Inspection Reports for
Mill Pond Health Campus
1014 Mill Pond Ln, Greencastle, IN 46135, GREENCASTLE, IN, 46135
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
27% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: May 29, 2025
Visit Reason
This visit was conducted to investigate Residential Complaint IN00458015 at Mill Pond Health Campus.
Complaint Details
Complaint IN00458015 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Re-Inspection
Census: 36
Capacity: 68
Deficiencies: 0
Date: May 22, 2025
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
Mill Pond Health Campus 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on March 7, 2025.
Findings
Mill Pond Health Campus 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
Life Safety
Census: 36
Capacity: 68
Deficiencies: 5
Date: Apr 7, 2025
Visit Reason
The visit 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).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with delayed egress locks, kitchen hood extinguishing system, and sprinkler system maintenance and testing.
Deficiencies (5)
LSC 7.2.1.6.1.1 Delayed-Egress Locking Systems: The facility failed to ensure the means of egress through 1 of 6 delayed egress locks was readily accessible as the irreversible release process did not initiate when the door was pushed.
NFPA 96 Cooking Facilities: The facility failed to provide an approved method for returning cooking appliances to their approved design location after maintenance or cleaning for 1 of 1 kitchen hood extinguishing system.
NFPA 96 Cooking Facilities: The facility failed to ensure the kitchen fire suppression system was inspected semiannually as required; documentation for the most recent inspection was not available.
NFPA 25 Sprinkler System - Maintenance and Testing: The facility failed to ensure the automatic sprinkler piping system was examined for internal obstructions every 5 years as required; the last inspection was in 2020 and no recent inspection was scheduled.
NFPA 25 Sprinkler System - Maintenance and Testing: The facility failed to provide written documentation for quarterly sprinkler system inspection for 1 of 4 quarters in 2024.
Report Facts
Certified beds: 68
Resident census: 36
Residents potentially affected: 36
Residents potentially affected: 12
Staff potentially affected: 6
Visitors potentially affected: 2
Inspection Report
Annual Inspection
Census: 32
Capacity: 50
Deficiencies: 5
Date: Mar 7, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from February 27 to March 7, 2025.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, lack of physician orders for certain treatments, improper respiratory equipment storage, delayed response to pharmacy recommendations, and improper labeling and disposal of prepared food items.
Deficiencies (5)
483.20(g) Accuracy of Assessments: The facility failed to ensure MDS assessments were accurately coded for 2 of 17 residents reviewed.
483.25 Quality of Care: The facility failed to ensure a physician order was obtained for a Tubigrip for 1 resident with limited range of motion.
483.25(i) Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure a nebulizer mask was bagged when not in use for 1 of 2 residents reviewed for respiratory care.
483.45(d)(1)-(6) Drug Regimen is Free from Unnecessary Drugs: The facility failed to ensure a pharmacist's recommendation was addressed timely for 1 of 5 residents reviewed.
483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure proper labeling of prepared food and disposal of expired food in 1 of 2 kitchen observations.
Report Facts
Residents reviewed for MDS assessments: 17
Total residents: 50
Residential Census: 32
Pharmacy recommendations audit frequency: 5
Nebulizer mask audits: 5
Kitchen observations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Frye | Executive Director | Signed the inspection report. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00437687 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00437687 was substantiated with a federal/state deficiency cited at F600 related to abuse. The deficient practice was corrected prior to the survey date.
Findings
The facility failed to ensure a staff member followed abuse and cell phone use policies, resulting in a social media video posted with an unidentifiable resident in a restroom. The staff member was terminated and corrective actions including education and monitoring were implemented.
Deficiencies (1)
§483.12(a)(1) The facility failed to prevent verbal, mental, sexual, or physical abuse by a staff member who posted a video on social media involving a resident. The staff member was terminated and education was provided to all staff.
