was reviewed on 12/31/25 at 9:21 a.m. Diagnoses included old myocardial infarction (heart attack), generalized edema, atherosclerotic heart disease of the native coronary artery without angina pectoris, chronic obstructive pulmonary disease, altered mental status, dementia, lymphedema, and peripheral vascular disease. Current orders included the following: Wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was served under sanitary methods regarding food handling, hand washing, and glove use. This deficient practice had the potential to impact 73 of 73 residents who received meals in the facility. Findings include: 1. A completed Roster Matrix form, provided by the facility on 10/30/24 following the entrance conference, indicated the facility had no residents who received nutrition by any alternate means other than oral eating. During a lunch meal service observation on 11/4/23 from 11:40 a.m. to 12:03 p.m., the following concerns regarding sanitary food preparation and distribution were made: Cook 5 wore gloves. She touched the outside of meal trays, thermal plate bases, heated tray pallets, bread bags, bread rolls, and cheese with her gloved hands. She did not change her gloved hands as she touched the various items. She used her solid gloved hands to open the bread rolls and placed cheese slices inside the roll. Using the same gloved hands, she handed the prepped roll to [NAME] 4, who took the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter was handled in a manner to support the resident's dignity when the drainage bag was left in the view of sight of others within the facility. (Resident 68) Findings include: During an observation on 11/1/24 at 10:11 a.m., Resident 68's was in bed, with the catheter bag hanging on the right side of the bed frame. The bag was exposed and urine could be seen in the bag. During an observation on 11/6/24 at 9:47 a.m., the resident was in bed, with the urinary catheter bag hanging on the right side of the bed frame. The bag was exposed and urine could be seen in the bag. Resident 68's clinical record was reviewed on 11/6/24 at 10:50 a.m. Physician orders, dated 5/15/24, indicated catheter care should be performed every shift. The catheter drainage bag was to be below the waist and covered every shift. During a catheter care observation on 11/7/24 at 10:16 a.m., RN 3 indicated there was a device on the left side of the resident's bed, on the railing, which contained the catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to serve a therapeutic pureed diet as ordered by a physician for 2 of 2 residents reviewed who received pureed diets ( Residents 42 and 43). Findings include: During a lunch meal observation on 11/4/24 from 11:20 a.m. to 11:47 a.m., a regular gelatin dessert with whipped topping was served to Residents 42 and 43. The gelatin was cubed in shape and topped with whipped cream. The cubes were solid pieces of gelatin. Both Residents 42 and 43 consumed a portion of the regular gelatin. During an observation on 11/4/24 at 11:50 a.m., Resident 43's meal ticket indicated gravy to meat and potatoes. Resident 43's meat and potatoes contained no gravy, nor was there gravy provided for a staff member to use for topping the food. A current facility lunch meal, portion size and texture serving guide (also known as a spread sheet), dated 11/4/24 and provided by the Administrator on 11/7/24 at 10:50 a.m., indicated residents who had pureed diet orders were menued to receive a 1/2 (#8 scoop) of pureed gelatin topped with whipped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

A. Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed according to facility policy and physician orders during wound care for 1 of 1 residents reviewed for wounds. (Resident 23) B. Based on observation and interview, the facility failed to ensure staff administered medications in a sanitary manner for 1 of 2 residents observed for medication administration. (Resident 20) Findings include: A. Resident 23's clinical record was reviewed on 11/6/24 at 3:02 p.m. Diagnoses included acute diastolic (congestive) heart failure, (other) abnormalities of gait and mobility, Type 2 diabetes mellitus with diabetic neuropathy, morbid (severe) obesity due to excess calories, unspecified fracture of left femur, and difficulty in walking. Current physician orders included (9/9/24) apply povidone iodine to left heel every shift for wound care, (6/7/24) skin protectant to right heel for skin protection, and (6/4/24) EBP during high-contact resident care. A current care plan, dated 6/4/24, indicated the resident required EBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pneumococcal vaccination (to protect against the bacterium Streptococcus pneumoniae) was offered or administered for 3 of 5 residents reviewed for immunizations. (Residents 32, 53, and 14) Findings include: 1. Resident 32's clinical