Mill Manor Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were adequately monitored for effectiveness and adverse reactions. This affected five (#1, #3, #11, #19, and #22) of five residents reviewed for unnecessary medications. The facility census was 23.Findings Include: 1. Review of the medical record for Resident #1 revealed an admission date of 06/03/25 and a discharge date of 11/20/25. Diagnoses included type two diabetes mellitus, hypertension, gastro-esophageal reflux disease, Parkinson's disease, major depressive disorder, and anxiety. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Review of Resident #1's physician orders dated 06/03/25 revealed orders for Prozac (an antidepressant) 40 milligrams (mg) daily for depression related to major depressive disorder and Buspar (an antianxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to implement physician order changes identified during a medication regimen review (MRR). This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 23.Findings include:Review of the medical record for Resident #19 revealed an admission on [DATE]. Diagnoses included unspecified intestinal obstruction, constipation, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively impaired.Review of Resident #19's medication regimen review (MRR) signed and dated by the physician on 11/06/25 revealed an note to change the stool softener, docusate sodium 100 milligrams (mg) to be administered as needed.Review of Resident #19's physician orders dated 11/11/25 revealed an order for docusate sodium 100 milligrams (mg) with instructions to give one tablet by mouth two times a day. Review of Resident #19's medication administration records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the Ohio Department of Health's (state survey agency) enhanced information dissemination collection (EIDC) system (computer database used by nursing facilities to report allegations of abuse, neglect and exploitation), and policy review the facility failed to ensure an allegation of alleged physical abuse was reported to the state survey agency (The Ohio Department of Health) as required. This affected one (Resident #28) of three residents reviewed for abuse. The facility census was 26. Findings Include Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (3.0) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and required extensive assistance for two staff persons for completing her activities of daily living. Review of Resident #28's record revealed no there were no documented notifications of the incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure it completed a thorough investigation related to an allegation of physical abuse by staff to a resident. This affected one (Resident #28) of three residents reviewed for abuse. The facility census was 26. Findings Include Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (3.0) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and required extensive assistance for two staff persons for completing her activities of daily living. Review of the incident report dated 05/25/24 revealed State Tested Nursing Assistant (STNA) #900 stated at about 11:40 P.M. on 05/24/24 she was sitting and doing daily charting when she heard screaming coming from Resident #28's room. Upon entering the room STNA #900 noted that Resident #28 was physically combative with STNA #901 whom was attempting to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the hospice contract, and review of the facility policy, the facility failed to ensure pain medications were available for a resident experiencing pain and discomfort at the end of life. This affected one (Resident #32) of three residents reviewed for pain management. The facility census was 28. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/10/18 and a discharge date of 02/12/24. Diagnoses included Parkinson's disease, dementia, and chronic kidney disease (CKD). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was admitted to hospice services. Resident #32 was cognitively impaired. Review of the physician orders for Resident #32 revealed an admission date to hospice care on 02/07/24, and morphine sulfate 20 milligram (mg)/milliliter (ml) and give 0.5 ml every two hours for pain and/or shortness of breath (SOB), written on 02/09/24 at 2:50 P.M. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide the residents with a reasonably quiet and peaceful environment. This affected one resident (#6) and had the potential to affect 10 residents residing on the 100-hall. The facility census was 30. Findings include: Review of Resident #20's medical record revealed an admission date of 05/22/22. Diagnoses included anxiety, dysphagia, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 05/31/23, revealed Resident #20 was cognitively impaired. Review of the behavior and intervention flow sheets, revealed Resident #20 was yelling on 01/02/23 at 3:00 A.M., on 01/05/23 at 12:00 A.M., on 01/20/23 at 5:00 A.M., on 01/21/23 at 4:00 A.M., on 01/29/23 at 4:00 A.M., on 01/30/23 at 1:00 A.M., on 03/06/23 at 9:00 P.M., and on 03/26/23 at 12:45 A.M. All attempted non-pharmacological interventions were ineffective. Review of the nursing progress notes revealed on 07/22/23 at 8:00 P.