Report Facts
Census Bed Type - SNF/NF: 51
Census Bed Type - Residential: 27
Total Census: 78
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 41
Staff Educated: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CRCA 9 | Certified Resident Care Assistant | Named in abuse finding for posting inappropriate social media video |
| Dementia Care Director | Interviewed regarding awareness of incident and staff education | |
| CRMA 4 | Certified Residential Medication Aide | Interviewed about awareness of social media video |
| Regional Nurse Consultant | Interviewed and provided facility policies | |
| Social Worker | Interviewed regarding resident condition | |
| Director of Health Services | Interviewed regarding incident response and staff termination | |
| Social Service Director | Interviewed regarding resident monitoring after incident |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Apr 22, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00431685 and IN00432056 regarding resident care and discharge practices.
Complaint Details
Complaint IN00431685 was substantiated with state deficiencies cited at R0044, R0045, and R0048. Complaint IN00432056 had no deficiencies related to the allegations.
Findings
The facility failed to allow a resident to remain in the facility after discharge, did not provide required bed hold and transfer/discharge documentation for hospitalized residents, and lacked a relocation plan for continuity of care for a discharged resident. The facility also lacked written policies for transfer/discharge procedures but followed state guidelines.
Deficiencies (3)
410 IAC 16.2-5-1.2(r)(1-5) Residents' Right - The facility failed to allow Resident C to remain in the facility after discharge despite the resident's condition and wishes.
410 IAC 16.2-5-1.2(r)(6-9) Residents' Rights - The facility failed to provide bed hold documentation and notice of transfer or discharge policies to Residents C, B, and D at the time of hospital transfers.
410 IAC 16.2-5-1.2(r)(18-24) Residents' Rights - The facility failed to prepare a relocation plan and provide continuity of care for Resident C upon discharge.
Report Facts
Residential Census: 27
Days to appeal discharge: 10
Eviction notice backdate days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about Resident C's discharge and readmission status. | |
| Registered Nurse Consultant (RN) 3 | Observed Resident C's suicide attempt and provided information about transfer/discharge documentation. | |
| Business Office Manager (BOM) | Discussed eviction notices and communication regarding Resident C. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The document reports on paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 03/07/2024 and completed on 03/26/2024.
Findings
Mill Pond Health Campus was found in compliance with Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code requirements including the 2012 NFPA 101 and state licensure regulations.
Inspection Report
Routine
Census: 45
Capacity: 68
Deficiencies: 3
Date: Mar 7, 2024
Visit Reason
A routine Emergency Preparedness and Life Safety Code survey was conducted to assess compliance with Medicare and Medicaid participation requirements and fire safety codes.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had deficiencies related to emergency plan documentation, fire alarm system maintenance, and fire extinguisher inspections.
Deficiencies (3)
42 CFR 483.73(d)(2): The facility failed to analyze and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the emergency plan as needed. An after-action report was not completed for a facility-based drill conducted on 02/09/24.
LSC 9.6.1.3: A smoke detector in the riser room was covered with a plastic bag, preventing proper activation of the fire alarm system.
NFPA 10 Section 7.2.1.2: One of 17 portable fire extinguishers, located in the beauty shop, was not inspected monthly from July through December 2023 as required.
Report Facts
Certified beds: 68
Resident census: 45
Portable fire extinguishers: 17
Inspection Report
Annual Inspection
Census: 35
Capacity: 82
Deficiencies: 4
Date: Jan 24, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00418482 and a State Residential Licensure Survey.
Complaint Details
Complaint IN00418482 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to medication labeling and storage, employee health screening including TB testing and physical exams, medication security for residents not capable of self-administration, and infection control program implementation for assisted living residents. No deficiencies were related to the complaint allegations.
Deficiencies (4)
483.45(g)(h)(1)(2) The facility failed to ensure an opened multi-dose vial of tuberculin protein derivative solution had documentation of the date it was opened for use.
3.1-14 PERSONNEL The facility failed to ensure annual TB skin tests were completed for 3 of 15 employees, chest X-rays every 5 years for 1 employee with a positive TB test, and pre-employment physical exams for 1 of 15 employees.
