Mill Run Care Center

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure a resident received a discharge summary and medications necessary for a safe and effective transition following discharge. This affected one (#56) out of three residents reviewed for the discharge process. The facility census was 54.

Inspectors wroteBased on resident record reviews, observations, interviews, review of service invoices, and review of facility policies, the facility failed to ensure residents received care and services in accordance with professional standards of practice and plans of care to meet each resident's individual identified needs. This resulted in Actual harm for one resident (#18) on 03/05/25 at 8:00 A.M. when a power outage occurred in the facility and the generator did not start. Resident #18, who was assessed to have chronic respiratory failure and was dependent on continuous oxygen, was not monitored for respiratory failure during the power outage. This resulted in a hospitalization for Resident #18 when on 03/05/25 at 9:18 A.M., a nurse was alerted that Resident #18 was confused and having a change in condition. [...]

Inspectors wroteBased on observation, record review, staff interview and review of the facility policy, the facility failed to identify and treat one (#40) resident's pressure ulcer on her left trochanter (hip) in a timely manner. This resulted in Actual Harm on 08/27/25 when the facility failed to identify and implement a treatment for Resident #40, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, when the resident was identified to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left trochanter (hip). On 08/28/25, Wound Physician #405 assessed the pressure ulcer to be an unstageable pressure injury. [...]

Inspectors wroteBased on observation, interview and facility policy review the facility failed to safely store and prepare food in the kitchen. This had the potential to affect all 53 of 53 residents who receive meals from the kitchen. The census was 53. Findings Include:1. Observation of the kitchen on 09/02/25 at 8:43 A.M. revealed the internal part of the ice machine had a red substance that was removed when wiped with a glove. Interview with the Dietary Manager on 09/02/25 at 8:43 A.M. verified there was a red substance inside of the ice machine.2. Observation of the dry storage in the kitchen on 09/02/25 at 8:52 A.M. revealed greasy and dirty shelving above open boxes of plastic utensils. Interview on 09/02/25 at 8:52 A.M. with the Dietary Manager verified the shelving was dirty above the open boxes of plastic utensils. [...]

Inspectors wroteBased on interviews and policy and procedure review the facility failed to ensure a Resident Trust authorization Forms were not witnessed by facility staff. This affected six residents (#10, #38, #45, #52, #75 and #76) reviewed for personal care need accounts. The census was 53. Findings Include: 1. Review of Resident #38's Resident Fund Management Service Authorization and Agreement to Handle Resident Funds revealed Business Office Manager # 321 signed as a witness to allow the facility to handle Resident #38 personal care needs account on 07/07/25.2. Review of Resident #10's Resident Fund Management Service Authorization and Agreement to Handle Resident Funds revealed Business Office Manager # 321 signed as a witness to allow the facility to handle Resident #10 personal care needs account on 02/12/24.3. [...]

Inspectors wroteBased on interview and record review the facility failed to identify, treat and monitor weight loss. This affected five residents (#42, #23, #29, #38 and #44) out of seven residents reviewed for weight changes. The facility census was 53. Findings Include: 1. Review of Resident #42's medical record revealed that she was admitted on [DATE]. Diagnoses for Resident #42 included Type II diabetes mellitus with diabetic chronic kidney disease, hypertensive heart and chronic kidney disease, and chronic respiratory failure with hypoxia. Review of Resident #42's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. Resident #42 functional ability assessment for eating as independent but was dependent for chair to bed transfers. Resident #42 was assessed weighing 222 pounds (lbs) having no significant weight change and on a therapeutic diet. [...]

Inspectors wroteBased on observation, record review, policy review, and interview the facility failed to implement infection control practices. This affected six residents (#38, #6, #9, #40, #23, and #77) of 53 residents residing in the facility. Findings Include:1. Review of Resident #38's medical record revealed diagnoses of Type II diabetes mellitus with chronic kidney disease and nonrheumatic aortic valve stenosis. Brief Interview for Mental Status (BIMS) score of 14. Review of Resident #6's medical record revealed diagnoses of Type II diabetes mellitus with diabetic neuropathy and dysphagia following cerebral infarction. Brief interview for Mental Status (BIMS) score of 10. Review of Resident #9's medical record revealed diagnoses of Type II diabetes with diabetic chronic kidney disease and chronic systolic heart failure. Brief Interview for Mental Status (BIMS) score of 07. [...]

