Inspection Report Summary
The most recent inspection on July 7, 2025, found no deficiencies related to the complaint investigated. Prior inspections showed a mix of findings, including several life safety code deficiencies noted in May 2025 related to fire safety equipment, door operability, and emergency procedures. Earlier reports cited issues with resident care such as failure to follow physician orders, infection control surveillance, and safe transfer practices that resulted in injuries. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases involving resident transfer planning and infection control data collection. The facility’s inspection history shows ongoing challenges with life safety compliance and resident care, with some improvements noted in complaint resolution and emergency preparedness.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
86 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Jul 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461867.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461867 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 86
Census Bed Type - SNF/NF: 3
Census Bed Type - SNF: 5
Census Bed Type - NF: 78
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 31
Inspection Report
Annual Inspection
Census: 87
Capacity: 127
Deficiencies: 20
May 27, 2025
Visit Reason
An annual life safety code survey and emergency preparedness survey were conducted to assess compliance with Medicare/Medicaid participation requirements and state licensure regulations.
Findings
The facility was found not in compliance with several life safety code requirements including exit door operability, hazardous storage door closure, corridor width, exit discharge walking surfaces, emergency lighting records, cleaning of smoke alarms, staff training on kitchen fire suppression, sprinkler head maintenance, corridor door integrity, smoke barrier penetrations, GFCI receptacle functionality, fire drill timing, oxygen room fire door inspections, power strip usage, and signage for oxygen transfilling rooms. Corrective actions and plans of correction were implemented for all deficiencies.
Severity Breakdown
SS=F: 5
SS=E: 8
SS=C: 5
SS=D: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Exit discharge door in the kitchen required extra effort or special knowledge to open. | SS=E |
| Hazardous storage room corridor door was held open with a chain, preventing proper closure. | SS=E |
| Fixed furniture in corridors was not securely attached, reducing clear width below code requirements. | SS=E |
| Exit discharge door #3 had uneven walking surfaces creating tripping hazards. | SS=E |
| Facility failed to maintain itemized records of emergency lighting inspections and tests. | SS=C |
| Battery-operated smoke alarms in resident rooms were not cleaned monthly as per manufacturer's instructions. | SS=C |
| Staff were not instructed in the use of the UL 300 hood fire suppression system in the kitchen. | SS=E |
| Sprinkler heads in kitchen and riser room were loaded, covered with foreign material, or corroded. | SS=E |
| Corridor doors to breakroom and linen room had holes compromising smoke and fire resistance. | SS=E |
| Smoke barrier walls had unsealed penetrations and were not continuous as required. | SS=F |
| Ground fault circuit interrupter (GFCI) in lobby restroom failed to trip and break electrical circuit. | SS=D |
| Facility failed to conduct quarterly fire drills at unexpected times on all shifts for 4 quarters. | SS=C |
| Annual inspection and testing of oxygen room fire doors was not completed. | SS=E |
| Power strips in non-patient care and patient care areas did not meet UL standards or were used improperly for high current draw equipment. | SS=E |
| Oxygen transfilling rooms lacked signs indicating when oxygen transfilling was occurring and not occurring. | SS=F |
| In Building Two, horizontal-sliding exit doors did not operate properly with breakaway feature. | SS=F |
| Battery backup lights in Building Two lacked itemized inspection and test records. | SS=C |
| Sprinkler system gauges in Building Two were not replaced or tested every 5 years as required. | SS=F |
| Quarterly fire drills in Building Two were not conducted at unexpected times on all shifts for 4 quarters. | SS=C |
| Flexible cord power strips in therapy gym did not meet required UL ratings. | SS=E |
Report Facts
Deficiencies cited: 19
Facility capacity: 127
Census: 87
Sprinkler heads corroded or loaded: 5
Battery backup lights: 10
Battery backup lights: 4
Power strips non-compliant: 4
Fire drills missing unexpected timing: 2
Sprinkler system gauges: 2
Oxygen room fire doors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zackary Freel | Administrator | Named in relation to review and exit conference of findings. |
| Maintenance Director | Participated in observations, interviews, and acknowledged deficiencies. |
Inspection Report
Annual Inspection
Census: 84
Capacity: 84
Deficiencies: 2
Apr 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00454347 and IN00454064.
