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Miller's Merry Manor

635 Oakhill Ave, Plymouth, IN 46563 · For profit - Corporation · 131 certified beds · (574) 936-9981 Medicare & Medicaid certified

Call the home — (574) 936-9981 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Apr 2024Resident-funds citation (F0567)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 28% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
105 Water St · (574) 540-2052 · Call to confirm hours
Pharmacy
301 N Michigan St · (574) 936-3167 · Call to confirm hours
Grocery
116 E Garro St · (574) 936-1900 · Call to confirm hours
Park
112 Water St · (574) 936-2876 · Typically dawn to dusk
Place of worship
209 S 5th St

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.8%11.0%15.4%better
Long-stay residents who lose too much weight3.0%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms11.9%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened14.9%11.9%16.1%typical
Long-stay residents on antianxiety or hypnotic medication18.6%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine98.4%95.4%95.3%typical
Long-stay residents with pressure ulcers5.9%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control4.9%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.0%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine97.5%79.0%79.4%better
Short-stay residents rehospitalized after admission22.3%22.2%22.6%typical
Short-stay residents with an outpatient ER visit13.8%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.251.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.811.441.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

64.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.3%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
41.5%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 41.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 53 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.3%CMS range 53.2–73.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.6–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge41.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.9–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.89
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.67
Aide hours/ resident / day
4.14
Total nurse hours/ resident / day
0.58
RN hoursweekends
56.0%
Total nursing turnover
23.5%
RN turnover

How full it usually is: this home is certified for 131 beds and averages 72.2 residents a day — about 55% occupied, or roughly 59 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.40 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.01 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-02-07)
10
at the previous standard inspection (2024-04-23)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

  • Potential for harm · E2025-02-07 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and observation, the facility failed to ensure resident funds were immediately available during non-business hours. This deificent practice had the potential to affect 24 of 24 residents with trust funds. Finding includes: During an interview, on 2/5/2025 at 9:25 A.M., Resident 12 indicated the facility had informed him he could only get his resident trust account funds when the business office was open. During an observation, on 2/7/2025 at 10:43 A.M., a sign at the front receptionist's desk was observed with the following: Resident Trust Funds Availability For those residents who have a Resident Trust Fund account with [facility name]: These funds are available to you seven [7] days a week, during the following times: Business Office Monday-Friday 8:30am-4:30pm ICF 1's Nurse's Station Saturday & Sunday 10:00am-2:00pm During an interview, on 2/7/2025 at 10:45 A.M., the Business Office Manger indicated residents could obtain their money during business hours, Monday through Friday and there was a time perimeter on Saturday and Sunday for residents to obtain…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow physician orders for daily weights and failed to transcribe physician orders accurately for 2 of 22 residents whose physician orders were reviewed. (Residents 55 & 267) Findings include: 1. The record for Resident 55 was reviewed on 2/6/2025 at 1:58 P.M. Diagnoses included, but were not limited to: diabetes, dementia, depression and anxiety. A Physician's Order, dated 2/19/2025, indicated an order for daily weight-after voiding and before breakfast/medications with the same clothes every day shift. A current Care Plan for nutrition, dated 1/10/2025, indicated the resident was at nutritional risk related to: Potential for weight fluctuations related to fluid shifts and receives diuretic therapy. Interventions included but were not limited to: Diet is served as ordered. Select my own menus. Monitor weights and intakes. The November weight documentation and Nursing Progress Notes, from 11/1/2024 through 11/30/2024, lacked daily weights and/or documentation of why the daily weight was not obtained for the following…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the physician was notified of abnormal blood sugar results for 1 of 1 residents reviewed for physician notification. (Resident 54) Findings include: 1. The record for Resident 