Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mill Pond Health Campus during CMS and state inspections, most recent first.
Improper Ice Scoop Storage and Uncovered Ice Bucket During Hall Tray Service: During hall tray meal service, an aide repeatedly returned the ice scoop to the ice bucket after using it and transported the ice bucket uncovered down the hallway with the scoop still inside. On another meal service observation, the same practice was observed again. Staff stated the ice bucket should be covered during transport and that the scoop had previously been kept in the ice bucket when not in use; the facility policy required ice scoops to be stored in a clean, protected location or in a closed container.
Resident Bathing Preferences Not Met: A resident with MS and DM had no cognitive deficit and was dependent for bathing, but her documented shower preference was not fully captured or followed. Staff only recorded shower versus bath preference, did not document how many showers she wanted, and the POC lacked refusal documentation even though the resident reported she was no longer receiving the 3 showers per week she had previously gotten.
Failure to maintain resident privacy during personal care and assessments. A resident reported staff entered the bathroom while she was on the toilet, checked her BP after she asked them to wait, and entered her room without knocking while she was dressing. In another event, a hospice nurse performed vitals and an assessment on a resident in a common area during lunch service, without speaking to him, while other residents and staff were nearby.
Failure to Communicate Transfer Information During Hospitalization: A resident with severe cognitive impairment and multiple diagnoses had a sudden decline, was assessed, the MD was notified, and the resident was sent to the hospital and admitted to the ICU. The record lacked documentation of a physician order for transfer and lacked evidence that a condition report was called to the ER or EMS, including current VS, meds, and allergies, as required by the facility’s transfer/discharge policy.
The facility failed to ensure accurate MDS coding for two residents. One resident’s record showed death in the facility, severe cognitive deficit, terminal illness, and hospice services, but no death in facility MDS was completed. Another resident had cirrhosis, Parkinson’s disease, palliative care, and hospice orders, yet one MDS incorrectly showed no hospice services during the look-back period even though the care plan and staff interview confirmed hospice/comfort care.
Insulin Pen Not Labeled With Date Opened: During a med cart observation, surveyors found an LPN storing a Lantus insulin pen for a resident with no date opened on the label. The resident had DM2 and an active order for Lantus insulin twice daily, and the facility policy required opened meds to be dated.
A resident with diabetes, ESRD, and cardiovascular conditions had repeated late MAR entries for scheduled meds, including insulin, Eliquis, amlodipine, and isosorbide dinitrate, and one insulin dose lacked documentation altogether. Staff said meds were given but charted late because of night-shift workload. In a separate event, another resident had a sudden decline, was sent to the hospital after the on-call physician was notified, but the chart lacked a written physician order for the transfer.
A resident with ALS and multiple comorbidities used a ventilator, cough assist, and suctioning devices, but the facility did not develop a care plan addressing these respiratory devices. Staff were not in-serviced on the equipment, and the care plan lacked required entries, despite the resident's dependence on these devices and facility policy requiring care planning for such needs.
A resident with ALS and multiple comorbidities used a cough assist and airway clearance device brought from home, but the facility did not obtain physician orders or include these devices in the care plan. The DON and Corporate Nurse Consultant confirmed the absence of orders and documentation, despite the resident's ongoing use of the equipment.
A facility failed to obtain a physician order for a Tubigrip used on a resident's left arm to prevent skin tears and manage swelling. The resident, with a history of brain mass, early-onset Alzheimer's, and edema, had a dressing on her arm due to an injury. Despite staff and family confirming the use of the Tubigrip, the resident's record lacked a physician order, violating the facility's policy for medical orders.
A resident's nebulizer mask was repeatedly observed un-bagged on the bedside table, contrary to facility policy requiring it to be stored in a dated plastic bag. The resident, with a history of heart disease and kidney issues, had a physician's order for nebulizer treatments. Despite recent flu symptoms, the care plans lacked documentation of respiratory concerns. Clinical Support staff confirmed the mask should have been properly stored.
A facility failed to timely address a pharmacist's recommendations for a resident's medication regimen. The resident, with chronic kidney disease and heart failure, was on Midodrine. Recommendations to adjust dosage times to prevent supine hypertension were not initially followed, and documentation was lacking. The facility relied on state and federal regulations without a specific policy for addressing such recommendations.
