Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Run Care Center during CMS and state inspections, most recent first.
The facility failed to follow care plans and document ordered treatments for multiple residents. A resident dependent on continuous O2 was not monitored during a power outage when the generator failed to start, and the resident became confused with an SpO2 of 45% and was hospitalized for hypoxia with acute kidney injury. Other residents had incomplete ear wax treatment after Debrox, no documented seizure details or post-seizure care after repeated PRN lorazepam use, and inaccurate documentation of TED hose/ace wrap treatment despite refusals and observations showing the devices were not in place.
Failure to identify and treat pressure ulcers: one resident’s left hip wound was reported by CNAs as red, hot, blistered, and peeling before it was later found to be an unstageable PI with eschar; another resident developed an in-house Stage 2 PI to the left gluteus and the ordered wound care was not carried out as documented; and a third resident was admitted with a Stage 3 PI to the right buttock but had no treatment ordered or completed until the wound team assessed the area.
Unsafe Food Storage and Food Preparation Practices: The kitchen had a red substance inside the ice machine, greasy and dirty shelving above open boxes of plastic utensils, and dented or smashed cans in dry storage. During dinner service, a Dietary Aide used a gloved hand to turn on a faucet, then continued food prep by cutting an onion without changing gloves or performing hand hygiene. Facility policies for food storage and hand washing were not followed.
Resident Trust authorization forms for six residents were witnessed by the Business Office Manager, and one form was not dated, while the forms authorized the facility to handle residents’ personal care needs accounts. The Administrator confirmed the issue, and the facility policy stated that when serving as a Representative Payee, it must follow federal rules.
Failure to identify and monitor significant weight loss. Several residents with chronic conditions, including DM, CKD, HF, COPD, traumatic brain injury, lupus, and malnutrition risk, had documented large weight changes that were not timely investigated or addressed. Staff noted possible scale discrepancies, but the dietitian was not consistently notified, the DON was unaware of the reweigh process for discrepancies, and no staff education on proper weighing procedures was provided.
A facility failed to follow infection control practices during meal service, wound care, blood sugar testing, and contact precautions. A CNA did not perform hand hygiene between residents during tray pass, staff did not wear gowns during EBP wound care for a resident with an open wound, an RN did not clean or barrier the overbed table and did not follow glucometer disinfection directions, and an LSW entered a room under contact precautions without PPE while setting up a meal tray.
Failure to maintain privacy during personal care affected two residents. A CNA left the blinds open during perineal care with the resident’s body exposed, and a hospice aide wheeled another resident down a hallway in a shower chair while the resident was naked with only a sheet covering her and her back exposed. Staff, including the DON, confirmed the observations, and the facility dignity policy stated residents will be treated with dignity and respect at all times.
Late Medicare Non-Coverage Notifications: The facility failed to notify two residents receiving skilled services within 48 hours of the end of Medicare Part A coverage. Review of beneficiary notices showed both residents signed their Medicare Non-Coverage letters before the last covered day, and the Administrator confirmed the notices were not provided within the required timeframe. The facility’s ABN policy requires timely written notice when Medicare coverage for skilled services ends.
Incorrect MDS Coding for Discharge and Death Assessments: The facility coded one resident’s discharge assessment as return anticipated even though the resident was sent out for chemotherapy and was not expected to return. A second resident’s MDS was coded as death in the facility after transfer to the hospital, despite the record showing the resident died in the hospital after treatment for acute respiratory failure, encephalopathy, sepsis, and hypoglycemia; the MDS coordinator stated the coding was based on the resident dying shortly after ER arrival.
A resident admitted with multiple diagnoses, including CHF, cellulitis, morbid obesity, atrial fib, diabetes, COPD, fibromyalgia, depression, anxiety, restless leg syndrome, and poly-osteoarthritis, had a pressure ulcer present on admission. The MDS was still in progress because the resident was a newer admission, and the care plan contained no evidence of a basic comprehensive plan for the pressure ulcer, as confirmed by the DON.
Missing Quarterly Care Conferences and Nutrition Care Plan: The facility failed to document quarterly care conferences for two residents and had no nutrition care plan for a resident with moderate protein calorie malnutrition. One resident had severe cognitive impairment with dementia and schizoaffective disorder, another had depression and multiple chronic conditions, and a third required extensive assistance with care and mobility. Records showed only limited care conference documentation for the two residents and no nutrition plan for the resident with nutritional needs.
