Mill-Pond

In the surveyor’s words

From the most serious findings on record at Mill-Pond, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 28, 2021

  Based on observation, clinical record review, and interviews, the facility failed to provide a safe method of transfer for one of four residents reviewed, (Resident #153.) The resident fell and sustained fractures of the bones in the left shoulder and right hip when staff failed to use a full mechanical lift. The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) with assessment date 6/11/20 revealed Resident #153 had a Brief Interview for Mental Status score of 11, which indicated of moderately impaired cognition. The resident required the extensive assistance of two staff for transfers, bed mobility and toilet use. […]

• No harm, potential for more than minimal, isolatedF605Mar 19, 2026

  Based on clinical record review, staff interview and policy review, the facility failed to attempt a gradual dose reduction for a resident prescribed psychotropic medication (medication that affect a person's mental state) for 1 of 5 residents reviewed for medications (Resident #16). The facility reported a census of 55 residents. Findings include:The Minimum Data Set (MDS), dated [DATE], documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of heart failure, anxiety disorder and depression. The MDS indicated Resident #16 took antianxiety and antidepressant medications during the lookback period. […]

• No harm, potential for more than minimal, isolatedF757Mar 19, 2026

  Based on clinical record review, staff interviews and policy review, the facility failed to ensure the drug regimen is free from unnecessary drugs, to include a resident on an antibiotic for excessive duration and without adequate monitoring for 1 of 5 residents reviewed for unnecessary medication (Resident #47). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include medically complex conditions and acne, unspecified. The MDS documented Resident #47 took an antibiotic in the look back period. […]

• No harm, potential for more than minimal, isolatedF812Mar 19, 2026

  Based on observation, staff interviews and policy review, the facility failed to date, seal, and label open food items stored in the kitchen pantry. The facility reported a census of 55 residents. Findings include:On 3/16/26 beginning at 12:45 PM observed the dry pantry storage area in the main kitchen, with the Certified Dietary Manager (CDM) present. The observation revealed the following items:a. 1 bag of dried croutons opened and unsealed without a label of the date received or opened.b. 1 bag of dried cereal opened and unsealed without a label of the date received or opened.c. 3 bags of dried pasta opened and unsealed without a label of the date received or opened.d. 1 bag of almonds opened and unsealed without a label of the date received or opened. […]

• No harm, potential for more than minimal, isolatedF800Mar 6, 2025

  Based on observation, staff interview, and policy review, the facility failed to obtain final cooking food temperatures on alternative menu items prepared in the satellite kitchen. The facility reported a census of 59 residents. Findings include: During a continuous lunch service observation on 3/5/25, at 11:45 AM, Staff A, Cook, and Staff B, server, both seen preparing tomato soup for two separate residents. In both instances, a final cooking temperature was not obtained after the soup was removed from the microwave and served to residents. Staff B also observed preparing a microwaveable cup of macaroni and cheese. A final cooking temperature was not obtained. […]