Inspection Report Summary
The most recent inspection on June 12, 2025, identified a deficiency related to resident abuse involving a staff member posting a resident’s video on social media; this issue was corrected before the survey and the staff member was terminated. Earlier inspections showed a mix of deficiencies including medication management, infection control, Life Safety Code compliance, and care-related documentation. Complaint investigations were mostly unsubstantiated except for one substantiated medication error in February 2023 that resulted in hospitalization and staff retraining. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with clinical care and safety standards, with some corrective actions implemented but issues persisting over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 1
Jun 12, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460207 and IN00461325. Complaint IN00460207 found no deficiencies, while complaint IN00461325 resulted in a federal deficiency citation.
Findings
The facility was found deficient for failing to ensure one resident was free from abuse related to a staff member posting a video of the resident on social media. The deficient practice was corrected prior to the survey start date, and the responsible staff member was terminated. Staff education on abuse policies and cell phone usage was completed.
Complaint Details
Complaint IN00461325 was substantiated with a federal deficiency cited. Complaint IN00460207 found no deficiencies related to the allegation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from abuse/exploitation related to a staff member's post of resident pictures/video on social media. | SS=D |
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 6
Medicaid Census: 36
Other Payor Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in abuse finding for posting resident video on social media and subsequently terminated |
| Director of Nursing | Director of Nursing | Conducted investigation, interviewed staff, terminated CNA 3, and provided facility policy |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452157.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00452157 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 7
Medicaid Census: 31
Other Payor Census: 10
Inspection Report
Life Safety
Census: 50
Capacity: 66
Deficiencies: 3
Jan 9, 2025
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with door latches on a public restroom door, lack of approved method to return cooking appliances to their designated location, and smoke barrier doors not restricting smoke movement properly.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 door to the public men's restroom was provided with door latches that required only one operation to open. | SS=E |
| Failed to provide an approved method for returning cooking appliances to their approved design location after maintenance or cleaning. | SS=E |
| Failed to ensure 1 of 4 sets of barrier doors would restrict the movement of smoke for at least 20 minutes due to a four-inch gap. | SS=E |
Report Facts
Certified beds: 66
Census: 50
Affected residents: 16
Affected staff: 5
Affected visitors: 2
Affected residents: 2
Affected staff: 4
Affected visitors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Craig Clemons | Administrator | Named as facility Administrator involved in exit conference |
| Maintenance Director | Named in relation to observations and corrective actions for deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Jan 9, 2025
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted on 01/09/2025.
Findings
Miller's Merry Manor was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Deficiencies: 0
Jan 7, 2025
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey completed on December 6, 2024.
Findings
Miller's Merry Manor was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 48
Capacity: 48
Deficiencies: 2
Dec 6, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from December 3 to December 6, 2024.
Findings
The facility was found deficient in notifying physicians of out-of-range blood sugar levels for one resident and in ensuring physician services met professional standards related to diagnosis and medication for another resident. Plans of correction were submitted addressing these issues.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician of out of range blood sugars for 1 of 2 residents reviewed for insulin (Resident 30). | SS=D |
| Failed to ensure physician services met professional standards related to diagnosis of schizophrenia for 1 of 2 residents reviewed for unnecessary medications (Residents 1, 25). | SS=D |
Report Facts
Census: 48
Total Capacity: 48
Behaviors recorded: 31
Behaviors recorded: 17
Behaviors recorded: 4
Behaviors recorded: 3
Behaviors recorded: 1
Behaviors recorded: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Craig Clemons | Administrator | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding physician notification and policy compliance |
| Social Service Director | Social Service Director | Interviewed regarding diagnosis changes for Resident 1 |
Inspection Report
Life Safety
Census: 52
Capacity: 66
Deficiencies: 0
Feb 13, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
Miller's Merry Manor was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered building with a fire alarm system and a diesel-powered generator, with no deficiencies cited.
Report Facts
Certified beds: 66
Census: 52
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 6
Jan 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 8 to January 12, 2024.