Inadequate Assistance With Bathing and Personal Hygiene: A resident who was dependent on staff for ADLs and bathing received only three documented bed baths/showers in a month. The resident had multiple chronic conditions, including CVA with hemiplegia, incontinence, edema, and frequent falls, and was observed with long facial hair and greasy hair while complaining about the lack of showers or baths. The DON confirmed the record did not show more than three baths in the month and stated this was not consistent with facility practice.
Respiratory equipment was not maintained in infection control conditions and nebulizer administration was not properly supervised for two residents. One resident with heart failure and prior CVA had an uncovered, unlabeled nebulizer mask stored near a plant and later was found asleep alone while the nebulizer machine was running. Another resident with COPD had a nebulizer, tubing, and mouthpiece left uncovered and not dated on the bedside stand. Facility policy required respiratory equipment to be labeled and stored in plastic bags when not in use, and staff were to remain with the resident until nebulizer medication administration was complete.
Pain Management Deficiencies: Two residents had pain management issues. One resident with multiple chronic conditions had a care plan calling for non-pharmacological pain interventions, but there was no documentation that those interventions were used. Another resident with chronic pain and lupus had PRN opioid orders without pain parameters, and opioids were administered repeatedly, including when pain was documented as zero.
Lack of Rationale for Declining Gradual Dose Reduction of Antidepressant: A resident with cerebral infarction, dementia, depression, and schizoaffective disorder, and severe cognitive impairment, was receiving Duloxetine for depression. The pharmacist recommended a gradual dose reduction trial, but the physician responded no change without providing an appropriate rationale, and the DON confirmed the response lacked the required rationale.
A resident with chronic respiratory failure, MDD, chronic pain syndrome, and GERD had oral/dental concerns noted in the care plan, including missing upper teeth and remaining lower teeth. A dental exam recommended extraction of the remaining teeth and full upper and lower dentures, but the facility did not timely submit the Medicaid prior auth or schedule follow-up, and the dental office reported no authorization had been received.
A resident with Alzheimer's disease, GERD, severe protein-calorie malnutrition, and dysphagia-related aspiration risk was observed being fed breakfast by a manager in the resident's room. The manager later confirmed she was feeding the resident even though she was not a certified feeding assistant or CNA, and the facility policy listed only RN, LPN, and STNA/CNA staff as responsible for feeding impaired residents.
A resident with CHF and atrial fibrillation returned from the hospital with Eliquis 5 mg BID listed on the discharge medication list, but the facility did not complete an accurate med rec on readmission. As a result, the anticoagulant was not included in the physician orders until three days later, and the DON confirmed the med rec was not thorough or accurate.
A resident in a facility developed an unstageable pressure ulcer due to the facility's failure to assess and treat a Stage II pressure ulcer upon admission. Despite being at high risk for skin breakdown, no baseline care plan was initiated, and no treatment was ordered until the ulcer worsened. The resident reported self-managing the wound, and staff failed to follow proper precautions during wound observation.
The facility failed to provide routine nail care for two residents dependent on staff for ADLs. One resident, with conditions like pulmonary fibrosis and diabetes, had long, jagged nails with a black substance, while another resident with Parkinson's and dementia had similar nail issues. Staff confirmed the residents' dependence on assistance for personal hygiene, contrary to the facility's hygiene policy.
A resident with a history of Parkinson's disease, peripheral vascular disease, diabetes mellitus, and dementia was found with long toenails curled over the ends of their toes, indicating a failure to provide routine podiatry care. Despite the care plan's inclusion of coordination for ancillary services, observations and CNA interviews confirmed the resident's need for nail care.
The facility failed to ensure the safe and sanitary storage of food items and maintenance of kitchen equipment. Observations revealed undated and improperly sealed food items in the refrigerator and freezer, and unsanitary conditions of the ice machine and fryer. The kitchen manager and corporate dietician confirmed these issues, indicating non-compliance with the facility's policies on food storage and equipment cleaning.
