Mill Pond Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident's bed was fully assembled which resulted in the resident having a fall from the bed and sustaining a hip fracture for 1 of 3 residents reviewed for accidents. (Resident B) The isolated actual harm deficient practice began on January 10, 2023 when the facility failed to ensure a resident's bed was fully assembled. The deficient practice was corrected on January 12, 2023, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: Resident B's clinical records were reviewed on January 19, 2023 at 9:55 a.m. […]

• Actual harm, isolatedF690Oct 5, 2022

  Based on interview, observation, and record review, the facility failed to ensure catheters (a tube inserted into the bladder to drain urine) were not inserted without a clinical justification resulting in actual harm when a resident had multiple urinary tract infections ([CONDITION(S)]) and 2 hospital transfers for [CONDITION(S)]'s (Resident 22) and catheter tubing and bags were not in direct contact with the floor (Residents 22 and 19) for 2 of 3 residents reviewed for catheters and [CONDITION(S)]'s. Findings include: 1. During an interview, on 9/27/22 at 10:51 a.m., Resident 22 indicated she was not sure why she had a catheter, and wished she did not have it. She had severe bladder pain, and was not sure if she had been checked for a [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper food handling for 2 of 2 hall tray meal service observations. This had the potential to affect residents receiving hall trays during the lunch meal service. Findings include:During a lunch meal service observation (healthcare lunch trays), on 5/7/26 at 12:40 p.m., Dietary Services Assistant 18 was preparing the hall trays at her hot cart (cart used to transport food and keep it warm) and removed ice from the ice bucket with the use of an ice scoop, she placed the ice in a cup and placed the ice scoop back into the ice bucket with the ice. She placed the drink cup on a tray to be served. At 12:44 p.m. […]

• No harm, potential for more than minimal, isolatedF561May 14, 2026

  Based on interview and record review, the facility failed to ensure a resident's preferences were met, for 1 of 2 residents reviewed for choices (Resident 18). Findings include:During an interview, on 5/7/26 at 10:47 a.m., Resident 18 indicated she used to receive 3 showers a week until she developed the need to use a shower chair. Now she was lucky if she got 2 per week. Resident 18's record was reviewed on 5/8/26 at 2:25 p.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis unspecified (a chronic neurological disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain) and diabetes mellitus with hyperglycemia (too much sugar in the blood). […]

• No harm, potential for more than minimal, isolatedF583May 14, 2026

  Based on observation interview and record review, the facility failed to ensure the privacy of the residents was maintained for 2 of 8 observations for privacy (Residents 29 and 32). Findings include: 1. On 5/8/26 at 10:47 a.m., during an interview Resident 29 indicated the staff had come into the bathroom while she was sitting on the toilet and checked her blood pressure. She indicated she had asked them to wait, but they came in anyway and checked her blood pressure. She indicated this was embarrassing and she should have time alone to use the bathroom facilities. She indicated there were times she was getting dressed and the staff walked in without asking permission to come in and failed to knock on the door. […]