Mill Run Care Center

In the surveyor’s words

From the most serious findings on record at Mill Run Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 10, 2025

  Based on resident record reviews, observations, interviews, review of service invoices, and review of facility policies, the facility failed to ensure residents received care and services in accordance with professional standards of practice and plans of care to meet each resident's individual identified needs. This resulted in Actual harm for one resident (#18) on 03/05/25 at 8:00 A.M. when a power outage occurred in the facility and the generator did not start. Resident #18, who was assessed to have chronic respiratory failure and was dependent on continuous oxygen, was not monitored for respiratory failure during the power outage. […]

• Actual harm, isolatedF686Sep 10, 2025

  Based on observation, record review, staff interview and review of the facility policy, the facility failed to identify and treat one (#40) resident's pressure ulcer on her left trochanter (hip) in a timely manner. This resulted in Actual Harm on 08/27/25 when the facility failed to identify and implement a treatment for Resident #40, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, when the resident was identified to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left trochanter (hip). […]

• Actual harm, isolatedF686Mar 27, 2025

  Based on observation, record review, resident and staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and facility policy and procedure review, the facility failed to comprehensively assess, provide timely interventions, and implement a treatment to an existing pressure ulcer. This resulted in Actual Harm to Resident #40 on 03/20/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #40 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) to the right gluteus. This affected one (#40) of three residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF686Jan 18, 2023

  Based on record review, interview, and facility policy and procedure review, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #8. Actual harm occurred on 11/19/22 when Resident #8, who was at risk for skin breakdown was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to his sacrum. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. […]

• Actual harm, isolatedF684Nov 21, 2022

  Based on record review, resident interview, family interview, and staff interview, the facility failed to ensure staff were aware a resident had a nephrostomy bag when transferring the resident from her wheelchair to bed resulting in the nephrostomy tube being dislodged. This affected one (Resident #58) of three residents reviewed for indwelling urinary catheters/ nephrostomies. Actual harm occurred to Resident #58 when her nephrostomy tube (a surgically inserted catheter tube inserted into the kidney to drain urine and sutured in place) was pulled out of her right lower back resulting in pain and requiring the resident to be sent to the hospital for reinsertion of the nephrostomy tube. […]