Failure to Follow Care Plans for Oxygen, Seizure, Ear Wax, and Edema Treatments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice and resident care plans for multiple residents. One resident with chronic respiratory failure, chronic kidney disease, and chronic congestive heart failure was dependent on continuous oxygen and was assessed as needing oxygen to keep saturation above 90%. On 03/05/25, a power outage occurred when excavation work cut the facility’s power lines, and the generator did not start because its settings were on manual instead of automatic. During the outage, the resident was not monitored for respiratory failure, and no oxygen saturation monitoring was documented. At 9:18 A.M., staff were alerted that the resident was confused and not acting like herself, and her oxygen saturation was documented at 45%. Emergency services were called, and the resident was sent to the hospital with hypoxia and acute kidney injury in the setting of hypoxia. Hospital records stated the facility reportedly lost power at 8:00 A.M., did not have a working backup generator, and the resident had been off supplemental oxygen for a significant period of time. The facility also failed to complete ordered ear wax treatment for a resident with hemiplegia, vascular dementia, and hearing impairment. An audiology note stated cerumen removal was needed and staff should contact the physician for orders. The physician ordered Debrox ear drops for four nights followed by ear irrigation after the last dose. The MAR showed the Debrox was administered, but there was no documentation that the ears were irrigated afterward. Progress notes also did not show that the irrigation was completed. The resident stated he had asked multiple people and nurses many times to have his ears cleaned and kept the television loud because he could not hear. For another resident with cerebral infarction, hypertension, convulsions, malignant neoplasm of the frontal lobe, epilepsy, anxiety, and cognitive communication deficit, the facility failed to document seizure activity and post-seizure care after multiple PRN doses of lorazepam were given for seizures. The record contained 18 administrations in one month and three more in the following month, but there were no progress notes describing seizure location, type of activity, duration, level of consciousness, incontinence, or post-ictal state. There was also no evidence that required post-seizure interventions such as turning the resident on the side, maintaining the airway, taking vital signs, performing a neuro check, or monitoring for neurological changes were documented. In addition, for a resident with heart failure and residual deficits from cerebral infarction, the facility documented TED hose or ace wraps as administered for edema and circulation even though observations showed the resident’s lower extremities without the ordered wraps, and the resident stated she had not been wearing them for months because she did not like them. Nursing staff confirmed refusals occurred and that the provider had not been notified.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify and treat a resident’s pressure ulcer on the left trochanter in a timely manner. The resident was admitted with severe cognitive impairment, dementia, moderate protein-calorie malnutrition, diabetes, dysphagia, and chronic diastolic heart failure, and required substantial to maximal assistance for bed mobility, transfers, ambulation, and activities of daily living. The resident was assessed as high risk for pressure injury development, and the care plan identified risk related to diabetes, impaired mobility, incontinence, malnutrition, and nutritional deficit. On 08/20/25, three CNAs reported to an LPN and the wound nurse that the resident had a red area on the left hip that was hot to touch, blistered, and peeling, but they were told the nurses already knew about the area. On 08/27/25, during morning rounds, an RN found an awkward bandage on the left hip; when it was removed, a pressure ulcer was revealed and reported to the DON. The wound was then documented as an unstageable pressure injury, and the wound physician later assessed it as 3.9 cm by 3.5 cm with 100% eschar. The resident’s MAR and TAR showed no treatment to the left hip before the ulcer was discovered. The facility also failed to prevent a Stage 2 pressure ulcer for another resident and failed to implement treatment for a third resident’s admitted pressure ulcer. One resident had severe cognitive impairment, very limited bed mobility, a Braden score of 10, and was later found to have an in-house acquired Stage 2 pressure ulcer to the left gluteus, along with a blister to the right heel. The wound consultant documented treatment orders, but the record showed the left gluteus wound was not treated as ordered and was left open to air during observation. A third resident was admitted with a Stage 3 pressure ulcer to the right buttock, had a high pressure ulcer risk score, and had no ordered treatment or completed treatment record until the wound team assessed the area and wrote an order for wound care.
Unsafe Food Storage and Food Preparation Practices
Penalty
Summary
The facility failed to safely store and prepare food in the kitchen. During observation of the kitchen, the internal part of the ice machine had a red substance that was removed when wiped with a glove, and the Dietary Manager verified the substance was present inside the ice machine. In dry storage, greasy and dirty shelving was observed above open boxes of plastic utensils, and the Dietary Manager verified the shelving was dirty. The facility’s Food Storage policy dated 04/01/22 stated that shelving in dry storage should be cleanable. Additional observations in dry storage showed two 50-ounce tomato soup cans with smashed top lids and four 13.5-ounce cans of tomato sauce with dented lids. The Dietary Manager verified these cans should not be out for use, and the facility’s Food Storage policy dated 04/01/22 stated dented cans must be removed from circulation, identified as damaged, and reported to the vendor for credit. During dinner service, Dietary Aide #217 used a gloved left hand to turn on the faucet knob to rinse a knife and then used the same gloved hand to cut an onion without changing gloves or performing hand hygiene in between. The Dietary Aide verified she did not change gloves or perform hand hygiene after touching the faucet knob and before cutting the onion. The facility’s Hand Washing policy dated 01/14/2025 stated food employees shall clean their hands before engaging in food preparation and as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks.