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy the facility failed to ensure privacy was maintained while providing personal care for residents. This affected two residents (#16, #67) of 31 sampled residents. The census was 53. Findings Include: 1. Review of Resident #67's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included CHF, cellulitis of the left lower limb, morbid obesity, atrial fib, diabetes, COPD, fibromyalgia, major depression, anxiety, restless leg syndrome and poly- osteoarthritis. Review of the minimum data set (MDS) assessment revealed it was in progress and not completed due to Resident #67 being a newer admission. On 09/04/25 at 10:59 A.M. [...]

Inspectors wroteBased on interviews, medical record reviews, and policy and procedure review, the facility failed to ensure residents receiving skilled services were notified within 48 hours of their skilled services ending. This affected two residents (#71 and #72 ) of three residents reviewed for Beneficiary Notices. The census was 53. Findings Include: Review of Resident #71's SNF Beneficiary Protection Notification Review revealed her Medicare Part A Skilled Services started on 07/04/25 and her last covered day of Part A Services was on 07/24/25. Resident #71 signed her notification of Medicare Non-Coverage letter on 07/23/25. Review of Resident #72's SNF Beneficiary Protection Notification Review revealed her Medicare Part A Skilled Services started on 06/17/25 and his last covered day of Part A Services was on 07/29/25. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were coded correctly. This affected two residents (#62, #5) of three residents reviewed for minimum data set transmission. The facility census was 53. Findings Include:1. Review of Resident #5's medical record revealed an admission date of [DATE] and discharge date of [DATE]. Diagnoses included malignant neoplasm of the esophagus and type II diabetes mellitus with diabetic polyneuropathy. Review of Resident #5's progress notes revealed a note on [DATE] that stated Resident #5's belongings were collected by son. Resident #5 was to be admitted to [NAME] for chemotherapy treatment. Review of the MDS dated [DATE] revealed the MDS was coded as discharge assessment- return anticipated. Interview on [DATE] at 3:35 P.M. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop and implement a plan of care upon the resident's admission in regard to a pressure ulcer that was present on admission. This affected one resident (#67) of three residents reviewed for pressure ulcers. The census was 53. Findings Include: Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included CHF, cellulitis of the left lower limb, morbid obesity, atrial fib, diabetes, COPD, fibromyalgia, major depression, anxiety, restless leg syndrome and poly- osteoarthritis. Review of the minimum data set (MDS) assessment revealed it was in progress and not completed due to Resident #67 being a newer admission to the facility. [...]

Inspectors wroteBased on resident record reviews, staff interviews and review of facility policy, the facility failed to have quarterly care conferences as expected for two residents (#9, #18). Also, the facility failed to have a nutrition care plan in place for one resident (#29). This affected three residents (#9, #18, #29) out of three residents reviewed for care planning. The facility census was 53 residents. Findings Include:

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received timely and adequate staff assistance with showers and personal hygiene. This affected one resident (#44) of two residents reviewed for ADL care. The facility census was 53. Findings Include:Review of the medical record for Resident #44 revealed an admission date of 08/14/24 with diagnoses of pulmonary heart disease, morbid obesity, heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, hemiplegia and hemiparesis, repeated falls and major depressive disorder. [...]

