Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Old Mill Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure the Dietary Manager met regulatory qualifications. Record review showed the DM had no formal education in food or nutrition and no DM certification. The Administrator confirmed the DM was not certified, the RD did not work full time, and no other DM was overseeing the kitchen while the DM awaited a course start date. The DON stated that all 36 residents ate food prepared in the facility kitchen.
Kitchen ventilation covers and walk-in cooler circulation fans were observed with visible dust-like buildup. Four ceiling vent covers over food prep areas had grey fuzzy specks, and two cooler fans had a heavy black fuzzy coating while blowing toward food on shelves. The DM confirmed the buildup and stated dust could fall into the food, and the DON confirmed all residents ate food prepared in the kitchen.
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic meds, failed to monitor for EPS/tardive dyskinesia with antipsychotic use, and used an inappropriate diagnosis for risperidone in one resident. One resident had intact cognition with depression, anxiety, hemiplegia, and seizure disorder, while the other had moderate cognitive impairment with dementia and depression; records and the DON confirmed that the CCP, orders, MAR, and EMR did not include resident-specific behavior monitoring or EPS assessments.
Failure to Include Ordered Fluid Restrictions in Care Plans: Two residents had physician-ordered fluid restrictions that were not included in their CCPs. One resident had a 1.5 L daily fluid restriction, and another resident with HTN, a BIMS score of 11, and supervision needs had an order for a fluid restriction related to HTN, but neither care plan addressed the nutritional intervention. The MDS Coordinator confirmed the omissions.
Surveyors found that ventilation covers in several resident bathrooms were coated with dust due to insufficient cleaning frequency and unclear documentation practices. The facility's cleaning assignments and policy did not specify how often or how to document the cleaning of these covers, leading to inconsistent maintenance.
The facility did not maintain operational ventilation systems in 11 resident bathrooms on one hallway, as observed when the ventilation failed to draw a single ply of toilet paper to the vent cover. The Maintenance Director confirmed that routine checks were not performed as required, and documentation showed the last facility-wide check occurred several months prior.
A resident with hypertension received Hydralazine outside of physician-ordered blood pressure parameters on several occasions, and the physician and resident representative were not notified as required. The MAR showed medication was given when the resident's systolic blood pressure was below the ordered threshold, and in some cases, blood pressure readings were not documented. Facility policy required notification and documentation, but these actions were not taken.
Two residents with orders for oxygen therapy and respiratory treatments did not have their respiratory care needs addressed in their comprehensive care plans, despite facility policy and physician orders requiring such documentation. Observations confirmed the use of oxygen and nebulizer equipment, and staff interviews acknowledged the omission of these needs from the care plans.
A resident with a history of repeated falls and osteoarthritis, who required two-person assistance for transfers per care plan, was transferred with only one staff member on multiple occasions. The resident reported a recent fall and pain, and staff interviews confirmed that the two-person transfer protocol was not followed.
A nurse aide was rehired without the facility completing the required criminal background, APS, or CPS checks as mandated by policy and state regulations. The administrator confirmed that these screenings, which had been done at initial hire, were not repeated at rehire.
A facility failed to ensure timely response to residents' call lights, with multiple instances of delays exceeding 20 minutes. Residents with varying medical needs and cognitive abilities experienced significant delays, leading to accidents and unmet care needs. The facility's policy lacked a specific timeframe for call light response, contributing to the deficiency.
A resident with gastrointestinal issues did not receive Dulcolax as ordered due to an entry error marking it as PRN instead of BID. Additionally, despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once, even though the resident experienced frequent diarrhea. The RN and DON confirmed these oversights, leading to a deficiency in care.
A resident with a history of heart and respiratory issues experienced a significant medication error when warfarin was administered despite an APRN's order to hold the medication due to a high INR. The resident received doses on two consecutive days, leading to an increased INR, which was confirmed by the DON and an LPN as a significant error.
The facility failed to complete tracking/discharge MDS for 17 residents. A review of discharge Electronic Health Records revealed the missing MDS. The newly hired MDS Coordinator confirmed the requirement to complete the MDS within 3 days of discharge. The facility Administrator was unaware of the incomplete MDS and acknowledged the oversight.
A facility failed to have a physician's order for CPAP for a resident with COPD, Obstructive Sleep Apnea, heart failure, and hypertension. The resident's care plan indicated CPAP use, but no order was found in the records. The resident confirmed nightly use of the CPAP with nursing staff assistance, and an LPN confirmed the absence of an order.