The facility failed to properly label and dispose of prepared food items in the kitchen, as observed during a tour. A container of chicken salad lacked a label or use-by date, and several other food items were found with expired dates. The Business Office Manager and Dietary Manager acknowledged these issues, which could affect all residents receiving food from the kitchen.
A CRCA violated the facility's abuse and cell phone policies by posting a video on social media featuring a resident with severe cognitive impairment. The video included inappropriate gestures and captions. The CRCA was suspended and later terminated after admitting to the violation. Staff were previously educated on these policies during onboarding.
Improper Ice Scoop Storage and Uncovered Ice Bucket During Hall Tray Service
Penalty
Summary
The facility failed to ensure proper food handling during hall tray meal service for 2 of 2 observed meal services. During a lunch observation, a Dietary Services Assistant prepared drinks at the hot cart and repeatedly removed ice with an ice scoop, then returned the scoop to the ice bucket with the ice after each use. The assistant later left the common area and proceeded down the 300 hallway with the ice bucket uncovered and the ice scoop still in the bucket. During a breakfast observation, the same Dietary Services Assistant was again observed with the ice scoop inside the ice bucket with the ice, and she left the common area with the cart and proceeded down the 300 hallway with the ice bucket uncovered. Staff interviews indicated the ice bucket should be covered with plastic when transported down the hallway, and that staff had previously kept the ice scoop in the ice bucket when not in use. The facility’s policy stated ice scoops should be stored in a clean, protected location or in food that is not potentially hazardous with handles above the top of the food within containers or equipment that can be closed, such as bins of ice.
Resident Bathing Preferences Not Met
Penalty
Summary
The facility failed to ensure a resident's bathing preferences were met for one resident reviewed for choices. The resident stated that she used to receive 3 showers per week until she began needing a shower chair, and then she was only getting 2 showers per week if she was lucky. Her record showed diagnoses including multiple sclerosis and diabetes mellitus with hyperglycemia, and an annual MDS indicated she had no cognitive deficit, no documented refusal behaviors, and was dependent for personal hygiene and bathing. Her annual Life Enrichment assessment documented that she preferred showers, but it did not state how many showers per week she preferred. The resident's care plan identified that she preferred showers and directed staff to shower her per schedule, but it did not document refusals related to ADL assistance. Review of the POC for April and May 2026 showed showers were provided on several dates, but there was no documentation of any resident refusals of care. The ADNS stated staff did not complete shower sheets and that the POC was used to document showers, baths, and refusals. The Life Enrichment Director stated she only asked residents whether they preferred a shower or bath and had not asked how many showers they preferred, while the Regional Clinical Support stated there was no specific policy for the number of showers but staff would attempt to ensure residents received 2 showers per week and could not find documentation of the resident's refusals.
Failure to Maintain Resident Privacy During Personal Care and Assessments
Penalty
Summary
The facility failed to maintain resident privacy for two residents during care and room entry. Resident 29 stated that staff entered the bathroom while she was sitting on the toilet and checked her blood pressure even after she asked them to wait, and she also reported that staff sometimes walked into her room while she was getting dressed without asking permission or knocking. During the interview, three staff members entered the room without knocking or waiting for permission, including an activities assistant who asked about activities, a CNA who delivered water, and another unidentified employee who walked to the other side of the room and left. Resident 29’s record showed diagnoses including unspecified dementia, diabetes mellitus, hemiplegia, and hemiparesis following cerebral infarction; the MDS indicated she was cognitively intact and needed staff assistance for daily care needs, while the care plan noted impaired cognition, short-term memory impairment, and risk for confusion, disorientation, altered mood, and reduced safety awareness related to dementia. Resident 32 was observed in a Broda chair in the common area during lunch service when a contracted hospice nurse sat next to him and obtained vital signs in the open area. The nurse took his blood pressure with a wrist cuff, checked a temporal temperature, obtained a pulse oximeter reading and heart rate, and palpated his abdomen with bare hands while other residents and staff were present in the hallway and dietary staff were preparing and serving lunch trays. The nurse did not address or communicate with the resident during the assessment and also took a phone call while charting and completing the assessment. Resident 32’s record listed diagnoses including unspecified dementia and dysphagia, and the quarterly MDS indicated he was rarely understood and was on hospice services. An RN stated that assessments and vital signs should not be performed in a common area and should be completed behind closed doors for privacy.