Resident Trust Authorization Forms Improperly Witnessed by Facility Staff
Penalty
Summary
The facility failed to ensure Resident Trust authorization forms were not witnessed by facility staff for six residents (#10, #38, #45, #52, #75, and #76) reviewed for personal care needs accounts. Review of the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds forms showed the Business Office Manager signed as a witness for Residents #38, #10, #52, #45, and #76, and the form for Resident #75 was not dated. These forms authorized the facility to handle each resident’s personal care needs account. During an interview on 09/04/25 at 9:15 A.M., the Administrator confirmed that the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds forms for Residents #10, #38, #45, #52, #75, and #76 were witnessed by the Business Office Manager. Review of the facility policy titled Resident Trust Fun, dated 07/05/24, stated that when a facility is serving as a Representative Payee, it shall fulfill its duties in accordance with the federal rules.
Failure to Identify and Monitor Significant Weight Loss
Penalty
Summary
The facility failed to identify, treat, and monitor significant weight loss for five residents reviewed for weight changes. The deficiency involved residents with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, pulmonary disease, traumatic brain injury, systemic lupus, and malnutrition risk. The record review and interviews showed that weight changes were documented, but the facility did not consistently investigate whether the changes reflected true weight loss or possible scale discrepancies, and the dietitian was not timely notified in several cases. For one resident with diabetes, chronic kidney disease, hypertensive heart disease, and chronic respiratory failure, the record showed a weight of 220.5 lbs. on one date and 186.9 lbs. later in the month. A progress note documented weight loss and suggested possible scale discrepancy or diuretic-related fluctuation, and staff interviews confirmed concerns about weighing issues and inconsistent scales. For another resident with pulmonary heart disease, morbid obesity, heart failure, COPD, diabetes, CKD, hemiplegia, repeated falls, and depression, the record showed a 34.4 lb. loss from 268.4 lbs. to 234 lbs., but the dietary note addressing the loss was not entered until later, and no additional follow-up was documented for the significant one-month loss. A third resident with diabetes, CKD, major depressive disorder, IBS with constipation, and GERD had a documented weight of 173.8 lbs. followed by 158 lbs., a 9.09% loss, but the dietitian was not notified of the significant change. Another resident with focal traumatic brain injury, chronic systolic heart failure, and pulmonary hypertension lost 26.6 lbs. in less than 30 days, and the dietitian had not yet addressed the change. A fifth resident with focal traumatic brain injury, moderate protein calorie malnutrition, and systemic lupus had weights documented at 172 lbs. and then 135.92 lbs., followed by additional low weights, yet the dietitian had not investigated the loss. The DON stated she was unaware of the reweigh policy for discrepancies and reported no staff education on proper weighing procedures or investigation of scale calibration issues.
Infection Control Practices Not Followed During Resident Care and Meal Service
Penalty
Summary
The facility failed to implement infection control practices during resident care and meal service. During breakfast tray pass on 09/04/25, CNA #291 served Resident #38, then left the room without performing hand hygiene before reaching into the warmer for trays for Resident #6 and Resident #9. The CNA also left Resident #6's room and Resident #9's room without performing hand hygiene after assisting with tray setup. CNA #291 later confirmed that hand hygiene was not performed during the observed tray pass. The facility's hand hygiene policy and infection control policy both identified hand hygiene as part of standard precautions. The facility also failed to follow Enhanced Barrier Precautions for Resident #40, who had dementia, Type II diabetes mellitus, moderate protein-calorie malnutrition, anxiety, muscle weakness, and an in-house acquired unstageable pressure injury on the left trochanter. The resident's care plan and physician order required EBP related to a wound, and EBP signage was posted outside the room. During observed wound care on 09/03/25, Unit Manager #402 and CNA #222 performed hand hygiene and donned gloves, but neither staff member wore a gown during the wound care procedure. Unit Manager #402 confirmed gowns should have been worn and acknowledged the EBP signage. The facility also failed to follow its glucometer cleaning process during finger stick blood sugar testing for Resident #77. RN #287 entered the resident's room, did not place a barrier on the overbed table or clean it before use, and after obtaining the blood sugar, wiped the glucometer with a bleach wipe for five seconds and placed it on the medication cart without a barrier to dry. The wipe directions required the surface to remain visibly wet for the contact time, and the facility's glucometer testing review stated the glucometer should be cleansed with germicidal wipes, remain visibly wet for three minutes, and be placed on a clean barrier. The facility also failed to follow contact precaution requirements for Resident #23, who was on contact precautions for conjunctivitis; LSW #212 entered the room without PPE and set up the lunch tray within close proximity to the resident while touching the bedside table.