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for the residents. This affected three (Residents #07, #12, and #23) of five residents reviewed for accuracy of assessments. The facility census was 30. Findings include: 1. Review of the medical record for Resident #07 revealed an admission date of 09/27/22. Diagnoses included cerebrovascular accident (stroke) with apraxia (a neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood), and hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) affecting right dominant side. Review of Resident #07's physician orders revealed an order dated 09/27/22 for Plavix (an antiplatelet medication) 75 milligram (mg) one tablet daily. Review of Resident #07's medication administration record (MAR) for July 2023 revealed Plavix was received daily. Resident #07 received no anticoagulant (blood thinning)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident's compression stockings and a hand splint were implemented per physician order. This affected one (Resident #20) of one resident reviewed for physician-ordered devices. The facility census was 30. Findings include: Review of Resident #20's medical record revealed an admission date of 05/22/22. Diagnoses included anxiety, dysphagia, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 05/31/23, revealed Resident #20 was cognitively impaired and was totally dependent on assistance from two staff for bed mobility, transfers, and toileting. Review of Resident #20's current physician orders for September 2023, identified an order for compression stockings to bilateral lower extremities one time per day for edema in A.M. before getting out of bed, may apply over dressing to lower right leg, and at bedtime to remove compression socks. The resident also had an order to apply right hand splint daily with A.M. care and off with P.M. care, remove if not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure fall prevention interventions were in place per physician's order. This affected two (Residents #23 and #234) of three residents reviewed for fall interventions. The facility census was 30. Findings include: 1. Review of the medical record revealed Resident #234 was admitted to the facility on [DATE]. Diagnoses included frequent falls, generalized weakness, ataxia (impaired coordination), and chronic back pain. Review of the baseline admission care plan, dated 08/29/23, identified the physician's orders serve as the initial care plan until a comprehensive care plan was developed and implemented. Review of Resident #234's physician orders revealed an order dated 08/29/23 for Universal Fall Precautions. Review of the document titled Universal Fall Interventions, undated, revealed beds should be placed in the low position. Observation on 09/05/23 at 8:40 A.M. revealed Resident #234 lying crooked in the bed. Resident #234's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and staff interview, the facility failed to ensure a resident's head of bed was elevated per physician order during tube feeding administration. This affected one (#22) of one resident reviewed for tube feeding (TF). The facility identified one resident receiving TF. The facility census was 30. Findings include: Review of Resident #22's medical record, revealed an admission date of 01/08/22. Diagnoses included aphasia, gastro-esophageal reflux disease, Alzheimer's disease, anxiety, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/16/23, revealed Resident #22 was severely cognitively impaired and was totally dependent on assistance from staff for activities of daily living. The resident had a feeding tube. Review of the current physician orders for September 2023, identified orders for Jevity 1.5 continuous tube feeding at 40 milliliters per hour and elevate head of bed between 30 and 45 degrees for all medications/feedings. Review of the plan of care, dated 08/11/22, revealed Resident #22 had altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure staff performed hand hygiene after care was provided to Resident #03. This affected one resident (#03) of four residents reviewed for appropriate hand hygiene. The facility census was 30. Findings include: Observation on 09/05/23 at 9:04 A.M. revealed State Tested Nursing Assistant (STNA) #248 entered Resident #03's room. She informed Resident #03 it was time for breakfast, and offered to assist Resident #03 in repositioning to sit on the edge of the bed. STNA #248 retrieved Resident #03's shoes, and applied Resident #03's shoes to both feet. STNA #248 touched both of Resident #03's feet with ungloved hands as she applied Resident #03's footwear. STNA #248 assisted Resident #03 in sitting edge of bed. STNA #248 exited the room and did not perform hand hygiene. Observation on 09/05/23 at 9:05 A.M. revealed STNA #248 retrieved Resident #03's breakfast tray from the hall cart. STNA #248 delivered the tray to Resident #03, and proceeded to remove the lid which covered the plate, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure a Resident's blood pressure was consistently monitored as ordered. This affected one Resident (#22) of five reviewed for adequate monitoring. The facility census was 28. Findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and essential primary hypertension (high blood pressure). Review of Resident #22's physician orders dated 02/19/21 revealed an order for Diltiazem (for high blood pressure) 120 milligrams (mg), every day. The order included to monitor the resident's blood pressure (BP) daily for 14 days and report the findings to the nurse practitioner for review after two weeks. Review of Resident #22's medication administration record (MAR) and treatment administration record (TAR) for the period 02/19/21 through 03/05/21 revealed there was no evidence the resident's BP was monitored on 02/20/21, 02/21/21, 02/22/21, 02/23/21, 02/26/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure ordered medications were documented as administered. This affected one Resident (#4) of five reviewed for medication review. The facility census was 28. Findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, agitation, history of a stroke, weight loss, and hypertension (high blood pressure). Review Resident #4's physician orders and Medication Administration Record (MAR) revealed the following: 1. Divalproex sodium sprinkles (anti-convulsant), 250 milligrams (mg) by mouth twice a day was ordered on 10/02/20. Review of the MAR revealed no evidence the medication was administered on 01/06/21, 01/07/21, 01/13/21, 02/10/21, 02/28/21, 03/08/21 for evening dose. There was no evidence the medication was given in the morning on 02/15/21 and 03/31/21. 2. Melatonin (for sleep) 3 mg by mouth every evening was ordered on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.