Failure to Communicate Transfer Information During Hospitalization
Penalty
Summary
The facility failed to ensure discharge reporting information was communicated to the receiving healthcare facility for 1 of 4 residents reviewed for hospitalization. Resident 2 was admitted with diagnoses including encephalopathy, hypertension, and type 2 diabetes mellitus. An admission MDS dated 4/7/26 indicated the resident had severe cognitive impairment and required maximum assistance from staff for all care needs. The medical record showed that on 4/26/26 the resident had a sudden change and decline in condition, was assessed, the physician was notified, and the resident was sent to the hospital and admitted to the ICU. The record lacked documentation that a resident condition report was called to the hospital ER or EMS at the time of discharge. It also lacked documentation of a written condition report that included the resident’s most recent vital signs, medication list, and allergies, as well as a physician order to transfer the resident to the hospital. During interview, RN 2 stated she would obtain a physician order, notify the family, call report to the ER nurse if she knew the destination, and document how the report was communicated. The regional nurse consultant acknowledged the record lacked evidence of a physician order and written report being given to the hospital. The facility policy titled Guidelines for Transfer and Discharge indicated nursing should obtain physician orders for emergency transfer or discharge and send the resident’s CCD with current diagnosis, vital signs, allergies, attending physician, current medications, treatments, and advanced directives.
Inaccurate MDS Assessments for Hospice and Death Reporting
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 of 29 MDS assessments reviewed. For Resident 26, the closed record showed a significant change MDS that documented severe cognitive deficit, a terminal illness, and hospice services, and the census indicated the resident expired; however, the record lacked a death in facility MDS. During interview, the MDS Coordinator stated the death in facility MDS had been overlooked and was not completed. For Resident 15, the record showed admission with diagnoses including unspecified cirrhosis of the liver, encounter for palliative care, and Parkinson's disease. A physician order indicated the resident was admitted under hospice services for a terminal diagnosis with a life expectancy of 6 months or less, and one MDS documented hospice services during the assessment period with severe cognitive impairment and maximum assistance for all care needs. Another MDS, however, indicated hospice services had not been provided during the assessment period, despite the care plan stating the resident had elected comfort care and chosen hospice services. The MDS nurse stated she did not catch the entry when completing the MDS and acknowledged the resident was on hospice during the look-back period.
Insulin Pen Not Labeled With Date Opened
Penalty
Summary
The facility failed to ensure medication was labeled with a date opened during observation of a medication cart. On 5/11/26 at 2:40 p.m., while observing the medication cart with an LPN, surveyors found an insulin pen containing Lantus insulin prescribed to Resident 18 with no date opened recorded on the label. At 2:42 p.m., the LPN acknowledged that insulin pens must have a date opened on the pen. Resident 18 was admitted to the facility with diagnoses including diabetes mellitus type 2, hypertension, and major depressive disorder. The medical record showed a physician order dated 8/8/25 for Lantus Solostar U-100 Insulin, 60 units subcutaneous twice a day. At 2:52 p.m., the Regional Nurse Consultant provided the facility policy titled Medication Storage In The Facility, dated 11/18, which stated that when the original seal of a manufacturer’s container or vial is initially broken, the container or vial will be dated and a date opened sticker shall be placed on the medication.
Medication Documentation and Hospital Transfer Order Deficiencies
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident who was cognitively intact and had diagnoses including type II diabetes mellitus, end stage renal disease, encephalopathy, hypertension, and CHF. The resident reported that nursing staff were often late giving insulin and other medications, and sometimes did not give them at all. Review of the resident’s MAR showed repeated late documentation for scheduled doses of amlodipine, Eliquis, and isosorbide dinitrate, with many entries charted hours after the ordered administration window and several documented by the same LPN as late due to patient care. The record also showed a missed documentation entry for Basaglar insulin on one evening, when the MAR lacked documentation that the insulin was administered. The resident’s orders included bedtime insulin and multiple cardiovascular medications scheduled at specific times, yet the MAR reflected inconsistent administration times and late charting across April and May. During interviews, nursing staff stated they would document medication administration immediately after giving the medication, while the LPN responsible for many of the entries stated she was busy on night shift, had to assist other staff, and was late documenting her medication pass. She also stated the resident often received medications on time even though the documentation did not always reflect that. The facility also failed to obtain a written physician order to send another resident to the hospital. That resident had diagnoses including encephalopathy, hypertension, and type 2 diabetes mellitus, and the record showed a sudden change and decline in condition on 4/26/26. The resident was assessed, the on-call physician was notified, and a telephone order was obtained to send the resident to the hospital, but the medical record lacked documentation of a physician order for the transfer. An RN stated she would obtain and document a physician order when sending a resident to the hospital, and the facility policy indicated nursing should obtain physician’s orders for emergency transfer or discharge.