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy was maintained while providing personal care for residents, affecting two residents. For Resident #67, who was admitted with diagnoses including CHF, cellulitis of the left lower limb, morbid obesity, atrial fib, diabetes, COPD, fibromyalgia, major depression, anxiety, restless leg syndrome, and poly-osteoarthritis, observation of perineal care showed CNA #342 completing care with the blinds left open while the resident’s body was exposed. CNA #342 later verified that the blinds had not been closed to provide privacy before the care was completed. For Resident #16, who had diagnoses including severe protein-calorie malnutrition, dementia, Alzheimer’s, COPD, chronic respiratory failure with hypoxia, hypertension, and major depressive disorder, the care plan identified the resident as needing one-person assist with showers. Observation showed Hospice Aide #406 wheeling the resident down the unit hallway in a Broda shower chair while the resident was naked with only a sheet covering her and her back exposed for public view, and the resident was saying, "Help me please, my back is hurting." Facility Aide #289 and the DON both confirmed the resident was brought out of the shower room naked with only a sheet wrapped around her as she was wheeled down the hallway. The facility policy stated residents will be treated with dignity and respect at all times.
Late Medicare Non-Coverage Notifications
Penalty
Summary
The facility failed to ensure residents receiving skilled services were notified within 48 hours of their skilled services ending, affecting two residents reviewed for Beneficiary Notices. Resident #71’s SNF Beneficiary Protection Notification Review showed Medicare Part A skilled services began on 07/04/25 and the last covered day was 07/24/25, but the resident signed the Medicare Non-Coverage letter on 07/23/25. Resident #72’s review showed Medicare Part A skilled services began on 06/17/25 and the last covered day was 07/29/25, but the resident signed the Medicare Non-Coverage letter on 07/28/25. During interview, the Administrator confirmed both residents did not receive notification of skilled services ending within 48 hours. Facility policy titled Advanced Beneficiary Notification (ABN), dated 03/01/25, states the facility is to provide timely written notice to traditional Medicare beneficiaries when Medicare will no longer provide coverage for skilled services.
Incorrect MDS Coding for Discharge and Death Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were coded correctly for two residents reviewed for MDS transmission. For one resident with diagnoses including malignant neoplasm of the esophagus and type II diabetes mellitus with diabetic polyneuropathy, the record showed the resident was discharged to another facility for chemotherapy treatment, and the MDS was coded as a discharge assessment with return anticipated. During interview, the MDS nurse verified the facility was not anticipating the resident returning and stated the MDS would be modified to reflect that. For another resident with diagnoses including surgical aftercare following digestive system surgery, hypertension, post-polio syndrome, poly-osteoarthritis, and generalized anxiety disorder, the progress note documented a change in condition that led to transfer to the hospital after the resident was observed with altered respirations, warmth to touch, fixed pupils, a glazed appearance, and unresponsiveness. The MDS was coded as death in the facility, but the hospital record showed the resident was admitted with acute respiratory failure with hypoxia and hypercapnia, encephalopathy, sepsis, and hypoglycemia, and later died after a decision was made to transition to comfort care and proceed with compassionate extubation. The MDS coordinator stated the assessment was coded as a death in the facility because the resident passed shortly after arriving at the emergency room, and cited a belief that death within 24 hours of transfer should be coded that way.
Failure to Develop Care Plan for Pressure Ulcer Present on Admission
Penalty
Summary
The facility failed to develop and implement a plan of care upon admission for Resident #67 in regard to a pressure ulcer that was present on admission. Resident #67 was admitted with diagnoses including 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 MDS showed it was still in progress and not completed because the resident was a newer admission to the facility. Review of the plan of care showed no evidence of a basic comprehensive plan of care for the pressure ulcer present at admission, and this was confirmed during interview with the DON.
