Miller's Merry Manor

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was rated at a 9 out of 10 with 10 being the worst pain felt. She was given Percocet 10-325 mg tablet-1 tablet by mouth for the right knee pain. The resident indicated her pain was constant but had not affected her sleep or ability to do day to day activities. Following the administration of the Percocet, Resident O indicated effectiveness with her pain level as it had decreased to a 2 out of 10.A Skilled Nurse Assessment, dated 8/10/25 at 10:07 a.m., indicated Resident O rated her pain at a 5 out of 10. The assessment indicated the interventions for pain control included the use of Percocet (Opioid), ice machine, and repositioning. A physician's order, dated 8/10/25, was to give Percocet 10-325 mg tablets-1 tablet every 4 hours routinely for pain.There was no documentation completed indicating the reason for changing the order for the Percocet from every six hours as needed to every 4 hours routinely. There was no documentation indicating Resident O had been notified of the reason for change in her opioid medication nor the risks vs benefits of taking opioid medication routinely, including the risk for tolerance and addiction.During an interview, on 10/8/25 at 2:00 P.M., Registered Nurse (RN) 2 indicated on 8/10/25, she had assessed Resident O and observed her in severe distress from her right knee pain. She had contacted

the NP and obtained the order changing the Percocet 10-325 mg tablets to be given every 4 hours in an attempt to help relieve the resident's pain. When asked, she indicated she had not spoken with the resident about the plan to give her opioid/pain medication every 4 hours nor had she explained the risks vs benefits of taking routine opioid medication. She indicated she had not documented notification to the NP or the change in orders in the clinical record.On 10/8/25 at 2:15 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. Both indicated Resident O had complained of withdrawal symptoms when attempting to wean her off the opioid medication. The physician and NP had been notified and orders had been received for medications to treat the withdrawal symptoms. The DON indicated staff should have consulted with and involved the resident in decisions about her pain management plan.

Resident O should have been educated on the risks vs benefits of using routine opioids for pain control and possible withdrawal symptoms which could occur when decreasing dosages and frequency of opioids.During an interview, on 10/8/25 at 4:05 P.M., the Regional Nurse Consultant indicated the facility had no specific policy for resident rights but followed Federal guidelines which indicated residents have the right to be involved in their care. She indicated Resident O should have been notified in advance of changes to her opioid medication orders, the risk and benefits of the change, the potential for withdrawal symptoms, and alternative, non-pharmacological interventions should have been offered.This Citation relates to Intake 2616114.3.1-3(n)(2)

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Miller's Merry Manor

500 Walkerton Tr Walkerton, IN 46574

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

affected by Resident U's behaviors. A current policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 10/6/25 at 12:00 P.M. The policy indicated all residents had the right to be free from abuse including physical abuse which includes hitting, kicking, slapping, biting, and punching. Abuse was defined as being willful with actions done deliberately. If a resident initiated the abuse, he/she would be maintained under direct supervision by staff until the immediate investigation was completed and resident safety maintained. When abuse was observed or alleged, the nurse was responsible to immediately examine and assess the resident to determine if any injuries had occurred and their extent. An investigation was to be completed to ensure other residents had not been affected by the incident or inappropriate behavior. The Interdisciplinary team were to assess a situation of resident-to-resident abuse and make recommendations for interventions to prevent recurrence.This Citation relates to Intake 2629854.3.1-27(a)(b)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Miller's Merry Manor

500 Walkerton Tr Walkerton, IN 46574

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to ensure allegations of physical abuse were reported for 2 of 2 cognitively impaired residents reviewed for abuse (Resident S and Resident U).Findings include:A report, dated 9/29/25, alleged Resident U had several physical altercations with Resident S due to Resident S wandering into her room. It was alleged there had been no interventions put in place to protect Resident S and staff had been instructed to not document these altercations. It was alleged during one of the altercations, Resident U had caused bruises on Resident S from kicking, punching, and swinging at her. On 10/6/25 at 12:30 P.M., Resident S's record was reviewed. Diagnoses included early-onset Alzheimer's and severe dementia without behaviors. A Nurses Progress note, dated 9/9/25 at 4:30 P.M., indicated Resident S had a 1-centimeter (cm) skin tear to her left hand due to Resident U hitting her hand.

