Health inspection·April 15, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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, 03/01/21, 03/02/21, 03/03/21, 03/04/21 and 03/05/21. Interview on 04/13/21 at 2:25 P.M. with the Assistant Director of Nursing (ADON) #500 revealed it was protocol for the vitals to be documented in the resident's MAR/TAR. The ADON verified there was no evidence Resident #22's BP was monitored 10 of 14 times between 02/19/21 through 03/05/21. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366031 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Manor Care Center 983 Exchange St Vermilion, OH 44089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)