Findings
The facility was found deficient in ensuring physician's orders were followed and physicians notified as ordered for 3 of 5 residents reviewed for quality of care. Additionally, the facility failed to ensure proper placement and function checks of a wanderguard bracelet for a resident at risk of elopement.
Complaint Details
Complaints IN00454347 and IN00454064 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure physician's orders were followed and physician notified as ordered for 3 of 5 residents reviewed for quality of care (Residents 85, 5, and 31). | SS=D |
| Failed to ensure a dependent resident with a wanderguard bracelet had the placement and function checked to ensure proper working order (Resident 29). | SS=D |
Report Facts
Survey dates: 6
Census: 84
Total capacity: 84
Residents reviewed for quality of care: 5
Residents with wanderguard: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding blood pressure monitoring and notification procedures for Resident 85 and PRN diuretic administration for Resident 5 and 31. | |
| Unit Manager 3 | Interviewed regarding blood pressure monitoring and medication administration for Resident 85. | |
| LPN 2 | Interviewed regarding weight monitoring and medication orders for Resident 5. | |
| RN 1 | Interviewed regarding weight monitoring and PRN medication administration for Resident 31. | |
| LPN 5 | Interviewed regarding wanderguard bracelet residents on the second floor. | |
| RN 4 | Interviewed regarding wanderguard bracelet orders, placement, and function checks. |
Inspection Report
Renewal
Deficiencies: 0
Apr 28, 2025
Visit Reason
Paper compliance review for 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 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Oct 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445044.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445044 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census bed type - SNF: 12
Census bed type - SNF/NF: 75
Total census: 87
Census payor type - Medicare: 11
Census payor type - Medicaid: 53
Census payor type - Other: 23
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00442716 completed on September 24, 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 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00442716 completed on September 24, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Sep 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442716 regarding the facility's handling of a resident transfer.
Findings
The facility failed to hold a relocation planning conference with the resident's Power of Attorney (POA) and the Administrator prior to transferring a resident from the memory care unit to the skilled nursing unit. The POA was not notified or given the opportunity to discuss or refuse the transfer, which was made due to the resident's inappropriate behaviors.
Complaint Details
Complaint IN00442716 was substantiated with federal/state deficiencies cited at F560 related to the allegation that the resident was moved without proper notification or consent from the POA.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a relocation planning conference meeting was held with the resident's POA and Administrator prior to moving the resident from the memory care unit to the skilled nursing unit. | SS=D |
Report Facts
Census: 91
SNF beds: 14
SNF/NF beds: 77
Medicare residents: 12
Medicaid residents: 52
Other payor residents: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer J. Gappa | HFA | Facility representative who signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 10, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00438342 completed on July 30, 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00438342 completed on July 30, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 1
Jul 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438342 regarding infection control concerns at the facility.
Findings
The facility failed to follow their Infection Control Surveillance Program policy and procedure related to accurate and complete data collection for infections, impacting all 94 residents. There was a COVID outbreak with multiple residents and staff affected, and incomplete infection surveillance data for June 2024 was noted.
Complaint Details
Complaint IN00438342 was substantiated with federal/state deficiencies cited at F880 related to infection control and surveillance data collection.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow Infection Control Surveillance Program policy and procedure regarding accurate and complete data collection for infections. | SS=F |
Report Facts
Residents positive for COVID: 24
Staff positive for COVID: 7
Total residents: 94
Survey dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gappa | HFA | Signed as Laboratory Director's or Provider/Supplier Representative. |
| Unnamed Executive Director | Executive Director | Provided information about COVID cases and survey details during interviews. |
| Unnamed Director of Nursing | Director of Nursing | Interviewed regarding infection control data and responsibilities. |
| Unnamed Infection Control Preventionist | Infection Control Preventionist | Responsible for infection control program and data collection; interviewed about deficiencies. |
Inspection Report
Re-Inspection
Census: 81
Capacity: 127
Deficiencies: 0
Jun 6, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/22/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Miller's Merry Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies for the main building.