54 was reviewed on 2/6/2025 at 3:57 P.M. Diagnoses included, but were not limited to: hemiplegai, neurogenic bladder, diabetes and cancer. A Quarterly Minimum Data Set (MDS) assessment, dated 1/22/2025, indicated the resident received antidepressant and hypoglycemic medications. Current Physician Orders for Resident 54 included the following: - Humalog Inject 15 units subcutaneously three times a day for diabetes. Give 15 minutes AC (before) meal/snack. Notify MD if BS (blood sugar) less than 100 or greater than 400. If s/s (signs/symptoms) present, follow blood sugar flowchart and document in progress note. Hold if blood sugar is less than 150. - Glargine insulin -Inject 32 units subcutaneously one time a day for diabetes. Hold if BS is less than 100 or greater than 400 and notify the MD. Monitor for s/s of hypo/hyperglycemia and notify MD if…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-07 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interview, the facility failed to provide activities for a dependent resident for 1 of 3 residents reviewed for activities. (Resident 40) Finding includes: During an observation, on 2/4/2025 at 9:46 A.M.,10:56 A.M. and 2:49 P.M., Resident 40 was observed in her room without visual or auditory stimulation. During an observation, on 2/5/2025 at 10:49 A.M., Resident 40 was seated in a reclined position in her Broda chair in her room without visual or auditory stimulation. During an observation, on 2/5/2025 at 3:04 P.M., Resident 40 was observed in her bed sleeping. During an observation, on 2/6/2025 at 11:02 A.M., Resident 40 was observed in her room without visual or auditory stimulation. A record review for Resident 40 was completed on 2/6/2025 at 1:12 P.M. Diagnoses included, but were not limited to: cerebral infarction, hemiplegia, dementia and delirium. A Quarterly Minimum Data Set (MDS) assessment, dated 1/31/2025, indicated Resident 40 was severely cognitively impaired and received hospice care. A current Care Plan, initiated 11/25/2022,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a PRN (as needed) antianxiety medication was not ordered/used for more than 14 days and lacked documentation for the use of an antipsychotic for 2 of 6 residents reviewed for unnecessary medications. (Resident 19 & 39) Findings include: A record review for Resident 19 was completed on 2/6/2025 at 11:36 A.M. Diagnoses included but were not limited to Alzheimer's, psychotic disorder with delusions, and anxiety. A Quarterly Minimum Data Set (MDS) assessment, dated 11/26/2024, indicated Resident 19 had exhibited signs of delusions but had not exhibited any other behaviors. The assessment also indicated Resident 19 had not received any psychotropic medications. A Physician's Order, dated 1/8/2025, and discontinued on 2/4/2025, indicated lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) by mouth every 4 hours as needed (PRN) for anxiety. A Physician's Order, dated 2/4/2025, and with a stop dated of 5/1/2025, indicated lorazepam 0.5mg by mouth every 4 hours PRN for anxiety. A Care Plan, initiated on 1/16/2025,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure over the counter medications were labeled properly and failed to ensure opened medications were dated when opened for 1 of 4 medication storage areas observed. (ICF 3 medication cart) Finding includes: On 2/6/2025 at 2:22 P.M., a medication storage observation of the ICF 3 medication cart was completed with RN 5 and the following was observed: - a bottle of ibuprofen 200 mg (milligrams) with no resident label. - an opened and unlabeled bottle of CoQ10. - an opened and unlabeled bottle of Vitamin D 3. - an opened and unlabeled bottle of aspirin 81 mg. - an opened and unlabeled bottle of Ferrosol 325 mg. - an opened and unlabeled bottle of Milk of Magnesia (MOM). - a bottle of Men's multi vitamin with no resident label. - a box of daily probiotic pills with no label. - an opened and undated bottle of Guaifenesin liquid. - 2 opened and undated bottles of MOM. During an interview, on 2/6/2025 at 2:36 P.M., RN 5 indicated the medications should have been labeled and should have had opened dates on them. On…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to provide enhanced barrier precautions (EBP) for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 46) Finding includes: During an interview, on 2/4/2025 at 10:28 A.M., Resident 46 indicated he had had a sore on his buttock for the past three weeks. A record review for Resident 46 was completed on 2/6/2024 at 9:45 A.M. Diagnoses included, but were not limited to: heart failure, diabetes mellitus type 2, obesity, polyneuropathy and edema. A Quarterly Minimum Data Set (M.DS) assessment, dated 1/31/2025, indicated Resident 46 was cognitively intact and had a Stage 2 pressure ulcer. A Pressure Injury Note, dated 1/2/2025 at 12:03 P.M., indicated a new in-house stage 2 pressure ulcer was observed to the left mid-buttock. A Physician's Order, dated 1/28/2025, indicated to cover the wound with Duoderm (moisture-resistant wound dressing) every Tuesday and as needed if displaced or soiled. A Care Plan, dated 1/2/2025, indicated Resident 46 had a pressure ulcer. The goal was 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-23 