Inspection Report Summary
The most recent inspection on July 2, 2025, was a complaint investigation and found no deficiencies related to the allegations. Earlier inspections showed a pattern of Life Safety Code deficiencies, including blocked exit doors, propped open smoke barrier doors, and issues with hazardous storage room doors, but immediate corrective actions were taken and ongoing monitoring was planned. Prior reports also noted care planning, infection control, and medication management issues, along with some deficiencies in emergency preparedness and staff vaccination compliance, though no fines or enforcement actions were listed in the available reports. Complaint investigations were generally unsubstantiated, with no substantiated complaints reported. The facility appears to have addressed many prior deficiencies, as recent inspections have shown improvement in compliance with Life Safety Code and care standards.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457740.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457740 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 55
Census Payor Type Total: 55
SNF/NF Beds: 44
SNF Beds: 11
Medicare Residents: 11
Medicaid Residents: 23
Other Payor Residents: 21
Inspection Report
Life Safety
Census: 42
Capacity: 107
Deficiencies: 3
Jan 21, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 01/21/2025 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included an exit door blocked by raised sidewalk due to frost, a kitchen smoke barrier door propped open with a wedge, and a hazardous area door with tape over the latch preventing it from closing properly. Immediate corrective actions were taken and ongoing monitoring was planned.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Exit Door #7 did not open when tested because the sidewalk rose due to low temperatures and blocked the door from opening. | SS=E |
| One of two kitchen smoke barrier doors was propped open with a wedge that did not release with the fire alarm. | SS=E |
| Corridor door to a hazardous storage room had tape over the latch preventing it from closing and latching properly. | SS=E |
Report Facts
Certified beds: 107
Census: 42
Affected residents: 25
Affected residents: 30
Affected residents: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rayne Wise | Administrator | Named during exit conference and signature on report |
| Maintenance Director #1 | Involved in observations and interviews regarding deficiencies | |
| Maintenance Director #2 | Involved in observations and interviews regarding deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Jan 21, 2025
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/21/25.
Findings
Miller's Merry Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, 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 and 410 IAC 16.2.
Inspection Report
Renewal
Census: 38
Deficiencies: 0
Dec 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over December 12, 13, 16, 17, and 18, 2024.
Findings
Miller's Merry Manor of Walkerton was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type Total: 38
Medicare Census: 1
Medicaid Census: 37
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Mar 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426667.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00426667 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 37
Census Payor Type Total: 37
SNF/NF beds: 30
SNF beds: 7
Medicare residents: 7
Medicaid residents: 26
Other payor residents: 4
Inspection Report
Follow-Up
Census: 37
Capacity: 107
Deficiencies: 0
Mar 1, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted 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 with appropriate fire alarm systems and smoke detectors in resident rooms.
Report Facts
Facility capacity: 107
Resident census: 37
Resident rooms: 63
Generator power: 100
Inspection Report
Annual Inspection
Census: 34
Capacity: 107
Deficiencies: 1
Feb 6, 2024
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) and NFPA 101 standards.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to three battery operated smoke alarms in resident sleeping rooms being over 10 years old. These smoke alarms were replaced during the survey.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 3 of over 60 battery operated smoke alarms installed in resident sleeping rooms were not over ten years old in accordance with NFPA 72. | SS=E |
Report Facts
Certified beds: 107
Census: 34
Battery operated smoke alarms over 10 years old: 3
Resident rooms with smoke detectors: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Clark | Administrator | Named in relation to findings and plan of correction |
| Maintenance Director | Interviewed regarding smoke alarm deficiencies |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 7
Jan 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted January 8-12, 2024.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans, failure to update fall care plans, failure to notify physicians of abnormal blood sugars, failure to follow physician orders for skin care, failure to prevent pressure ulcers, failure to maintain respiratory equipment, failure to limit psychotropic medication use, and failure to follow infection control practices.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for a resident with depression. | SS=D |
| Failed to update a fall care plan with new interventions after a fall. | SS=D |
| Failed to notify physician of blood sugars out of ordered range and failed to follow physician orders for skin care. | SS=D |
| Failed to implement measures to prevent pressure ulcers. | SS=D |
| Failed to ensure oxygen humidification bottles were changed weekly. | SS=D |
| Failed to limit use of as needed psychotropic medication to 14 days unless documented otherwise. | SS=D |
| Failed to follow infection control practices during incontinence care and pressure ulcer treatment. | SS=D |
Report Facts
Census: 41
Survey dates: 5
Residents reviewed for comprehensive care plan: 19
Residents reviewed for falls: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for edema: 1
Residents reviewed for pressure ulcers: 1
Residents reviewed for oxygen use: 2
Residents reviewed for psychotropic medication use: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Clark | Administrator | Signed plan of correction and contact for further information |
| Social Services Director | Interviewed regarding care plan deficiencies for Resident 34 and psychotropic medication use | |
| Director of Nursing | Provided policies and interviewed regarding care plan development, fall care plan updates, blood sugar notifications, and psychotropic medication policies | |
| MDS Coordinator | Interviewed regarding fall care plan update for Resident 27 | |
| QMA 2 | Interviewed regarding blood sugar reporting and resident encouragement | |
| Assistant Director of Nursing | Provided policies and interviewed regarding pressure ulcer prevention and infection control | |
| RN 3 | Observed and interviewed regarding pressure ulcer treatment and infection control practices | |
| CNA 4 | Observed and interviewed regarding incontinence care and infection control practices | |
| Nurse Practitioner | Provided progress note regarding fall evaluation for Resident 27 |
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed January 12, 2024.
