Inspection Reports for
Mill Pond

Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance with health requirements.

The facility failed to attempt a gradual dose reduction for a resident prescribed psychotropic medication, failed to ensure a resident's drug regimen was free from unnecessary drugs including excessive antibiotic use without adequate monitoring, and failed to date, seal, and label open food items stored in the kitchen pantry. The facility reported a census of 55 residents.

Complaint #1778464-C and facility reported incident #2666895-I were investigated and found to be in substantial compliance.

The facility was found to be in substantial compliance.

Complaint #2640934-C was investigated and the facility was found to be in substantial compliance.

The facility was found to be in substantial compliance.

The facility will be certified in compliance effective March 26, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.

The facility failed to meet food safety requirements by not obtaining final cooking temperatures on alternative menu items and failed to ensure proper documentation of insulin administration for a resident. Deficiencies were noted in food safety compliance and resident medication records.

The facility failed to obtain final cooking temperatures on alternative menu items prepared in the satellite kitchen and failed to ensure documentation of insulin administration for one resident. Both issues were identified through observation, record review, and staff interviews.

Investigation related to Complaint #124181-C and Facility Reported Incident #123158-I; facility found in substantial compliance.

The facility was found to be in substantial compliance.

The facility was found to be in substantial compliance based on the credible allegation and plan of correction accepted by the surveyors.

The complaint involved Resident #45 reporting rough and disrespectful treatment by two agency CNAs on 1/17/24, including improper handling of his brace and shoes causing pain and fear. The resident reported the abuse to staff and via email. The facility failed to report the abuse timely to the State Agency, failed to investigate promptly, and failed to separate the alleged perpetrators from residents. Staff J and Staff K were agency CNAs involved and were asked to leave the facility after the incident. The facility also failed to notify the provider timely about a pressure ulcer condition change for Resident #37.

The facility failed to ensure residents were treated with dignity and respect, timely report and investigate allegations of abuse, and separate alleged perpetrators from residents. Additionally, the facility failed to notify the provider of a change in condition for a pressure ulcer in Resident #37.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to timely report and investigate abuse allegations, failure to provide adequate oral and incontinent care, and failure to notify providers of changes in pressure ulcer conditions.

The facility failed to report an allegation of abuse timely to the State Agency and did not initiate an abuse investigation or separate alleged perpetrators from the resident promptly after the resident reported maltreatment. The resident described rough and disrespectful treatment by two agency CNAs, which was corroborated by staff interviews and documentation.

Complaint #113365-C was investigated and the facility was found to be in substantial compliance.

The facility was found to be in substantial compliance.

The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective March 20, 2023.

The facility failed to maintain acceptable nutritional status for one resident, including failure to properly weigh and notify physicians of significant weight loss. Additionally, the facility failed to answer call lights promptly for three residents, with documented wait times exceeding 15 minutes.

The inspection included an investigation of complaint #109836-C.

The facility was found deficient in maintaining acceptable nutritional status for one resident who experienced significant weight loss without proper physician notification. Additionally, the facility failed to answer call lights promptly for three residents, with wait times up to 34 minutes, despite administrative expectations for response within 15 minutes.

Complaint #106791 was substantiated without a deficiency.

Complaint #106791 was substantiated without a deficiency. No other deficiencies or findings are explicitly stated in the report.

The facility failed to provide a safe method of transfer for one resident, resulting in fractures due to improper use of a mechanical lift. The incident was substantiated, and the facility implemented staff retraining and corrective actions to ensure compliance with care plans and safety protocols.

The facility failed to provide a safe transfer method for Resident #153, who fell and sustained fractures when staff did not use a full mechanical lift as required. The investigation revealed staff did not follow the care plan and proper lift procedures, leading to the resident's injuries.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility failed to provide the correct pureed diet to one of two residents on a pureed diet, resulting in a resident receiving ground steak instead of pureed steak. The facility implemented corrective actions including staff coaching, education, and ongoing audits to ensure compliance with therapeutic diet orders.