Missing Quarterly Care Conferences and Nutrition Care Plan
Penalty
Summary
The facility failed to have quarterly care conferences documented for two residents and failed to have a nutrition care plan in place for one resident. Resident #9 was admitted with diagnoses including cerebral infarction, dementia, and schizoaffective disorder, and her most recent MDS showed a BIMS of 07, indicating severe cognitive impairment. Her care plan included psychosocial well-being concerns related to dementia and schizoaffective disorder, with a goal of demonstrating adjustment to nursing home placement and an intervention to provide opportunities for the resident and family to participate in care. Review of the record showed care conferences only on 05/25/23, 09/11/24, and 04/18/25, with no additional conferences documented. Resident #18 was admitted with diagnoses including chronic respiratory failure, depression, chronic kidney disease, and chronic congestive heart failure. Her most recent MDS showed a BIMS of 12, indicating intact cognitive status, and she required assistance with showering/bathing, dressing, and mobility. Her care plan also addressed psychosocial well-being related to depression and included a goal of adjustment to the nursing home placement with an intervention for resident and family participation in care. Her record showed care conferences only on 09/24/24 and 05/29/25. Resident #29 was admitted with diagnoses including focal traumatic brain injury, moderate protein calorie malnutrition, and systemic lupus; her MDS showed a BIMS of 15 and she required substantial to maximal assistance with personal hygiene and was dependent for mobility. Review of her record found no nutrition care plan, and the corporate dietitian confirmed that none was in place.
Inadequate Assistance With Bathing and Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living received timely and adequate assistance with showers and personal hygiene. Resident #44 was admitted with diagnoses including pulmonary heart disease, morbid obesity, heart failure, COPD, type 2 diabetes mellitus, chronic kidney disease, hemiplegia and hemiparesis, repeated falls, and major depressive disorder. The care plan identified an ADL self-care deficit with need for assistance of 1-2 persons, incontinence, edema of both lower extremities, and recent and frequent falls, and included interventions for assistance with bathing/showering and daily hygiene, grooming, dressing, oral care, and eating. Record review showed the resident was cognitively intact and dependent on staff for showering and bathing, yet the bathing task documented only three bed baths/showers over a one-month period. Progress notes showed no leave of absence or hospitalization during that time. During interview, the resident was observed with long facial hair and complained about greasy hair and the lack of showers or baths. The DON confirmed the medical record did not show more than three baths completed in a month and stated this was not consistent with facility practice, noting residents are to receive at least 2-3 baths per week or as preferred. The shower policy stated residents will be provided showers as requested and per facility schedule based on preference and safety.
Respiratory equipment was left uncovered and nebulizer treatment was not continuously supervised
Penalty
Summary
The facility failed to maintain infection control with respiratory equipment and the administration of respiratory medication for two residents reviewed for oxygen/respiratory therapy. Resident #50 had diagnoses including hypertensive heart disease with heart failure, chronic diastolic heart failure, and cerebral infarction with residual deficits, and had a BIMS score of 12. On observation, an uncovered and unlabeled nebulizer mask was placed beside a plant on top of the air conditioning unit in the resident’s room. The Unit Manager verified the mask was uncovered and placed near the plant and on top of the air conditioning unit. The facility’s Oxygen Equipment policy stated nasal cannulas, tubing, and masks are to be labeled when new and stored in a plastic bag when not in use, with the bag changed weekly and dated. Resident #50 was later observed alone and asleep in a chair while the nebulizer machine was on and the nebulizer mask was under a blanket. The LPN verified the nurse administering the nebulizer treatment should stay with the resident throughout the treatment, and the facility’s Medication Administration policy stated the nurse is to remain with the resident until medication administration is complete. Resident #68, who had diagnoses including COPD, severe protein calorie malnutrition, peripheral vascular disease, chronic pain syndrome, anxiety, and UTI, had a nebulizer observed on the bedside stand with the tubing and mouthpiece uncovered and not dated. The RN verified this observation, and the facility policy stated respiratory equipment should be labeled and stored in plastic bags when not in use.
Pain Management Deficiencies
Penalty
Summary
Safe, appropriate pain management was not provided for two residents reviewed for pain management. One resident with CHF, cellulitis of the left lower limb, morbid obesity, atrial fibrillation, diabetes, COPD, fibromyalgia, major depression, anxiety, restless leg syndrome, and poly-osteoarthritis had an order for Percocet as needed for moderate pain. Her care plan directed staff to implement non-pharmacological interventions such as music, art, exercise, therapeutic modalities, massage, relaxation techniques, counseling, warm/cool compresses, and positioning to assist with pain and monitor effectiveness, but the progress notes and MAR contained no documentation that any non-pharmacological interventions were used. A second resident with focal traumatic brain injury, moderate protein calorie malnutrition, chronic pain syndrome, and systemic lupus had orders for Oxycodone HCl and Morphine Sulfate as needed for pain every four hours, but the orders did not include parameters for when the medications should be administered. The MAR showed repeated administration of Oxycodone HCl and Morphine Sulfate across multiple days, including doses given when the resident’s pain level was documented as zero. A Regional RN confirmed that the resident did not have pain parameters in place for the as-needed opioid medications.