Report Facts
Facility capacity: 127
Census: 81
Inspection Report
Life Safety
Census: 81
Capacity: 127
Deficiencies: 3
Apr 22, 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
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included a kitchen door with double locks requiring more than one operation to open, corridors obstructed by wheeled equipment reducing clear width below required minimum, and a portable fire extinguisher obstructed by a wheeled cart.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 doors to the main dining area from the kitchen was provided with door latches that required only one operation to open. | SS=E |
| Failed to meet the clear width requirement for 1 of 11 corridors due to wheeled equipment stored in the corridor reducing clear width to approximately 36 inches instead of the required minimum of 60 inches. | SS=E |
| Failed to ensure 1 of 1 portable fire extinguisher in the corridor outside resident rooms #308 and #310 was kept readily accessible and not obstructed by a wheeled cart. | SS=E |
Report Facts
Certified beds: 127
Census: 81
Corridors inspected: 11
Corridors deficient: 1
Staff affected by door latch deficiency: 5
Residents affected by corridor width deficiency: 4
Staff affected by corridor width deficiency: 2
Visitors affected by corridor width deficiency: 2
Residents affected by fire extinguisher obstruction: 24
Staff affected by fire extinguisher obstruction: 6
Visitors affected by fire extinguisher obstruction: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gappa | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Acknowledged door latch and corridor obstruction deficiencies during observations and interviews | |
| Administrator-in-training | Participated in observations and exit conference regarding deficiencies |
Inspection Report
Annual Inspection
Census: 83
Capacity: 83
Deficiencies: 2
Mar 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included complaint investigations IN00413485 and IN00427038.
Findings
The facility was found deficient in two areas: failure to follow elopement alarm procedures for one resident, and failure to provide trauma-informed care for a resident with PTSD. Both deficiencies were addressed with updated care plans and staff in-service training.
Complaint Details
Complaint IN00413485 and Complaint IN00427038 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure elopement alarm was followed for 1 of 1 resident reviewed (Resident 77). | SS=D |
| Failure to ensure personalized trauma-informed care for 1 of 1 resident reviewed (Resident 72) with PTSD. | SS=D |
Report Facts
Census SNF/NF beds: 68
Census SNF beds: 15
Total census: 83
Medicare census: 15
Medicaid census: 47
Other payor census: 21
Wander guard check days January 2024: 31
Wander guard check days February 2024: 29
Wander guard check days March 2024: 21
PTSD anxiety episodes in 90 days: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gappa | HFA | Laboratory Director or Provider/Supplier Representative signature on report |
| CNA 2 | Certified Nurse Assistant | Interviewed regarding Resident 72's anxiety and PTSD triggers |
| Director of Nursing | Interviewed regarding Resident 77's wander guard removal and care plan updates | |
| Unit Manager | Interviewed regarding Resident 72's PTSD triggers and care instructions |
Inspection Report
Renewal
Deficiencies: 0
Mar 22, 2024
Visit Reason
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 for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 88
Capacity: 127
Deficiencies: 0
May 4, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/13/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Miller's Merry Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies. The facility is fully sprinklered except for one detached garage.
Report Facts
Facility capacity: 127
Census: 88
Inspection Report
Annual Inspection
Census: 86
Capacity: 127
Deficiencies: 4
Mar 13, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Medicare/Medicaid participation requirements and life safety codes.
Findings
The facility was found not in compliance with certain Life Safety Code requirements including fire door self-closing mechanisms, sprinkler system installation, portable fire extinguisher accessibility, and improper use of multi-plug adapters. Corrective actions were planned and implemented by 04/10/2023. The Rehabilitation wing was found in compliance.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 2 fire door sets in a horizontal exit was arranged to automatically close and latch, leaving an eight-inch gap. | SS=E |
| Failed to maintain ceiling construction in main entry overhang; escutcheon was pushed up leaving a one-inch gap around sprinkler head. | SS=E |
| Failed to ensure 1 portable fire extinguisher outside resident room #308 was unobstructed and readily accessible; it was blocked by a Hoyer lift assist. | SS=E |
| Failed to ensure 1 M.D.S. office did not use flexible cords or multi-plug adapters as a substitute for fixed wiring; a multi-plug adapter was used to convert one outlet into four. | SS=E |
Report Facts
Deficiencies cited: 4
Residents potentially affected: 18
Residents potentially affected: 6
Residents potentially affected: 16
Residents potentially affected: 4
Facility capacity: 127
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lily Price | Administrator | Named in plan of correction and exit conference. |
| Maintenance Director | Interviewed regarding fire door, fire extinguisher, and electrical deficiencies. | |
| Maintenance Assistant | Interviewed regarding sprinkler escutcheon deficiency. |
Inspection Report
Renewal
Census: 81
Capacity: 81
Deficiencies: 6
Feb 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over February 16, 17, 20, 21 and 22, 2023.