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Base on observation, interview and record review, the facility failed to ensure staff-directed activities were provided in the evening and on the weekends for 1 of 1 resident reviewed for activities. (Resident 3). This had the potential to affect 52 out of 70 residents residing in the facility. Finding includes: During an interview on 4/17/2024 at 10:02 A.M., Resident 3 indicated the facility had no activities in the evenings or on the weekend. She would like to attend activities in the evening and on the weekends. They only had holiday type activities on the weekend for days like Easter and Christmas. A record review was completed on 4/19/2024 at 2:34 P.M. Diagnoses included, but were not limited to: end stage renal disease, type 2 diabetes, and heart failure. An Activity Care Plan, dated 11/11/2022, indicated that she enjoyed increased socialization, stimulation received through her involvement in group activities. She was a social person and attended most activities. The Activity Calendar, dated April of 2024, indicated the last activity during the week was scheduled at either…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure housekeeping maintained a sanitary room environment related to dust and floors not swept or mopped for 1 of 1 resident reviewed for environment. (Resident 42) Finding includes: During an interview and observation on [DATE] at 11:06 A.M., Resident 42 indicated she did not feel her room was clean. They had one housekeeper that was fantastic but was no longer here. The other housekeepers cleaned the toilet, bathroom sink and took out the trash. They seldom mopped and swept the floors in the bedroom, and they did not dust. The blinds needed to be dusted, it's been at least 2 months. The blinds, picture frames, and shelves in the bathroom with angel figurines were observed to be dusty. During an interview and observation on [DATE] at 1:19 P.M., Resident 42 indicated that staff had cleaned the bathroom and dry mopped the floors, but did not wash the floor. The blinds, picture frames and shelves in the bathroom with angel figurines were…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure an allegation of a resident's missing property was reported immediately or within 2 hours after an allegation was made to the State Survey Agency for 1 of 1 resident reviewed for abuse. (Resident 42) Finding includes: During an interview on 4/17/2024 at 10:51 A.M., Resident 42 indicated she just found out $25.00 was missing from her purse today. The last time she saw it was last Friday, and she had it for about 2 weeks. She has always kept her money in her wallet inside her purse, which was placed in a small area between two dressers. She did not put her money anywhere else. Once a month, activities would order food out from a restaurant and today was gyros. When she went to get her money, it was not there. She planned on telling the Social Services Director and indicated it had happened before. She planned on asking for a lock box from the social worker. During an interview on 4/19/2024 at 9:43 A.M., the resident indicated she had told the social worker, and he was doing an investigation. He did give…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-04-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a thorough investigation was initiated for an allegation of a resident's missing property for 1 of 1 resident reviewed for abuse. (Resident 42) Finding includes: During an interview on 4/17/2024 at 10:51 A.M., Resident 42 indicated she just found out $25.00 was missing from her purse today. The last time she saw it was last Friday, and she had it for about 2 weeks. She has always kept her money in her wallet inside her purse, which was placed in a small area between two dressers. She did not put her money anywhere else. Once a month, activities would order food out from a restaurant and today was gyros. When she went to get her money, it was not there. She planned on telling the Social Services Director and indicated it had happened before. She planned on asking for a lock box from the social worker. During an interview on 4/19/2024 at 9:43 A.M., the resident indicated she had told the social worker, and he was doing an investigation. He did give her a lock box to keep her money it i, which she now kept…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and interview, the facility failed to update a care plan regarding the use of splints for 1 of 18 residents reviewed for care plans. (Resident 19) Finding includes: A record review for Resident 19 was completed on 4/18/2024 at 1:13 P.M. Diagnoses included, but were not limited to: functional quadriplegia, lobster-claw hand, contracture of muscle right hand, and muscle weakness. A Quarterly Minimum Data Set (MDS) assessment, dated 2/5/2024, indicated upper extremity impairment on both upper extremities. During an observation on 4/18/2024 at 9:27 A.M., Resident 19 was observed to have contracture on both hands, and Resident 19 indicated he wears splints during the nighttime hours. A Physician's Order, dated 2/6/2020, indicated Resident 19 to wear a left palm protector with finger separators during sleeping hours, and indicated Resident 19 to wear a right-handed