410 IAC 16.2-5-6(a) The facility failed to ensure medications were kept secure outside the resident's room for 1 of 7 residents whose service plan indicated they were not capable of self-administration.
410 IAC 16.2-5-12(b)(1-4) The facility failed to ensure an infection control program was completed for all 35 assisted living residents, lacking surveillance logs and monitoring during a staff maternity leave period.
Report Facts
Census Bed Type Total: 82
Residential Census: 35
Employees missing annual TB test: 3
Employees missing chest X-ray: 1
Employees missing pre-employment physical: 1
Residents observed with unsecured medications: 1
Assisted living residents: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 19 | Licensed Practical Nurse | Missing annual TB test and chest X-ray documentation |
| Employee 20 | Registered Nurse | Missing pre-employment physical exam documentation |
| Employee 21 | Qualified Medication Aide | Missing annual TB test documentation |
| Employee 22 | Environmental (Housekeeping) Employee | Missing annual TB test documentation |
| Employee 23 | Dietary Employee | Missing annual TB test documentation |
| Timothy Yale | Executive Director | Named as facility representative and signer of report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey.
Findings
Mill Pond Health Campus 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.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00399133 regarding a resident fall incident.
Complaint Details
Complaint IN00399133 was substantiated. The deficiency related to the complaint involved failure to ensure bed safety, resulting in a resident fall and injury.
Findings
The facility failed to ensure a resident's bed was fully assembled, resulting in a fall and hip fracture for one resident. The deficient practice was corrected prior to the survey and was cited as past noncompliance.
Deficiencies (1)
F689 The facility failed to ensure a resident's bed was fully assembled, which caused a fall and hip fracture for one resident. The bed was missing a foot board and mattress guards, allowing the mattress to slide off the bed.
Report Facts
Resident census: 68
SNF beds: 9
SNF/NF beds: 35
Residential beds: 24
Medicare residents: 8
Medicaid residents: 28
Other payor residents: 8
Total payor residents: 44
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 0
Date: Dec 19, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 5, 2022.
Findings
Mill Pond Health Campus 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 Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 44
Census Payor Type: 44
Inspection Report
Routine
Census: 44
Capacity: 68
Deficiencies: 5
Date: Nov 14, 2022
Visit Reason
A routine Emergency Preparedness and Life Safety Code survey was conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found substantially compliant with Emergency Preparedness requirements but failed to conduct required emergency preparedness exercises twice per year. Life Safety Code deficiencies included obstructed means of egress, lack of monthly and annual testing of emergency lighting, unsecured electrical panels, and missing quarterly fire drills for two quarters.
Deficiencies (5)
The facility failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures.
The facility failed to ensure one of five means of egress was continuously maintained free of obstructions; a non-wheeled cart was blocking a corridor.
The facility failed to ensure one of four battery backup emergency lights was tested monthly and annually for 90 minutes with written records maintained.
The facility failed to ensure all electrical panels in corridors were secured from unauthorized personnel; one panel was found unlocked.
The facility failed to conduct quarterly fire drills for two of four quarters in 2022, missing drills on third shift in Q1 and second or third shifts in Q2.
Report Facts
Certified beds: 68
Census: 44
Fire drills missing: 2
Battery-operated emergency lights: 4
Corridor obstructions: 1
Electrical panels unsecured: 1
Inspection Report
Deficiencies: 0
Date: Nov 14, 2022
Visit Reason
The visit was conducted to complete the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey for Mill Pond Health Campus.
Findings
Mill Pond Health Campus was found in compliance with the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and with the Life Safety Code requirements including the 2012 Edition of the NFPA 101 and applicable state regulations.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Oct 24, 2022
Visit Reason
This visit was for the investigation of complaints IN00392307 and IN00392818 at Mill Pond Health Campus.
Complaint Details
Complaint IN00392307 - Substantiated with no deficiencies cited. Complaint IN00392818 - Substantiated with no deficiencies cited.