Findings
Millers 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 Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 32
Capacity: 107
Deficiencies: 0
Feb 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/29/22 was performed to verify compliance with previous deficiencies.
Findings
At this Post Survey Revisit, Miller's Merry Manor - Walkerton was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Facility capacity: 107
Census: 32
Resident rooms: 63
Generator power: 100
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed November 21, 2022.
Findings
Millers Merry Manor of Walkerton was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2, in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 35
Capacity: 107
Deficiencies: 4
Dec 29, 2022
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, with deficiencies including failure to ensure self-closing and latching corridor doors to a hazardous storage room, inadequate clearance below sprinkler deflectors, failure to maintain ceiling construction around sprinklers, and the emergency generator annunciator panel not being readily observed by operating personnel.
Severity Breakdown
SS=D: 1
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the corridor door to a hazardous storage room near resident room 127 was equipped with a self-closing device that latches into the door frame. | SS=D |
| Failed to maintain at least 18 inches clearance below the level of sprinkler deflectors in one of over 60 rooms, specifically in the Unit 2 shower room where privacy curtains obstructed sprinkler coverage. | SS=E |
| Failed to maintain ceiling construction in one of six smoke compartments; a 1-inch gap near a sprinkler head in the kitchen storage room could delay sprinkler activation. | SS=E |
| Failed to ensure the emergency generator annunciator panel was readily observed by operating personnel due to its location in a closed wing not continuously monitored. | SS=F |
Report Facts
Facility capacity: 107
Census: 35
Number of resident rooms: 63
Number of rooms with sprinkler clearance issue: 1
Number of smoke compartments with ceiling construction issue: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Clark | Administrator | Named in relation to findings and plan of correction |
| Maintenance Director | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 31
Capacity: 31
Deficiencies: 12
Nov 21, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted November 14-21, 2022.
Findings
The facility was found deficient in multiple areas including comprehensive assessments, care plan completeness and revision, medication administration timing, quality assurance and performance improvement (QAPI) program implementation, infection control practices, and staff COVID-19 vaccination compliance.
Severity Breakdown
SS=D: 11
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure bowel incontinence was thoroughly assessed for 1 of 3 residents reviewed for incontinence (Resident 24). | SS=D |
| Failed to ensure care plans were complete for 2 residents in a sample of 12 (Residents 15 and 6). | SS=D |
| Failed to ensure care plan was revised for 1 of 13 residents reviewed for care plan revision (Resident 6). | SS=D |
| Failed to ensure insulin is administered at an appropriate time after obtaining a blood sugar (Resident 1). | SS=D |
| Failed to ensure physician orders were followed for 1 of 1 resident reviewed for heel protectors (Resident 6). | SS=D |
| Failed to ensure resident who is incontinent of bladder and bowel receives appropriate treatment and services to maintain or restore continence (Resident 18). | SS=D |
| Failed to ensure signage was posted on resident doors that oxygen is in use, CPAP and nebulizers were stored properly, and supplies were not stored on the floor (Residents 4 and 14). | SS=D |
| Failed to ensure physician responded timely to pharmacy recommendation for 1 of 5 residents reviewed for medication use (Resident 15). | SS=D |
| Failed to ensure appropriate diagnosis for an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medication (Resident 3). | SS=D |
| Failed to ensure Quality Assurance and Performance Improvement Plan (QAPI) was carried out per their policy. | SS=E |
| Failed to ensure gloves were worn during administration of subcutaneous injection of insulin and glucometer was disinfected after use for 1 of 1 resident reviewed for medication administration. | SS=D |
| Failed to ensure all staff were fully vaccinated for COVID-19 except for those staff having a granted exemption. One employee was only partially vaccinated. | SS=D |
Report Facts
Census: 31
Total Capacity: 31
Number of employees: 42
Fully vaccinated staff: 31
Staff with religious exemptions: 10
Partially vaccinated staff: 1
Residents reviewed for care plans: 12
Residents reviewed for care plan revision: 13
Residents reviewed for incontinence: 3
Residents reviewed for medication use: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Clark | Administrator | Named in plan of correction submission and QAPI oversight |
| RN 4 | Registered Nurse | Observed obtaining blood sugar and interviewed about insulin administration timing |
| LPN 6 | Licensed Practical Nurse | Observed administering insulin and interviewed about medication administration practices |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding resident continence and toileting assistance |
| Assistant Director of Nursing | Provided multiple policies and interviewed regarding care plans and infection control | |
| Director of Nursing | Interviewed regarding pharmacy recommendations and QAPI program | |
| Social Service | Interviewed regarding psychotropic medication diagnosis | |
| Employee 9 | Dietary Employee | Partially vaccinated staff for COVID-19 |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Aug 30, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00375947.
Findings
The complaint IN00375947 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00375947 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 30
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 5
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