splint during the night/sleeping hours, dated 4/25/2023. A Care Plan dated 6/2/2020, indicated a splint/brace program with assistance needed for application of the brace to bilateral hands due…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of blood sugars outside the ordered parameters for 1 of 1 resident reviewed for insulin, and weight changes due to heart failure for 1 of 3 residents reviewed for hospitalization. (Resident 19) Finding includes: During an interview on 4/17/2024 at 10:47 A.M., Resident 19 indicated he had high blood sugar and had been recently hospitalized for muscle problems. A record review for Resident 19 was completed on 4/18/2024 at 2:17 P.M. Diagnoses included, but were not limited to: heart failure, diabetes mellitus type 2, chronic kidney disease, atrial fibrillation, and anemia. An admission Minimum Data Set (MDS) assessment, dated 3/12/2024, indicated Resident 19 received insulin for 7 days during the assessment period, and had heart failure and diabetes mellitus as diagnoses. A Physician's Order dated 3/5/2024, indicated to check the blood sugar as needed for signs and symptoms of hypo/hyperglycemia, and to notify the physician for blood…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to provide ordered nutritional supplements for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 10) Finding includes: During an observation on 4/17/2024 at 10:19 A.M., Resident 10 was observed lying in bed sleeping, and a note on the bedside table indicated to please see the nurse before giving fluids. A record review for Resident 10 was completed on 4/19/2024 at 11:01 A.M. Diagnoses included, but were not limited to: hemiplegia, diabetes mellitus type 2, and dysphagia. A Care Plan, dated 8/1/2019, indicated Resident 10 was at nutritional risk related to a cerebral vascular accident (stroke) and anemia. The interventions included offering replacement foods/beverages if meal consumption was 50 percent less, and monitoring weights and intakes. The weight record indicated on 3/5/2025 at 8:32 A.M., Resident 10's weight was recorded as 154.8 pounds and on 4/8/2024 at 1:06 P.M., her weight was 146.2 pounds. A Nurse's Note, dated 4/8/2024 at 4:03 P.M., indicated the Nurse…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-23 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide safe side rails and complete an assessment for 1 of 2 residents reviewed for environment. (Resident 19) Finding includes: During an observation on 04/17/2024 at 9:26 A.M., Resident 19's bed had a side rail in the up position on the left side of the bed when standing at the foot of the bed. The side rail had 3 openings with one opening appearing larger than the recommended dimensions for safety. A record review was completed on 4/18/2024 at 2:17 P.M. Diagnoses included, but were not limited to: bipolar disorder, functional quadriplegia, unspecified dementia, lobster-claw left hand, lack of coordination, contracture of muscle right hand, and delusional disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 2/5/2024, indicated bed rails were not in use, and Resident 19 had no impairment of his extremities. A Physician's Order, dated 4/7/2024, indicated an assistive device of half side rails on both sides of the bed to assist with mobility and safety. A Care Plan, dated 4/7/2024, indicated that…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure it was free of medication error of greater than 5 percent for 3 of 3 residents (Resident 24, 56, and 60) observed during medication pass. Three medication error were observed during 31 opportunities for error in medication administration. This resulted in a medication error rate of 9.68 percent. Findings include: 1. During an observation on 4/22/2024 at 10:48 A.M., LPN 7 administered insulin to Resident 56, 8 units of Novolog for a blood sugar result of 313. A record review was completed for Resident 56 on 4/22/2024 at 1:30 P.M. Diagnoses included, but were not limited to: type 2 diabetes. The Physician Order, dated 1/25/2024, indicated Novolog injection solution 100 units/ML (milliliters), inject as per sliding scale: 151-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350=8 units, 351-400=10 units. Notify MD if blood sugar >400, subcutaneously four times a day for DM 15 min before meal/snack. During an interview on 4/22/2024 at 11:46 A.M., Resident 56 indicated he had not received a snack or…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure infection control practices were followed for 2 of 2 residents receiving blood glucose monitoring. (Resident 56 & 60) Findings include: 1. During an observation on [DATE] at 10:42 A.M., LPN 7 checked Resident 56's blood sugar, returned to her cart and cleaned the glucometer with one alcohol prep pad, then set it back down on the medication cart. A record review was completed for Resident 56 on [DATE] at 1:30 P.M. Diagnoses included, but were not limited to: type 2 diabetes. 