Inspection visit

Health inspectionSeptember 7, 2023

MILL MANOR CARE CENTERCMS #3660316 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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., Resident #20 was screaming in the dining room and wanted to go to his room. The resident was taken to his room and continued to scream at a loud pitch. The resident went to bed and continued to yell. On 07/24/23 at 2:30 A.M., Resident #20 began yelling at approximately 12:15 A.M. The resident was checked on and assisted and continued to yell. On 07/24/23 at 4:30 A.M., an as needed Tylenol was administered at 2:35 A.M. and Resident #20 continued to yell. On 07/24/23 at 8:00 P.M., Resident #20 was yelling help me. The resident could not provide an answer on why he was yelling. Medication was given and the resident was in bed while still yelling. On 07/31/23, Resident #20 was yelling/screaming all night. Care was provided and the resident continued to yell. Residents residing in the hall were becoming upset. On 08/05/23 at 3:00 A.M., Resident #20 was in his room yelling help me. As needed Tylenol was administered to the resident. At 6:00 A.M., the resident continued to yell. On 08/09/23 at 5:15 A.M., Resident #20 had been awake and yelling since 1:30 A.M. The resident's needs had been met but the resident continued to yell for help. The resident was presently up in his wheelchair by the nursing station and continued to call out loudly. On 08/10/23 at 5:00 A.M., Resident #20 had been awake and yelling since 2:30 A.M. despite all needs being met. On 08/14/23 at 1:40 A.M., Resident #20 continued yelling out help me and waking residents in room [ROOM NUMBER], #105, #107, and #108. On 08/18/23 at 1:30 A.M., Resident #20 woke up at 12:00 A.M. and began yelling. All of the resident's needs were met and the resident continued to yell. Review of the sleep logs revealed Resident #20 was awake with behaviors of yelling and/or calling out on 08/21/23 at 9:30 P.M., on 08/22/23 between 9:00 P.M. and 9:45 P.M., and between 1:30 A.M. and (continued on next page) 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 9 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 09/07/2023 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3:00 A.M., on 08/23/23 at 12:00 A.M., 1:30 A.M., between 9:00 P.M. and 9:30 P.M., and 10:00 P.M., on 08/25/23 between 11:00 P.M. and 1:40 P.M., 2:30 A.M., 8:00 P.M., 8:30 P.M., and 9:30 P.M., on 08/26/23 at 12:00 A.M., 1:00 A.M., 2:00 A.M., 3:00 A.M., and 5:00 A.M., on 08/27/23 at 6:30 P.M., 6:50 P.M., 7:50 P.M., 8:30 P.M., 10:00 P.M., and 10:30 P.M., on 08/28/23 at 8:35 P.M. and upsetting other residents, on 08/29/23 at 5:00 P.M., 8:00 P.M., and 9:00 P.M., on 08/30/23 between 2:30 A.M. and 4:00 A.M. and between 8:00 P.M. and 9:00 P.M., on 08/31/23 between 11:00 P.M. and 1:00 A.M., on 09/01/23 at 4:00 A.M., on 09/02/23 at various times, on 09/03/23 between 7:00 P.M. and 10:00 P.M., and on 09/04/23 at various times. Interview on 09/05/23 at 9:38 A.M. with Resident #6 revealed Resident #20 could often be heard yelling out throughout the night, which made it difficult for Resident #6 to fall or stay asleep. Resident #6 reported it was not Resident #20's fault, but Resident #6 was often unable to sleep at night due to the noise. Interview on 09/06/23 at 1:57 P.M. with State Tested Nurse Aide (STNA) #258 revealed Resident #20 yelled out regularly throughout the night and a lot of residents, including Resident #6, complained about the noise. Interview on 09/07/23 at 8:41 A.M. with STNA #248 revealed Resident #20 yelled out frequently and residents residing on the 100-hall, including Resident #6, complained about the noise. STNA #248 reported most of the residents were understanding and could ask staff to close their doors. Observation on 09/07/23 at 3:30 P.M. revealed Resident #20 was yelling out and could be heard throughout the 100-hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 2 of 9 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 09/07/2023 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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) medication during the month of July 2023. Review of the quarterly MDS 3.0 assessment, dated 07/22/23, identified Resident #07 as having received anticoagulant medication on seven out of seven days of the look back period. Interview on 09/07/23 at 10:47 A.M. with MDS Coordinator Registered Nurse #234 verified Resident #07's MDS assessment was coded incorrectly, and stated Plavix was not a blood thinning medication. 2. Review of the medical record for Resident #12 revealed an admission date of 07/13/21. Diagnoses included dementia with behavioral disturbances, depression, anxiety, and delusional disorder. Review of Resident #12's physician orders revealed an order dated 04/25/23 for Risperdal (an antipsychotic medication) 0.25 milligrams (mg) one tablet daily at bedtime for dementia. The medication was discontinued on 05/09/23. Review of the Medication Administration Record (MAR) revealed no antipsychotic medications were administered to Resident #12 in the month of July 2023. Review of the quarterly MDS 3.0 assessment, dated 07/08/23, identified Resident #12 having received antipsychotic medication on a routine basis, on seven out of seven days of the look back period. Interview on 09/07/23 at 10:47 A.M. with MDS Coordinator Registered Nurse #234 verified Resident #12's MDS assessment was coded incorrectly, and antipsychotic medication should not have been coded on the MDS assessment dated [DATE]. 3. Review of the medical record for Resident #23 revealed an admission date of 07/14/22. Diagnoses included dementia, macular degeneration, and dysphagia (difficulty swallowing). Review of Resident #23's physician's orders revealed an order dated 07/14/23 for a pureed diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 3 of 9 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 09/07/2023 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the quarterly MDS 3.0 assessment, dated 08/03/23 revealed the assessment did not identify Resident #23 as having received a mechanically altered diet during the seven day look back period. Interview on 09/07/23 at 10:47 A.M. with MDS Coordinator Registered Nurse #234 verified the assessment was coded incorrectly and Resident #23 should have been coded as having received a mechanically altered diet. Event ID: Facility ID: 366031 If continuation sheet Page 4 of 9 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 09/07/2023 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)