Inspectors wroteBased on observation, medical record review, observation, staff interview, and facility policy review, the facility failed to maintain infection control with the storage of respiratory equipment and the administration of respiratory medication. This affected two residents (#50, #68) of two residents reviewed for oxygen/respiratory therapy. The census was 53. Findings Include: 1. Record review of Resident #50's medical record revealed medical diagnoses of hypertensive heart disease with heart failure, chronic diastolic heart failure, and cerebral infarction with residual deficits. The resident had a BIMS score of 12. Observation on 09/02/25 at 12:09 P.M. of Resident #50's room revealed an uncovered and unlabeled nebulizer mask placed beside a plant on top of the air conditioning unit. Interview on 09/02/25 at 2:30 P.M. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure non-pharmacological interventions were implemented for pain per care plans for one resident (Resident #67). Additionally, the facility failed to ensure that parameters were in place for pain medication administration for Resident #29. This affected two residents (Resident #29 and #67) out of two residents reviewed for pain management. The facility census was 53 residents. Findings Include: 1. Review of Resident #67's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included CHF, cellulitis of the left lower limb, morbid obesity, atrial fib, diabetes, chronic obstructive pulmonary disease (COPD), fibromyalgia, major depression, anxiety, restless leg syndrome and poly- osteoarthritis. [...]

Inspectors wroteBased on review of the medical record, review of the pharmacist's medication regimen reviews, staff interviews, the facility failed to ensure that appropriate rationale was given for not attempting a gradual dosage reduction for an antidepressant medication. This affected one resident (Resident #9) out of five residents reviewed for unnecessary medications. The facility census was 53 residents. Findings Include:Review of Resident #9's medical record revealed that the resident was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, dementia, depression, and schizoaffective disorder. Review of Resident #9's most recent comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) of 07, indicative of severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free from significant medication errors when an accurate medication reconciliation was not conducted upon the resident's return to the facility from the hospital. This affected one (Resident #69) out of three residents reviewed for facility admissions. The facility census was 53. Findings Include:Review of the medical record for Resident #69 revealed an admission date of 07/10/25, a readmission date of 08/12/25 and a discharge home date of 08/19/25. Diagnoses included metabolic encephalopathy, acute kidney failure, heart disease, chronic diastolic heart failure (CHF), major depressive disorder and paroxysmal atrial fibrillation. [...]

Inspectors wroteBased on record review, policy review, and interview the facility failed to ensure dental recommendations and prior authorization was submitted in a timely manner. This affected one (Resident #46) out of two residents reviewed for ancillary services. The facility census was 53. Findings Include: Review of the medical record for Resident #46 revealed an admission date of 12/16/22 with diagnoses including chronic respiratory failure with hypoxia, major depressive disorder, chronic pain syndrome, and gastroesophageal reflux disease without esophagitis. Review of the care plan dated 02/16/23 revealed the resident had oral/dental health concerns due to the absence of upper teeth and the presence of some natural lower teeth. Interventions included monitoring and reporting oral health issues and providing dental consults as needed. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure staff who were competent/certified were assisting residents with feeding. This affected one resident (#16) of three residents observed being assisted with eating by staff. The census was 53. Findings Include:Review of Resident #16's medical record revealed an admission date of 04/24/20. Diagnoses included Alzheimer's disease with late onset, gastro-esophageal reflux disease without esophagitis and unspecified severe protein-calorie malnutrition. Review of Resident #16's care plan focus dated 11/30/22 stated Resident #16 had a risk for aspiration related to diagnosis of dysphagia. Interventions included assist with meals, feed at times, do not leave alone. [...]

Inspectors wroteBased on observation, record review, resident and staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and facility policy and procedure review, the facility failed to comprehensively assess, provide timely interventions, and implement a treatment to an existing pressure ulcer. This resulted in Actual Harm to Resident #40 on 03/20/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #40 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) to the right gluteus. This affected one (#40) of three residents reviewed for pressure ulcers. The facility census was 63.

Inspectors wroteBased on observation, record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) were provided routine nail care. This affected two (#20 and #40) of three residents reviewed for ADL care. The facility census was 62.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure one resident (#20) received routine podiatry care. This affected one (#20) of one resident reviewed for podiatry. The facility census was 62.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure safe and sanitary storage of food items in the refrigerator and freezer and failed to ensure kitchen equipment was maintained in a safe and sanitary manner. This had the potential to affect all the residents except for one resident (#62). The facility identified Resident #62 did not receive food from the kitchen. The facility census was 62.