Findings
Both complaints IN00392307 and IN00392818 were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Recertification
Census: 32
Deficiencies: 18
Date: Oct 5, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found in substantial compliance with state licensure requirements. Deficiencies were cited related to resident rights, dignity, call light accessibility, self-determination, notification of changes, accuracy of assessments, care planning, ADL care, accident prevention, catheter use, hydration, psychotropic medication use, food safety, infection control, and employee training.
Deficiencies (18)
Resident 22 and 36 were not provided privacy during catheter care and were dressed in clothing with holes, violating dignity rights.
Resident 25's call light was repeatedly found out of reach, risking resident safety.
Resident 27 was not consistently provided showers as per preference and schedule.
Facility failed to notify physician timely and provide intervention for Resident 8's respiratory difficulty.
Resident 43's Minimum Data Set (MDS) discharge assessment inaccurately coded discharge location.
Resident 8's care plan for depression was not person-centered and lacked individualized interventions.
Resident 39 was not invited or given opportunity to attend care plan meetings.
Resident 8's fall care plan was not implemented properly; dycem was not in wheelchair as ordered.
Resident 25 had long, untrimmed fingernails despite receiving hospice care; nail care was not documented or provided by facility staff.
Resident 8 sustained a left ankle fracture during a transfer due to inadequate supervision and post-fall interventions.
Resident 22 had a Foley catheter inserted without clinical justification, resulting in multiple UTIs and hospitalizations; catheter tubing and bags were observed touching the floor.
Resident 19's catheter tubing was observed touching the floor multiple times, increasing infection risk.
Residents 42, 39, and 5 were not consistently provided fresh water as observed during multiple checks.
Staff failed to perform hand hygiene between assisting multiple residents during restorative dining observations.
Registered Nurse 17 administered insulin without wearing gloves, violating infection control standards.
Resident 25 had a PRN antianxiety medication order exceeding 14 days without documented clinical justification or monitoring of non-pharmacological interventions.
Facility failed to ensure annual tuberculosis skin test was completed for Licensed Practical Nurse 21.
Facility failed to ensure required annual inservice training was completed for 3 of 10 employee records reviewed.
Report Facts
Residential Census: 32
Deficiencies cited: 16
PRN lorazepam administrations: 20
Insulin dose: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 21 | LPN | Employee record lacked annual TB skin test and required inservice training |
| Qualified Medication Aide 22 | QMA | Employee record lacked required annual inservice training |
| Registered Nurse 8 | RN | Employee record lacked required annual inservice training |
| Registered Nurse 17 | RN | Observed administering insulin without gloves; received education and competency training |
| Certified Nursing Assistant 13 | CNA | Observed failing to perform hand hygiene between residents during feeding |
| Certified Nursing Assistant 10 | CNA | Involved in resident fall during transfer |
Inspection Report
Follow-Up
Census: 42
Capacity: 72
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to an unrelated deficiency cited during the Investigation of Nursing Home Complaint IN00383221 completed on June 30, 2022, and was conducted in conjunction with the Investigation of Nursing Home Complaint IN00386247 and Residential Complaint IN00386247.
Complaint Details
Complaint IN00383221 was unrelated and corrected. Complaint IN00386247 was substantiated but no deficiencies were cited related to the allegations.
Findings
The unrelated deficiency cited during Complaint IN00383221 was corrected. Complaint IN00386247 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations during this visit.
Report Facts
Census Bed Type Total: 72
Census Payor Type Total: 42
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
This visit was for the investigation of Residential Complaint IN00386247, which included the investigation of Nursing Home Complaint IN00386247. It was also conducted in conjunction with a Post Survey Revisit to an unrelated deficiency cited during a previous complaint investigation completed on June 30, 2022.
Complaint Details
Complaint IN00386247 was substantiated but no deficiencies related to the allegations were cited.
Findings
Complaint IN00386247 was substantiated but no deficiencies related to the allegations were cited. The unrelated deficiency from Complaint IN00383221 was corrected. The facility was found to be in compliance with applicable regulations regarding the investigated complaint.
Report Facts
Residential Census: 30
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