The facility failed to provide written notification and a reason for discharge to a resident or the resident's representative, despite the resident being transferred to the hospital due to urgent medical needs. This deficiency was confirmed through interviews with the facility Administrator.
The facility staff failed to notify the practitioner or responsible party of falls for two residents. One resident experienced a fall with injuries, and the family was not informed. Another resident fell multiple times, and neither the family nor the physician was notified. This was confirmed through record reviews and interviews with the facility administrator.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager was qualified under regulations. Record review of the Dietary Manager’s employee file showed a hire date of 3/27/26, with no formal education in food or nutrition and no certification as a Dietary Manager. During interview on 03/30/2026 at 10:55 AM, the Administrator confirmed that the Dietary Manager was not currently certified and was enrolled in a class scheduled to start 05/01/2026. The Administrator also confirmed that the Registered Dietician did not work full time in the facility and that no other Dietary Manager was currently working with the existing Dietary Manager to oversee the facility until the dietary management course could be completed. During interview on 04/01/2026 at 2:37 PM, the DON stated that all 36 residents in the facility ate foods prepared in the facility kitchen.
Kitchen Ventilation and Cooler Fans Not Kept Clean
Penalty
Summary
The facility failed to ensure the cleanliness of ceiling ventilation system covers in the kitchen and ventilation fans in the walk-in cooler. During observation with the Dietary Manager, specks of a grey fuzzy substance resembling dust were seen on the exterior of 4 ceiling ventilation covers located directly over food preparation areas in the kitchen. In the walk-in cooler, 2 circulation fans had a heavy coating of a black fuzzy substance and were turned on, blowing toward food stored on shelves. The Dietary Manager confirmed the presence of the dust-like substance on the ventilation covers and fans and stated there was a potential for the dust to fall into the food, but was unable to confirm when the covers and fans were last cleaned. The Director of Nursing confirmed that all 36 residents in the facility ate food prepared in the kitchen.
Failure to Monitor Psychotropic Medication Use and Resident-Specific Behaviors
Penalty
Summary
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic medications, failed to monitor for tardive dyskinesia/extrapyramidal symptoms for both residents, and failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for one resident. Resident 48 was admitted with a BIMS score of 15/15 and diagnoses including depression, anxiety disorder, hemiplegia/hemiparesis, and seizure disorder. The record showed an order for risperidone, but the DON confirmed that generalized anxiety disorder was not an appropriate diagnosis for risperidone. The resident’s EMR contained no assessment to monitor extrapyramidal symptoms, and the DON confirmed that no such assessment had been completed. The order to monitor anxiety used a generalized standing order rather than resident-specific behaviors. Resident 5 was admitted with diagnoses including major depressive disorder, unspecified dementia, and anxiety, and had a 5-day MDS BIMS score of 10, indicating moderate cognitive impairment. The resident’s CCP listed psychotropic medications including quetiapine for dementia and desvenlafaxine for major depressive disorder, but the CCP did not include resident-specific target behaviors for continued use of either medication. Physician orders and the MAR also did not identify or monitor resident-specific target behaviors for quetiapine or desvenlafaxine. The EMR showed no monitoring for extrapyramidal symptoms related to quetiapine, and the DON confirmed that resident-specific target behaviors should have been identified and documented daily on the MAR and that no assessment for extrapyramidal symptoms had been completed.
Failure to Include Ordered Fluid Restrictions in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans related to physician-ordered fluid restrictions for 2 residents. Resident 44 had a comprehensive care plan that did not address the ordered 1500 cc daily fluid restriction. The record included an order summary dated 3/31/26 showing a 1.5 L fluid restriction and a dietary progress note dated 4/1/26 identifying a 1500 ml/day fluid restriction. During interview, the MDS Coordinator confirmed that the fluid restriction should have been included in the care plan in the nutritional section. Resident 9 was admitted on 03/16/26 with diagnoses including fracture of the right femur and hypertension. The admission MDS showed a BIMS score of 11, indicating moderately impaired cognition, and identified that the resident required supervision with activities of daily living and had no special nutritional approaches. The order summary dated 04/01/2026 showed an order for a 2000 Liter fluid restriction two times per day related to hypertension, starting on 03/26/26, but the resident's care plan dated 02/24/2026 did not include any specific information about the ordered fluid restriction. The MDS Coordinator confirmed that the fluid restriction had not been identified on the care plan and should have been included in the nutritional section.