Failure to Develop Care Plan for Resident's Respiratory Equipment
Penalty
Summary
The facility failed to develop a care plan addressing the use of respiratory durable medical equipment, specifically a cough assist device and a suctioning device, for a resident diagnosed with amyotrophic lateral sclerosis (ALS), dysphagia, rheumatoid arthritis, depression, and anxiety. The resident, who was admitted from home and receiving hospice services, was cognitively intact but unable to speak, requiring substantial to maximal assistance with daily activities and was dependent on staff for transfers and mobility. The resident used a ventilator at night and had an airway clearance device at bedside, but the care plan did not include any problems, goals, or approaches related to these respiratory devices. Interviews with facility staff revealed that the resident had been using the respiratory equipment at home and continued to use them independently in the facility. Staff had not been in-serviced on the use of the cough assist device or the ventilator, and only one staff member was familiar with the ventilator. The care plan lacked entries for the respiratory devices, and although the hospice care plan indicated hospice was responsible for medical supplies, the facility did not include the devices in the resident's care plan as required by facility policy.
Failure to Obtain Physician Orders for Resident's Respiratory Devices
Penalty
Summary
The facility failed to obtain physician's orders or conduct an assessment for the use of a cough assist device and an airway clearance device (suctioning) for a resident diagnosed with amyotrophic lateral sclerosis (ALS), dysphagia, rheumatoid arthritis, depression, and anxiety. The resident, who was admitted from home and receiving hospice services, was cognitively intact but unable to speak, requiring substantial to maximal assistance with daily activities and dependent on staff for transfers and mobility. The resident communicated using a whiteboard and had a gastric tube for nutrition, with orders entered for her supplements. Despite the resident's use of a ventilator at night and the presence of an airway clearance device at bedside, there were no physician's orders for the cough assist or suctioning devices. Interviews with the DON and Corporate Nurse Consultant confirmed that the resident had brought the respiratory equipment from home and used them as needed, but the facility had not entered corresponding care plan entries or physician orders for these devices. The hospice care plan indicated hospice was responsible for medical supplies, but the facility lacked documentation and policy regarding the use of these respiratory devices.
Failure to Obtain Physician Order for Tubigrip Use
Penalty
Summary
The facility failed to obtain a physician order for the use of a Tubigrip on a resident's left arm, which was used as a preventive measure for skin tears and swelling. During an observation, the resident was seen with a dressing on her left arm, which she indicated had been there for a while due to an injury from banging it on the bed's side rail. The resident's medical history included a brain mass, early-onset Alzheimer's disease, and unspecified edema. The care plan did not include an intervention for the Tubigrip, despite the resident's risk for skin breakdown and need for assistance with mobility and transfers. Interviews with staff and a family member confirmed the use of the dressing/sleeve due to skin tears and swelling in the resident's left arm. However, the resident's record lacked documentation of a physician order for the Tubigrip. The facility's policy required physician notification for changes in condition or injuries, but this was not adhered to in this case. The Clinical Support Nurse confirmed the absence of a physician order for the Tubigrip, highlighting a deficiency in following the facility's policy for obtaining necessary medical orders.
Improper Storage of Nebulizer Mask for Resident
Penalty
Summary
The facility failed to ensure proper storage of a nebulizer mask for a resident, identified as Resident 19, who was receiving respiratory care. During multiple observations on different days, the nebulizer mask was found un-bagged and sitting on the resident's bedside table. This was contrary to the facility's policy, which required nebulizer masks to be stored in a plastic bag marked with the date and the resident's name when not in use. The Clinical Support staff confirmed that the mask should have been bagged and dated for storage. Resident 19 had a history of atherosclerotic heart disease and stage 4 chronic kidney disease. The resident's medical records indicated a physician's order for nebulizer treatments with ipratropium-albuterol solution every four hours as needed, which was administered once for congestion. Despite the resident's recent flu and productive cough, there was no documentation of shortness of breath or respiratory concerns in the care plans. The failure to properly store the nebulizer mask was observed by the Clinical Support staff, who acknowledged the oversight.