Lack of Rationale for Declining Gradual Dose Reduction of Antidepressant
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review, including the medical chart, in accordance with its policies and procedures for irregularity reporting. During review of Resident #9’s record, the resident was found to have diagnoses including cerebral infarction, dementia, depression, and schizoaffective disorder, and the most recent MDS showed a BIMS score of 07, indicating severe cognitive impairment. The resident was also assessed as needing partial to moderate assistance with toileting hygiene, showering, and mobility, and was receiving an antidepressant medication. The pharmacist’s medication regimen review dated 10/25/24 documented that Resident #9 was taking Duloxetine 60 mg daily and recommended a gradual dosage reduction trial to 40 mg daily. The physician responded “no change” on 11/01/24, but did not provide a rationale for not attempting the gradual dosage reduction. During an interview on 09/04/25 at 9:08 A.M., the DON confirmed that the pharmacist’s recommendation and the physician’s response did not include appropriate rationale for declining the gradual dosage reduction trial.
Delayed Dental Authorization and Follow-Up
Penalty
Summary
The facility failed to ensure dental recommendations and prior authorization were submitted in a timely manner for one resident reviewed for ancillary services. Resident #46 was admitted with diagnoses including chronic respiratory failure with hypoxia, major depressive disorder, chronic pain syndrome, and gastroesophageal reflux disease without esophagitis. The care plan identified oral/dental health concerns because the resident had no upper teeth and some natural lower teeth, with interventions to monitor and report oral health issues and provide dental consults as needed. A dental visit found the resident needed extraction of the remaining upper and lower teeth, and the dental provider recommended submitting the treatment plan to Medicaid for approval for full upper and lower dentures. The dental office documented that no treatment authorizations had been received and no appointments had been scheduled to proceed with the treatment plan. The resident stated she had spoken with facility staff about the service but had not received a follow-up appointment date. The LSW confirmed that neither he nor anyone else had followed up to schedule the recommended procedures or submit authorization, and the Administrator confirmed the prior authorization was not sent until eight months after the initial recommendation.
Unqualified Staff Fed a Resident With Dysphagia
Penalty
Summary
The facility failed to ensure that staff assisting residents with feeding were competent or certified, affecting one resident observed being fed by staff. Resident #16 was admitted with diagnoses including Alzheimer's disease with late onset, gastro-esophageal reflux disease without esophagitis, and unspecified severe protein-calorie malnutrition. The resident's care plan identified a risk for aspiration related to dysphagia and directed staff to assist with meals, feed at times, and not leave the resident alone, with the intervention assigned to CNA/STNA, RN, and LPN staff. During observation, a manager was seen assisting Resident #16 with eating breakfast in the resident's room, and later verified that she was feeding the resident even though she was not a certified feeding assistant or certified nursing aide. The facility policy on feeding impaired residents identified RN, LPN, and STNA/CNA staff as the roles responsible for feeding impaired residents.