Findings
The facility was found deficient in multiple areas including resident rights related to dignity in dining services, informed consent for psychotropic medications, pressure ulcer treatment, psychotropic medication monitoring, sufficient dietary staffing, and preparation of pureed foods according to recipe.
Severity Breakdown
SS=E: 2
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure all residents received their food on the same type of dinnerware for 2 of 3 units reviewed for dining. | SS=E |
| Facility failed to ensure residents who received psychotropic medications had the benefits and risks reviewed with them and their representatives for 2 of 5 residents reviewed. | SS=D |
| Facility failed to ensure bilateral cushioned boots were worn and a pillow was placed between a resident's knees with pressure ulcers as ordered by the physician for 1 of 3 residents reviewed. | SS=D |
| Facility failed to identify resident specific delusions, distress caused by delusions, and non-easily redirected behaviors for residents prescribed antipsychotics for their delusions for 2 of 5 residents reviewed. | SS=D |
| Facility failed to ensure there was sufficient dietary staff to provide residents with meals on regular dinnerware instead of disposable dinnerware for 66 of 81 residents observed for dining. | SS=E |
| Facility failed to prepare pureed food based on the recipe for puree diets for 1 of 1 staff member observed preparing pureed diets. | SS=D |
Report Facts
Census: 81
Total Capacity: 81
Residents on Psychotropic Medications Reviewed: 5
Residents with Deficient Psychotropic Medication Documentation: 2
Residents Observed with Food Served on Disposable Dinnerware: 66
Inspection Report
Renewal
Deficiencies: 0
Feb 22, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on February 22, 2023.
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 for Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Nov 9, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00376587 completed on September 28, 2022.
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 in regard to the PSR to the Investigation of Complaint IN00376587.
Complaint Details
Complaint IN00376587 was investigated and found to be corrected.
Report Facts
Census: 87
Census SNF: 17
Census SNF/NF: 70
Census Payor Medicare: 17
Census Payor Medicaid: 52
Census Payor Other: 18
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Sep 28, 2022
Visit Reason
This visit was for Investigation of Complaint IN00376587, which was substantiated. The complaint involved failure to provide showers as scheduled and safe transfer practices.
Findings
The facility failed to ensure residents received showers according to their scheduled days and preferences for 3 residents. Additionally, the facility failed to follow care plans and transfer policies, resulting in fractures for 2 residents during transfers using mechanical lifts or manual assistance.
Complaint Details
Complaint IN00376587 was substantiated. The complaint involved failure to provide showers as scheduled and safe transfer practices that resulted in injuries.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents were given showers according to scheduled days and preferences for 3 residents (Residents C, D, and E). | SS=D |
| Failed to ensure residents' care plans and transfer policies were followed to ensure safe transfers, resulting in fractures for 2 residents (Residents E and B). | SS=G |
Report Facts
Census: 84
SNF beds: 32
SNF/NF beds: 52
Medicare residents: 11
Medicaid residents: 51
Other payor residents: 22
Shower days missed - Resident C: 5
Shower days missed - Resident D: 9
Shower days missed - Resident E: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Reported injury to Resident E during Hoyer lift transfer |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shower schedules and transfer policies |
| RPT 7 | Registered Physical Therapist | Provided information on Resident E's transfer assistance level |
| CNA 4 | Certified Nursing Assistant | Involved in transfer of Resident B when injury occurred |
| LPN 13 | Licensed Practical Nurse | Assessed Resident B after injury and communicated with physician |
| QMA 16 | Qualified Medication Aide | Assisted CNA 4 with Resident B after injury |
| Executive Director | Executive Director (ED) | Provided policy documents and interviewed about transfer policies |
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