Failure to Maintain Clean Ventilation Covers in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain the cleanliness of interior and exterior ventilation covers in eight occupied resident rooms along the south hallway. During a walkthrough with the Administrator and Maintenance Director, it was noted that the ventilation covers in resident bathrooms were coated with a white and gray fuzzy substance resembling dust. The Administrator confirmed the presence of this buildup and acknowledged that the current practice was to clean the covers monthly or upon resident discharge, which was not sufficient to prevent dust accumulation. A review of facility cleaning documentation revealed inconsistencies, with some records undated and lacking clear evidence of when cleaning was completed. The facility's cleaning assignments included a general note to check and wipe vents, but did not specify the frequency or documentation requirements for cleaning ventilation covers. Additionally, the facility's policy on routine cleaning and disinfection did not address the cleaning of ventilation covers in resident bathrooms. The Administrator confirmed that both the cleaning assignments and policy lacked necessary specificity regarding these tasks.
Failure to Maintain Operational Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation systems in resident bathrooms were operational in 11 out of 21 occupied bathrooms located on the south hallway. During an observation conducted with the Administrator and Maintenance Director, it was found that the ventilation system in these bathrooms was not functional, as evidenced by the inability of the system to draw a single ply of toilet paper to the surface of the ventilation cover. The Maintenance Director confirmed that the ventilation systems had not been routinely checked for proper function in these areas and that only one check had been performed since the Maintenance Director began employment in October 2024. Further review of facility records revealed that the last documented check of the ventilation systems facility-wide was on 11/24/25, with no other documentation available regarding ongoing checks. The facility's policy requires the Maintenance Director to maintain documentation of all inspections, tests, and maintenance of the HVAC system. The Administrator confirmed that staff should have been checking the ventilation system at least monthly, and ideally weekly, to ensure proper operation, but this was not done.
Failure to Notify Physician and Representative of Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to notify the physician and resident representative when a resident received Hydralazine outside of the physician-ordered blood pressure parameters. The resident, who was cognitively intact with a BIMS score of 14, had an order for Hydralazine to be held if the systolic blood pressure (SBP) was less than 150. Despite this, the medication was administered multiple times when the resident's SBP was below the ordered threshold, as documented in the Medication Administration Record (MAR). In some instances, blood pressure readings were not recorded on the MAR at all. Interviews confirmed that the family member was concerned about the administration of blood pressure medication outside of prescribed parameters, and the Director of Nursing acknowledged that the physician should have been notified when the medication was given outside of parameters. Facility policy required staff to obtain and record vital signs, hold medications outside of parameters, and notify the physician in the event of a medication error, but these steps were not followed in this case.
Failure to Develop Comprehensive Care Plans for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CCPs) that addressed the respiratory care and oxygen needs for two residents who required such services. Facility policy required that CCPs include specific interventions for oxygen therapy, such as the type of delivery system, administration schedule, flow rates, monitoring requirements, and potential complications. However, for both residents sampled, the CCPs did not contain any information related to their respiratory care or oxygen use, despite physician orders and assessments indicating the need for continuous or as-needed oxygen therapy. One resident was observed using an oxygen concentrator set at 3 liters per minute and had diagnoses of chronic respiratory failure with hypoxia and acute pulmonary edema. The resident's Minimum Data Set (MDS) and physician orders documented the need for continuous oxygen and specific parameters for administration, yet the CCP lacked any mention of these needs. Interviews with the MDS coordinator and Director of Nursing confirmed that the care plan did not address the resident's respiratory care or oxygen use, and that this was not in accordance with facility policy. Another resident had physician orders for nebulizer treatments and as-needed oxygen to maintain saturation above 90%, with the MDS also indicating continuous oxygen use. Observations confirmed the presence of oxygen and nebulizer equipment in the resident's room, but the CCP did not reflect any respiratory care needs. Additionally, an LPN was unaware of the current nebulizer orders, and the MDS coordinator confirmed the omission of respiratory care needs from the care plan.