Findings
The facility was found deficient in multiple areas including medication storage and labeling, quality of care related to treatment adherence, respiratory care equipment storage, food safety and sanitation, and infection prevention and control practices. Several residents were observed with medications improperly stored or administered, treatments not carried out per physician orders, and infection control protocols not consistently followed.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Medications were stored at the bedside without authorization and evaluation for self-administration for 2 residents. | SS=D |
| Failed to ensure treatments were carried out per Physician's Orders for 3 residents. | SS=D |
| Respiratory equipment/tubing was improperly stored and distilled water was unlabeled for 1 resident. | SS=D |
| Over the counter medications were not labeled properly on 2 medication carts and insulin was expired on 1 medication cart. | SS=D |
| Food and equipment were improperly stored; undated opened food and air-dry pitchers, coffee cups, and resident water cups were not inverted and free from contamination. | SS=F |
| Failed to ensure nursing staff followed infection control policies regarding hand washing, equipment cleaning and storage, and dressing change procedures. | SS=E |
Report Facts
Census: 50
Survey dates: 5
Deficiencies cited: 6
Medication carts observed: 2
Residents reviewed for quality of care: 3
Residents reviewed for respiratory care: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Hill | Administrator | Signed the report |
| LPN 8 | Licensed Practical Nurse | Observed obtaining blood glucose and cleaning glucometer |
| LPN 4 | Licensed Practical Nurse | Observed performing dressing change with infection control deficiencies |
| QMA 7 | Qualified Medication Aide | Observed administering medications without proper hand hygiene |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding medication storage and resident care |
| RN 3 | Registered Nurse | Interviewed regarding medication storage and resident care |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding resident care and helmet use |
| Director of Nursing | Director of Nursing | Provided policies and interviewed about facility practices |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and kitchen sanitation |
| Dietary Aide | Dietary Aide | Interviewed regarding drying and storage of kitchen utensils |
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2024
Visit Reason
The visit was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Miller's Merry Manor was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Jun 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410615.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00410615 found no deficiencies related to the allegations; complaint was not substantiated.
Report Facts
Census: 46
Total Capacity: 46
Medicare Census: 6
Medicaid Census: 28
Other Payor Census: 12
Inspection Report
Re-Inspection
Census: 41
Capacity: 66
Deficiencies: 0
Mar 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building is fully sprinklered and protected by a fire alarm system and diesel-powered generator.
Report Facts
Facility capacity: 66
Census: 41
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Feb 9, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00400398, which was substantiated with related federal and state deficiencies cited.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically a medication error involving the wrong administration of insulin to a resident, which resulted in hospitalization and required corrective actions including staff education and policy reinforcement.
Complaint Details
Complaint IN00400398 was substantiated. The medication error involved a nurse administering 100 units of Toujeo insulin to the wrong resident, resulting in hospitalization and subsequent corrective actions including staff in-service and return demonstrations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a significant medication error did not occur for one of five residents reviewed, involving incorrect insulin administration. | SS=G |
Report Facts
Census: 49
Total Capacity: 49
Medicare Residents: 12
Medicaid Residents: 28
Other Payor Residents: 9
Insulin Dose Administered in Error: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in medication error finding for administering insulin to the wrong resident |
| Director of Nursing | Director of Nursing | Provided interview details regarding the medication error and facility policies |
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2023
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey completed on December 2, 2022.
Findings
Millers Merry Manor of Culver was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 40
Capacity: 66
Deficiencies: 2
Jan 9, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to ensure a self-closing device on a hazardous storage room door and failure to maintain accurate time and date on the fire alarm system control panel.
Severity Breakdown
SS=E: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the corridor door to a hazardous storage room over 50 square feet was provided with a self-closing device to automatically close and latch. | SS=E |
| Failed to maintain the fire alarm system to assure it had accurate time and date information in accordance with NFPA guidelines. | SS=C |
Report Facts
Certified beds: 66
Census: 40
Hazardous storage room size: 120
Mattresses in storage room: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Hill | Administrator | Named as the facility Administrator; not present at exit conference |
| Maintenance Supervisor | Interviewed regarding hazardous storage room and fire alarm system deficiencies |
Inspection Report
Renewal
Census: 38
Capacity: 38
Deficiencies: 3
Dec 2, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from November 28 to December 2, 2022.
Findings
The facility was found deficient in three areas: accuracy of admission assessments, assistance with activities of daily living (bathing), and following physician orders for pain medication. Corrective actions and staff in-service plans were outlined for each deficiency.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an Admission MDS Assessment was accurate for 1 of 17 residents reviewed (Resident 40). | SS=D |
| Failed to ensure 1 of 3 residents received assistance related to bathing needs (Resident 35). | SS=D |
| Failed to follow physician orders for pain medication in 1 of 2 residents reviewed (Resident 44). | SS=D |
Report Facts
Residents reviewed for assessments: 17
Residents reviewed for ADL assistance: 3
Residents reviewed for pain medication: 2
Shower documentation gap: 16
Medication days given: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Hill | Administrator | Signed the report. |
| Director of Nursing | Interviewed regarding assessment accuracy, policy provision, and medication error. | |
| RN 4 | Interviewed regarding inaccuracy of Resident 40's assessment. | |
| QMA 2 | Interviewed regarding bathing documentation for Resident 35. | |
| CNA 5 | Interviewed regarding bathing and documentation practices. |
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