Inspectors wroteBased on observations, medical record review, review of Resident Council meeting minutes, review of the therapeutic spreadsheet, staff interview, training review and policy review, the facility failed to ensure three residents (#10, #30, and #80) received their ordered therapeutic diet as physician ordered. This affected three (#10, #30, and #80) of three residents observed for therapeutic diets. The facility identified 28 residents who had therapeutic diets and one resident who received nothing by mouth. The facility census was 63.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a medications were ingested at the time of administration and failed to ensure medications were properly secured in storage. This affected four (#11, #14, #15, and #30) of four residents reviewed for medication storage. The facility census was 58.

Inspectors wroteBased on observations, staff interview, medical record review, and policy review, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#44) of three reviewed for dignity and respect. The census was 58.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were provided as required. This affected one (#44) of one resident reviewed for care conferences. The census was 58.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a resident's cervical collar was cleaned as ordered. This affected one (#6) of one resident reviewed for cleanliness of cervical collars. The census was 58.

Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to administer medications are ordered. This affected one (#4) of three residents reviewed for antibiotic usage. The facility census was 58.

Inspectors wroteBased on observation, interview, review of the infection control logs, and policy review, the facility failed to maintain appropriate infection control measures to prevent the spread of COVID-19. This had the potential to affect all residents who reside in the facility. The facility census was 42. 1. Observation and interview on 06/07/21 at 8:00 A.M., upon entrance to the facility, Licensed Practical Nurse (LPN) #05 walked through the reception area after completing nasal swab testing wearing a yellow gown. LPN #05 was not noted to change her personal protective equipment (PPE). This was verified with the Regional Business Officer #80 the LPN was wearing PPE through the reception area while testing staff. 2. Observation and interview on 06/07/21 at 11:16 A.M., with LPN # 64 verified the quarantine area entry doors were open and resident room doors were open. 3. [...]

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to ensure a resident was turned safely while in bed during incontinence care and failed to ensure there were two staff members present during the incontinence care. This affected one (#38) of three reviewed for incontinence care. The facility identified nine residents who were incontinent. The facility census was 42.

Inspectors wroteBased on medical record review, resident and staff interviews, observations, and review of the dialysis communication form, the facility failed to timely address recommendations from the dialysis physician. This affected one resident (#05) of one resident who received dialysis treatment. The facility census was 42. Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included end stage kidney failure, cellulitis of the left limb, atrial fibrillation, and hypertension. A care plan relative to psychological and medical needs revealed individualized interventions with measurable goals. Review of the physician orders for June 1, 2021 to June 08, 2021 revealed the resident continued on a 1500 cubic centimeter (cc) fluid restriction. [...]

Inspectors wroteBased on medical record review, resident and staff interviews, and review of the pharmacy recommendations, the facility failed to ensure a resident was free from unnecessary medication use. This had the potential to effect one resident (#46) of five residents reviewed for unnecessary medications. The facility census was 42. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included fractured right-side ribs, dementia, anxiety disorder, respiratory failure, and malnutrition. Review of Resident #46's care plan revealed the resident received rehabilitation services with a goal to be discharged home. Further review of the the plan of care dated 05/14/21 revealed no plan for psychosis behaviors. [...]

Inspectors wroteBased on medical record review, observation, and interview, review of the dietary spread sheets, and review of the diet manual, the facility failed to ensure residents on a mechanical soft diet were served food of an appropriate texture. This affected two residents (#07 and #25) of seven residents who received a mechanical soft diet. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #07 revealed an admission date of 06/11/20. Diagnoses included psychotic disorder with delusions, dysphagia, and senile degeneration of the brain. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #07 had severely impaired cognitive skills for daily decision making and required supervision assistance with eating and extensive to total dependence assistance with all other activities of daily living. [...]