2. During an observation on [DATE] at 10:54 A.M., LPN 7 proceeded to check Resident 60's blood sugar using the same glucose monitor she had used on Resident 56. LPN 7 cleaned it again with one alcohol prep and proceeded to check the resident's blood sugar. A record review was completed for Resident 60 on [DATE] at 1:35 P.M. Diagnoses included, but were not limited to: type 2 diabetes. During an interview on [DATE] at 10:57 A.M., LPN 7 indicated she did not know what the policy…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to develop a person-centered care plan for 1 of 22 residents whose care plans were reviewed. (Resident 17) Finding includes: During an observation, on 2/21/2023 at 9:53 A.M., Resident 17's left right was very edematous, and scratches were noted. Resident 17 indicated his leg itched sometimes and he scratched it earlier that morning. A clinical record review, done on 2/23/2023 at 9:58 A.M., Resident 17's admission MDS (Minimum Data Set) Assessment, dated 2/10/2023, indicated, a BIMS (Brief Interview of Mental Status) was 15, which indicated no impairment. His active diagnoses included, but were not limited to, diabetes mellitus. He required extensive assist of 2 staff for bed mobility, transfers, and toileting, and extensive assist of 1 staff for dressing. He had a surgical wound with wound care due to a knee replacement. No pressure ulcers or other skin conditions were noted. Other diagnoses included, but were not limited to, unspecified edema. Physician orders for Resident 17 included, but were not limited to,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and record review, the facility failed to revise a care plan for the use of an antidepressant medication in 1 of 22 residents whose care plans were reviewed. ( Resident 31)\ Finding includes: A clinical record review was completed on, 2/23/2023 at 9:51 A.M. Resident 31's diagnoses included, but were not limited to: dementia, malnutrition, insomnia, dysphagia, and benign prostate. A Quarterly MDS, dated [DATE], indicated the resident required extensive assist of 2 staff for bed mobility, toilet use, 1 staff for dressing and eating and total assist for transfers. Received antianxiety and antidepressant medications and was receiving Hospice services. A current care plan, dated 12/23/2022, indicated the resident had sleeplessness/insomnia and had a routine medication prescribed for sleep (trazadone). Resident 31's current medication orders indicated the previous order for trazadone was discontinued on 2/7/2023. A NP (Nurse Practitioner) Note, dated 2/7/2023, indicated she did a…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and clinical record review, the facility failed to ensure that 1 out of 22 residents reviewed received treatment and care in accordance with professional standards of practice and the comprehensive care plan. (Resident 17) Finding includes: During an observation, on 2/21/2023 at 9:53 A.M., Resident 17's right leg was very edematous, and scratches were noted. Resident 17 indicated his leg itched sometimes and he scratched it earlier that morning. During a clinical record review, done on 2/23/2023 at 9:58 A.M., Resident 17's admission MDS (Minimum Data Set) Assessment, dated 2/10/2023, indicated, but was not limited to, a BIMS (Brief Interview of Mental Status) was 15, which indicated no impairment. His active diagnoses included, but were not limited to, diabetes mellitus. He required extensive assist of 2 staff for bed mobility, transfers, and toileting, and extensive assist of 1 staff for dressing. He had a surgical wound with wound care due to a knee replacement. No pressure ulcers or other skin conditions were noted. Other diagnoses included, but…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MILLER'S MERRY MANOR — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.5+0.5 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 53.7+1.3 vs chain
The other 13 homes this chain runs (chain average 3.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
JOHNSON MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 07/01/2012
LUMENT FINANCE TRUST INCOrganization5% OR GREATER MORTGAGE INTERESTsince 11/01/2014
DUNKLE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
FORVIS MAZARS LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
MILLER'S HEALTH SYSTEMS INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2013
THERACARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
BOYLE, PATRICKIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/01/2025
DECOLA, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
HAUG, LORIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
HOLM, BYRONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
ROBINSON, TINAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
ZEHR, BRYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MILLER'S MERRY MANOR PLYMOUTH LLCOrganizationADP OF THE SNFsince 07/01/2012
MMM-INVEST INCOrganizationADP OF THE SNFsince 07/01/2012

CMS files one row per role, so the 21 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.1M
Net patient revenuemost recent cost report
-20.3%
Operating marginrevenue minus expenses
$3.1M
Related-party expense28% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 10%Other / private 39%

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$461per resident / day
operating cost
$14,016per month
≈ monthly operating cost
$383per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155102. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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