Medication Reconciliation Failure Delayed Anticoagulant Order
Penalty
Summary
Resident #69 was readmitted to the facility after a hospital stay with diagnoses including metabolic encephalopathy, acute kidney failure, heart disease, chronic diastolic heart failure, major depressive disorder, and paroxysmal atrial fibrillation. The discharge MDS showed the resident was cognitively intact, had active CHF, and was receiving anticoagulant therapy. The hospital after-visit summary from the prior stay listed Eliquis 5 mg by mouth twice daily, with the last documented administration given on the day of return to the facility. The facility failed to complete an accurate medication reconciliation when the resident returned from the hospital, and Eliquis was not included in the physician orders at that time. A physician order for Eliquis 5 mg twice daily for atrial fibrillation was not received until three days after the resident returned, and the MAR shows the medication was then started that evening. The DON stated in interview that nursing staff did not complete a thorough and accurate medication reconciliation upon readmission, which resulted in the delay in ordering Eliquis.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and provide timely interventions for a pressure ulcer in Resident #40, resulting in actual harm. Upon admission, Resident #40 had no skin abnormalities, but a weekly skin and wound evaluation later identified a Stage II pressure ulcer on the right gluteus. Despite this, no measurements or descriptions of the wound were recorded, and no treatment was ordered. The resident was at high risk for skin breakdown, requiring extensive assistance with bed mobility and toileting, yet no baseline care plan was initiated to address these risks. From the time of admission to a week later, there was no evidence of a nutrition/dietary supplement being ordered for wound healing, nor was there evidence of a turning and repositioning schedule being implemented. The facility also failed to obtain physician orders for treating the Stage II pressure ulcer. As a result, the pressure ulcer deteriorated to an unstageable state, characterized by full-thickness tissue loss covered by slough, with no exudate present. The facility only implemented a treatment plan after the ulcer had worsened. Interviews and observations revealed that the resident was not receiving appropriate care for the pressure ulcer. The resident reported applying Vaseline to the wound and off-loading with her hand to alleviate pain, indicating a lack of professional intervention. Staff members, including an LPN and CNA, failed to follow enhanced barrier precautions during wound observation. The Regional Nurse confirmed the lack of comprehensive assessment and treatment initiation for the pressure ulcer, acknowledging the deterioration from Stage II to unstageable.
Failure to Provide Routine Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide routine nail care for residents who were dependent on staff for activities of daily living (ADL), affecting two residents. Resident #40, who was admitted with diagnoses including pulmonary fibrosis, diabetes mellitus, and chronic pain syndrome, was observed with long, jagged fingernails and a black substance on her nails. Despite having no cognitive deficit, Resident #40 expressed uncertainty about the substance and a desire for nail care. Interviews with staff confirmed the condition of her nails and noted her dependence on staff for personal hygiene due to a lack of motivation. Resident #20, admitted with conditions such as Parkinson's disease, peripheral vascular disease, and dementia, also exhibited long, jagged nails with a brown substance underneath. The resident's care plan indicated a self-care deficit requiring assistance with ADLs, including hygiene. Observations and staff interviews verified the state of Resident #20's nails. The facility's policy on hygiene and grooming, which mandates addressing residents' needs and preferences, was not adhered to, leading to this deficiency.
Failure to Provide Routine Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident received routine podiatry care, as evidenced by observations and staff interviews. Resident #20, who has a medical history including Parkinson's disease, peripheral vascular disease, diabetes mellitus, and dementia, was observed on two occasions with long toenails curled over the ends of his toes. The resident's care plan included coordination with Social Services for scheduling necessary ancillary services, such as podiatry. However, during an observation on 03/26/25, the resident was found in bed with long toenails, and a subsequent observation during incontinence care confirmed the need for both fingernail and toenail care. A CNA verified the resident's need for nail care, indicating a lapse in the provision of routine podiatry services for the resident.
Failure to Ensure Safe and Sanitary Food Storage and Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in the refrigerator and freezer, as well as the maintenance of kitchen equipment. Observations and interviews revealed several items in the refrigerator and freezer were not properly sealed and dated. These items included undated berry dessert, undated pitchers of lemonade and fruit punch, undated opened lettuce bag, roast beef lunch meat without a use-by date, and various other food items. The kitchen manager confirmed the food items were not dated and/or open to air and was unaware that meat needed to be dated upon delivery. The corporate dietician confirmed the facility had issues with kitchen sanitation and that all food items should be dated upon delivery and when opened or removed from original packaging. The facility's policies on food storage and labeling were not followed, leading to the improper storage of food items. Additionally, the facility failed to maintain kitchen equipment in a safe and sanitary manner. Observations revealed the ice machine had a layer of dust on the rubber seam and door, and the fryer had a layer of grease and grime, with dark brown grease sitting in the fryer. The kitchen manager confirmed the fryer had not been cleaned properly and that the ice machine had dust around the rubber lining. The corporate dietician and administrator confirmed the facility had issues with kitchen sanitation and that the kitchen manager had a performance improvement plan in place. The facility's policy on cleaning fryers was not followed, leading to the unsanitary condition of the kitchen equipment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 814 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hilliard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwich Springs Health Campus | 1.3 mi | ★★★★★ | 3 | 0 |
| Trueman Pointe Care Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Darby Glenn Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Mayfair Village Nursing Care Center | 3.1 mi | ★★★★★ | 19 | 0 |
| Sapphire Rehabilitation And Care Center | 3.4 mi | ★★★★★ | 69 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.