Resident S's family and staff had witnessed the altercation between Resident S and Resident U. There was no follow up documentation, investigation completed or reporting of the altercation as required. A Nursing Occurrence Initial Assessment form, dated 9/18/25 at 11:57 a.m., indicated Resident S was observed with scattered bruising to both lower legs. Her right lower leg had 5 bruises measuring: #1- 4 cm x 2 cm; #2- 2 cm x 2 cm; #3- 2.5 cm x 2 cm; #4- 3 cm x 2 cm and #5- 5 cm x 4 cm. The left lower leg had 3 bruises measuring: #1- 13 cm x 7 cm; #2- 1 cm x 2 cm and #3- 1 cm x 1.5 cm. There was no description of the color of the bruises or assessment of pain from the bruises. There was no investigation, incident reporting or follow up documentation completed for the cause of extensive bruising to Resident S's legs. A New Behavior Initial Assessment form, dated 9/19/25 at 11:00 p.m., indicated Resident U had been observed in

the hallway in her wheelchair when Resident S walked by her. Resident U began yelling, kicking and hitting

the other resident several times until staff intervened. The Administrator was notified of the altercation, but there was no documentation of an investigation into the altercation nor was the incident reported as required by State and Federal regulations. A Nursing-Occurrence Initial Assessment form, dated 9/25/25 at 2:25 p.m., indicated Resident S was observed with a mark on her face below her left eye. The form indicated it was an isolated incident and no further information was documented. There was no documentation completed indicating the injury of unknown origin had been investigated, the cause determined, and reporting completed as required.During an interview, on 10/8/25 at 1:30 P.M., the Administrator indicated she had not been informed of the extensive bruising observed on Resident S's legs

on 9/18/25. She had not been notified of the circumstances surrounding the 4 alleged altercations between Resident U and Resident S. She indicated there should have been an investigation into the altercations and results of investigation reported to State and Federal agencies as required. A current policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 10/6/25 at 12:00 P.M. The policy indicated all residents had the right to be free from abuse including physical abuse which includes hitting, kicking, slapping, biting, and punching. Abuse was defined as being willful with actions done deliberately. The policy indicated alleged abuse and unusual occurrences must be reported to the Administrator immediately. The facility was to report allegations of abuse/unusual occurrences with 2 hours of discovery if the resident had visible injuries or 24 hours when no injuries were visible. An investigation was to occur immediately and results of the investigation reported to the Indiana Department of Health within 5 days of the initial report.This Citation relates to Intake 2629854.3.1-28(c)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Miller's Merry Manor

500 Walkerton Tr Walkerton, IN 46574

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

management was aware of Resident U's behaviors prior to accepting her at the facility, because she had come from a sister facility. Staff indicated interventions should have been put in place upon admission to prevent the behaviors before they occurred. Staff indicated concern with there being no current interventions in place to protect ambulatory, wandering residents from injury related to wandering into Resident U's room. Staff indicated that Resident U's behaviors were escalating and staff alleged she had had altercations with multiple residents who resided on the unit.On 10/7/25 at 12:15 P.M., the Social Services Designee (SSD) was interviewed. The SSD indicated she had been made aware of an altercation occurring on 9/9/25, when Resident U hit another resident on the hand causing a skin tear. She indicated

she had followed up with Resident U and the other resident involved in the altercation and neither resident indicated changes in mood or behaviors. When asked, the SSD indicated when a new behavior was identified, nurses were to complete a New Behavior Initial Assessment form, notify her, the Administrator and DON, and complete a 72 hour follow up assessment. She indicated after the 72 hour follow up assessments were completed, the Interdisciplinary Team (IDT) would meet and discuss any needed changes to the care plan. When asked if these meetings were documented in the resident's records, she indicated they had not been. She indicated she had been unaware of the other altercations and had not known about injuries to another resident, caused by Resident U. When asked, the SSD indicated Resident U was not being monitored on the behavior tracking forms for aggressive behaviors towards other residents, only towards staff.On 10/7/25 at 10:47 A.M., the DON provided a current copy of the facility policy titled, Behavior Assessment and Management which indicated the purpose of the policy was to have

a systematic method for identifying specific behaviors which could impact a resident's quality of life or cause concern for other residents. Dangerous behaviors were to be observed for, documented in the clinical record, and attempts made to determine the cause and prevention of such behaviors. When new behaviors occurred, which could present a danger to the resident or others, interfere with activities of daily living, and/or cause the resident distress, nurses were to document the episode on the New Behavior Initial Assessment form, communicate the new behavior to all disciplines, and complete 3 days of behavior follow up assessments. After the 3 day assessments were completed, the IDT would review and document their evaluation and plan for the resident in the medical record. The IDT were responsible for determining whether the behavior or distress was preventable or required further assessment and would initiate a behavior management care plan, if needed, with interventions to assist in reducing or eliminating problem behaviors.This Citation relates to Intake 2629854.3.1-37

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Facility ID:

If continuation sheet