Failure to Implement Two-Person Transfer Protocol for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with a history of repeated falls, primary osteoarthritis, and a recent urinary tract infection. The resident's care plan specified the need for assistance from two staff members (Ax2) for all transfers and use of a wheelchair for mobility. Despite this, documentation and interviews revealed that the resident was transferred with only one staff member assisting on at least one occasion, contrary to the care plan requirements. The provider was notified of an incident where the resident was transferred with only one staff member, and the resident reported experiencing a fall in the bathroom a couple of days prior, resulting in pain in the right arm and shoulder. Observation further confirmed that the resident was transferred from the bed to a chair with only one staff member assisting, despite the presence of both an occupational therapist and a nursing assistant in the room. Interviews with staff confirmed that the resident should have been transferred with two staff members, and that this protocol was not followed during the observed transfer. These actions demonstrate a failure to provide adequate supervision and implement fall prevention interventions as assessed and documented in the resident's care plan.
Failure to Complete Required Background Checks at Rehire
Penalty
Summary
The facility failed to complete required criminal background checks (CBG), Adult Protective Services (APS) checks, and Child Protective Services (CPS) checks at the time of rehire for one nurse aide. According to the facility's abuse prohibition policy, all potential employees, including rehires, must undergo background, reference, and credential checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. Documentation of these screenings is required to be maintained by the facility. Record review showed that the nurse aide in question had previously worked at the facility, with all required checks completed at the time of initial hire. However, upon rehire, there was no documentation that the necessary CBG, APS, or CPS checks were repeated. The facility administrator confirmed during an interview that these checks were not completed at the time of rehire, as required by facility policy and state regulations.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure that residents' call lights were answered within 20 minutes, as expected, for four sampled residents. The facility's policy on call light response did not specify a timeframe for answering call lights, which contributed to the deficiency. The facility's Patient Concern Forms revealed multiple complaints about long call light response times from residents and their families. Resident 1, who was cognitively intact and had specific medical conditions requiring prompt assistance, experienced multiple instances where call lights were not answered within 20 minutes. The resident's family reported incidents where the resident had to wait for assistance after vomiting and during a diarrhea episode, leading to significant delays in care. The Past Calls log documented numerous instances of call lights running for over 20 minutes, with some exceeding 30 minutes. Resident 4, also cognitively intact, required substantial assistance with daily activities and experienced similar delays in call light responses, with some instances exceeding 40 minutes. The resident confirmed having accidents while waiting for assistance. Residents 2 and 3, with varying levels of cognitive impairment and assistance needs, also experienced prolonged call light response times, with logs showing multiple instances of delays over 20 minutes. The Director of Nursing confirmed that the facility's goal was to answer call lights within 6-7 minutes, but the expectation was within 20 minutes.
Failure to Administer Medications as Ordered for Gastrointestinal Issues
Penalty
Summary
The facility failed to administer Dulcolax as per the provider's orders for a resident with a suspected bowel obstruction. The resident, who was cognitively intact and required assistance with daily activities, had a medical history of partial intestinal obstruction and other gastrointestinal issues. A verbal order for Dulcolax suppository twice daily was given by an APRN and documented by an RN, but the medication was only administered once due to an error in entering the order as PRN instead of BID. This oversight was confirmed by the RN and the Director of Nursing (DON) upon review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Additionally, the facility did not adequately address the resident's recurrent diarrhea. Despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once during a period when the resident experienced loose stools almost daily. The RN acknowledged being informed by nursing assistants about the resident's condition but did not assess the resident or administer the medication, citing instructions from the APRN not to administer it starting on a specific date. However, the order for Loperamide remained active and was not placed on hold. The DON confirmed the resident's frequent loose stools and the lack of consistent administration of the PRN Loperamide, which should have been offered to the resident even if not requested. The failure to follow the provider's orders for both Dulcolax and Loperamide resulted in a deficiency in the facility's care for the resident's gastrointestinal issues.
Significant Medication Error with Warfarin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of warfarin, an anticoagulant medication. The resident, who had a history of respiratory failure, heart failure, atrial fibrillation, venous insufficiency, and a pacemaker, was prescribed warfarin with specific dosing instructions. Despite an order from the Advance Practice Registered Nurse (APRN) to hold the medication due to a high International Normalized Ratio (INR) of 5, indicating an increased risk of bleeding, the resident received doses of warfarin on two consecutive days. This administration occurred on 07/19/2024 and 07/20/2024, contrary to the APRN's directive to hold the medication and recheck the INR on 07/21/2024. The error was confirmed through interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged that the warfarin should not have been administered given the elevated INR levels. The INR further increased to 8.0 by 07/21/2024, exacerbating the risk of bleeding. The facility's policy on medication errors defines a significant error as one that jeopardizes the resident's health and safety, which was the case here due to the failure to adhere to the physician's orders and the subsequent increase in the resident's INR levels.