record was reviewed on 11/4/24 at 11:40 a.m. Diagnoses included left-side non-dominant hemiplegia and hemiparesis following cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus. The resident admitted in 2020. Resident 32's immunization record indicated an undated refusal for the pneumococcal 13-valent conjugate vaccine (PCV 13) and pneumococcal polysaccharide vaccine (PPSV 23). A Pneumococcal/Prevnar 13 Vaccine Consent form, provided by the Infection Preventionist on 11/7/24 at 11:09 a.m., indicated the resident had refused the above vaccines on 2/28/20. During an interview, on 11/7/24 at 11:09 a.m., the Infection Preventionist indicated she discussed the importance of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner regarding dating and labeling foods, and failed to ensure the kitchen and equipment was maintained in a sanitary manner. This deficient practice had the potential to impact 66 residents who received meals prepared in the kitchen of 67 in the facility. Findings include: During a kitchen tour, accompanied by Dietary Aide 8, on 5/9/24 at 8:56 a.m., the following was observed: a. The walk-in refrigerator had undated and unlabeled foods as follows: a piece of meat in a tin pan, identified by the Dietary Aide as Salisbury steak, eight dessert cups contained honey dew melon, a dessert cup with a sliced tomato and sliced onion, a clear container with a green lid that contained a tan colored liquid identified by the Dietary Aide as chicken noodle soup, three foam cups contained sliced onion, sliced pickle and sliced tomato in each cup, four dessert cups contained mixed fruit, one dessert cup contained a brown and white substance identified by the Dietary Aide as chocolate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to implement individualized interventions to prevent the worsening of a pressure injury. (Resident 63) Finding includes: During an observation, on 1/25/24 at 9:15 a.m., Resident 63 was sitting on the edge of his bed looking at items on his bedside table. During an observation, on 1/26/24 at 10:24 a.m., the resident was lying on his back in bed with his eyes closed. During an observation, on 1/26/23 at 4:08 p.m., the resident was sitting in his wheelchair in his room. During an observation, on 1/29/24 at 11:30 a.m., the resident was sitting on the edge of his bed feeding himself lunch. Resident 63's clinical record was reviewed on 1/26/24 at 3:36 p.m. His diagnoses included depression, generalized anxiety disorder, metabolic encephalopathy, combined systolic and diastolic congestive heart failure, end stage renal disease, dependence on renal dialysis, fracture of the neck of the left femur, and polyneuropathy. His current physician orders included protein supplement two times a day (dated 1/16/24) and wash left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure biologicals requiring refrigeration for Residents 55 and 122 were monitored per CDC guidelines for 2 of 2 refrigerators reviewed for medication/biological storage. Findings include: During an observation of the North 2 nursing unit medication storage room on 1/30/24 at 9:43 a.m., the medication refrigerator was locked. At the same time, the ADON indicated the medication room refrigerator temperature was checked daily and contained medications and vaccines. She did not have a key to the refrigerator. During an observation of the Boulevard nursing unit medication storage room on 1/30/24 at 9:53 a.m., the refrigerator contained a COVID 19 vaccine for Resident 55. At the same time, QMA 4 indicated she did not know what was usually kept in the refrigerator, as she did not pass insulin or typically have refrigerated medications she administered on the unit. The refrigerator temperature was checked daily by night shift. Review of a facility document, titled Med Room Refrigerator Temperature Settings, provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff followed physician orders for enhanced barrier precautions during an aerosol-generating procedure for 1 of 1 residents reviewed for respiratory care. (Resident 15) Finding includes: Resident 15's medical record was reviewed on 1/26/24 at 10:22 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia (an insufficient amount of oxygen), and generalized anxiety disorder. Her physician's orders included droplet isolation precautions during tracheostomy care, suctioning, and aerosol treatments (dated 4/20/22) and enhanced barrier precautions (EBP) during high contact resident care for her tracheostomy (dated 5/26/23). During an observation, on 1/25/24 at 3:15 p.m., a sign on the resident's door indicated enhanced barrier precautions were to be performed by anyone performing high-contact resident care activities. Instructions included performing hand hygiene and wearing gloves and a gown, when caring for or accessing the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.