Failure to Address Pharmacist's Recommendations for Medication Regimen
Penalty
Summary
The facility failed to address a pharmacist's recommendation regarding a resident's medication regimen in a timely manner. Resident 22, who has diagnoses including hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, was receiving Midodrine, an anti-hypotensive medication. A pharmacy recommendation dated April 29, 2024, suggested adjusting the dose times and hold parameters for Midodrine. However, the document was marked with 'Leave alone' on May 2, 2024, without any physician documentation to justify this decision. The Clinical Support staff could not find any rationale for this statement during an interview on March 3, 2025. Further pharmacy recommendations on June 24, 2024, and July 22, 2024, advised avoiding the evening dose of Midodrine after the evening meal or within four hours of bedtime to prevent supine hypertension. Although the task was marked as completed, the June 24 medication administration record (MAR) showed the medication was given between 6:00 p.m. and 10:00 p.m., lacking specific administration times. By July, the evening dosage times were adjusted to 4:00 p.m. to 6:00 p.m. The Executive Director stated that pharmacy recommendations should be addressed before the next medication regimen review, but the Clinical Support could not locate a specific policy for addressing these recommendations, indicating reliance on state and federal regulations.
Improper Food Labeling and Disposal in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and disposal of prepared food items, as observed during a kitchen tour. A plastic container of prepared chicken salad was found in the walk-in refrigerator without a label or use-by date. The Business Office Manager, who was present during the tour, was unable to determine when the chicken salad was prepared or how long it had been stored. Dietary Services Assistant 8 mentioned that prepared food should be discarded after four days, indicating a lack of adherence to this guideline. Additionally, several containers of prepared food items, including poppy seed dressing, lemonade, apple raspberry juice, blue Gatorade, and thickened liquid, were found in the refrigerator with expired use-by dates. The Business Office Manager acknowledged that these items should have been discarded. The Dietary Manager later confirmed that prepared food items should be labeled with a use-by date and discarded after three days, as per the facility's policy on leftover food storage. This failure to follow proper food storage and labeling procedures had the potential to affect all 50 residents receiving food from the kitchen.
Staff Violation of Abuse and Cell Phone Policies
Penalty
Summary
The facility failed to ensure that a staff member adhered to its abuse and cell phone use policies, resulting in a deficiency related to the protection of residents from abuse. A Certified Resident Care Assistant (CRCA) posted a video on a social media platform featuring an unidentifiable resident in the restroom. The video included a caption that was inappropriate and disrespectful, and the CRCA was seen making a grimacing face and an offensive hand gesture. This incident was reported to the Executive Director, and the CRCA was immediately suspended pending an investigation. The investigation revealed that the CRCA admitted to violating the facility's abuse policy. The resident in the video, identified as Resident B, had severe cognitive impairment due to conditions such as depression, generalized anxiety disorder, and Alzheimer's disease. Interviews with various staff members, including the Dementia Care Director and the Director of Health Services, indicated that they were unaware of any previous disciplinary issues with the CRCA. The staff were educated on cell phone usage and social media posting during their onboarding training. The facility's policies on cell phone use and abuse were reviewed, highlighting that personal cell phones and electronic devices are prohibited in work areas, and unauthorized recording of residents is not allowed. The CRCA's actions were deemed a poor choice, and she was terminated from her position. The incident was documented in an Episodic Event form, and the facility took immediate steps to educate current staff members on the relevant policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greencastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Towers Health Care Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Hickory Creek At Sunset | 1.4 mi | ★★★★★ | 7 | 0 |
| Waters Of Greencastle, The | 1.4 mi | ★★★★★ | 12 | 0 |
| Aperion Care Summerfield | 9.3 mi | ★★★★★ | 0 | 0 |
| Cloverleaf Of Knightsville | 15.3 mi | ★★★★★ | 6 | 0 |
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