Failure to Complete Tracking/Discharge MDS for 17 Residents
Penalty
Summary
The facility failed to complete tracking/discharge Minimum Data Sets (MDS) for 17 residents (2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42, and 44). A record review of the sampled residents' discharge Electronic Health Records revealed that these residents did not have a tracking discharge MDS completed. During an interview, the newly hired MDS Coordinator confirmed that a tracking discharge MDS should be completed within 3 days of a resident's discharge from the facility. The MDS Coordinator had started their position on 04/08/2024. Additionally, the facility Administrator confirmed they were unaware that the tracking discharge MDS were not completed for the mentioned residents and acknowledged that they should have been completed after the residents' discharge from the facility.
Lack of Physician's Order for CPAP
Penalty
Summary
The facility failed to have a physician's order for Continuous Positive Airway Pressure (CPAP) for one resident. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, unspecified diastolic heart failure, and essential hypertension, was admitted on a specified date. The resident's care plan indicated the use of a CPAP machine due to sleep apnea, but no order for the CPAP was found in the resident's Order Summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). An observation confirmed the presence of a CPAP machine in the resident's room, and the resident confirmed its nightly use with assistance from nursing staff. An interview with an LPN confirmed the absence of an order for the CPAP or the oxygen bled into the CPAP.
Failure to Provide Written Notification of Discharge
Penalty
Summary
The facility failed to provide written notification of discharge to Resident 50 or to the resident's representative, and did not provide a written reason for the discharge. Resident 50 was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, sepsis, lymphocytosis, major depressive disorder, and mixed hyperlipidemia. On the day of the incident, the resident's oxygen saturation levels were critically low, and the night nurse found the resident visibly struggling to breathe. The resident's provider was notified, and an order was given to transfer the resident to the hospital. The resident's daughter was informed of the transfer, and the resident was taken to the hospital by rescue squad. However, no written notice or reason for the discharge was provided to the resident or the resident's representative as required by the facility's policy and regulatory guidelines. The facility's Transfer and Discharge policy mandates that notice must be provided at least 30 days prior to a facility-initiated transfer or discharge, with exceptions for urgent medical needs. In such cases, notice must be provided as soon as practicable. Despite these guidelines, the facility did not send a written reason for discharge or a notice of discharge to Resident 50 or the resident's representative. This deficiency was confirmed through interviews with the facility Administrator, who acknowledged the failure to provide the required documentation.
Failure to Notify Practitioner or Family of Resident Falls
Penalty
Summary
The facility staff failed to notify the practitioner or responsible party of falls for two residents. Resident 1, admitted with multiple diagnoses including Respiratory Syncytial Virus Pneumonia and Diabetes Type II, experienced a fall on 2/12/24. The incident report indicated that Resident 1 was found on the floor with injuries including skin tears and a bump on the left temple. However, the facility did not notify Resident 1's family about the fall, as confirmed by both the resident's emergency contact and the facility administrator during interviews conducted on 3/5/24. Resident 3, admitted with conditions such as Acute Respiratory Failure and a history of stroke, fell multiple times between 11/05/2023 and 12/19/2023. The facility's records revealed that neither the resident's family nor the physician was notified of these falls. This was confirmed through a review of progress notes and an interview with the facility administrator. The facility's policies on fall prevention and notification of changes were not adhered to, leading to a failure in communication regarding the residents' falls and injuries.
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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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How nearby facilities compare on the same public inspection record.
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| Rose Blumkin Jewish Home | 2.1 mi | ★★★★★ | 7 | 0 |
| The Banyan At Montclair | 3.3 mi | — | 19 | 0 |
| Keystone Ridge Post Acute Nursing And Rehabilitati | 3.6 mi | ★★★★★ | 2 | 0 |
| Hillcrest Millard Llc | 3.8 mi | ★★★★★ | 10 | 0 |
| Maple Crest Health Center | 4 mi | ★★★★★ | 25 | 0 |
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