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 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. Residents Affected - Few 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 tolerating and report to nurse. Observations on 09/05/23 at 12:36 P.M., on 09/06/23 at 10:15 A.M, and on 09/06/23 at 1:54 P.M., revealed Resident #20 did not have the hand splint or compression stockings in place. Interview on 09/06/23 at 1:57 P.M. with State Tested Nurse Aide (STNA) #258, verified Resident #20 did not have the hand splint or compression stockings in place. STNA #258 reported Resident #20 never wore a hand splint or compression stockings. Additional observations on 09/07/23 at 7:12 A.M. and at 8:38 A.M., revealed Resident #20 did not have the hand splint or compression stockings in place. Interview on 09/07/23 at 8:41 A.M. with STNA #248, identified she regularly provided care to Resident #20, verified Resident #20 did not have the hand splint or compression stockings in place. STNA #248 reported Resident #20 never wore compression stockings or a hand splint. Interview on 09/07/23 at 10:33 A.M. with Registered Nurse (RN) #235 verified Resident #20 did not have the compression stockings or hand splint in place per physician order. RN #235 reported she would tell STNA #248 to go and put them on the resident. Observation on 09/07/23 at 1:12 P.M. revealed Resident #20 was wearing compression stockings but was not wearing a hand splint. Interview on 09/07/23 at 1:16 P.M. with STNA #248 verified Resident #20 did not have the hand splint in place. STNA #248 reported she searched the resident's room and was unable to find a hand splint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 5 of 9 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 09/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 head was against the right side rail, and his legs were over the edge of the left side of the bed. The bed was in the elevated position at waist height. The corded bed control remote was dangling off the edge of the bed below the left side rail, out of view and reach of Resident #234. Interview on 09/05/23 at 8:44 A.M. with Registered Nurse (RN) #235 verified Resident #234 should not have the bed in the high position. RN #235 retrieved the bed control and lowered Resident #234's bed to the low position. Observation on 09/07/23 at 8:18 A.M. revealed Resident #234 lying in bed. The bed was observed to be in the high position at approximately waist level. The corded bed control remote was not in view or reach of Resident #234. Interview on 09/07/23 at 8:31 A.M. with State Tested Nursing Assistant (STNA) #248 verified the bed was left in the high position as STNA #248 had intended on returning to get Resident #234 up to the wheelchair for breakfast. STNA #248 further verified the corded bed control remote was out of reach of Resident #234. 2. Review of the medical record for Resident #23 revealed an admission date of 07/14/22. Diagnoses included dementia, generalized weakness, macular degeneration, and anxiety. Review of the physician's orders revealed an order dated 06/30/23 for a personal alarm at all times to alert staff of attempt to get up without supervision/assistance. Review of Resident #23's fall plan of care revealed no indication Resident #23 utilized a personal alarm for a fall prevention intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 6 of 9 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 09/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 09/05/23 at 11:20 A.M. revealed Resident #23 seated in her wheelchair in the activity room. There was no personal alarm in place to her wheelchair. Observation on 09/06/23 at 8:19 A.M. revealed Resident #23 seated in her wheelchair in front of the nurse's station. There was no personal alarm in place to her wheelchair. Residents Affected - Few Interview on 09/06/23 at 3:52 P.M. with the Director of Nursing (DON) revealed the Assistant Director of Nursing (ADON) #500 was primarily responsible for coordination of assessments and decisions made regarding alarms. ADON #500 also utilized an state tested nursing aide (STNA) who provided recommendations on who needed alarms and who did not. DON stated personal alarms were not included in the universal fall precautions, they were an individualized intervention. The DON further stated alarms required a physician's order and would be on the falls care plan. Observation on 09/07/23 11:10 A.M. revealed Resident #23 seated in her wheelchair in the activity room. There was no personal alarm in place to her wheelchair. Interview on 09/07/23 at 11:12 A.M. with Registered Nurse (RN) #235 revealed Resident #23 needed a personal alarm on at all times. RN #235 stated Resident #23 was known to fidget in her chair, could become agitated and attempt to rise unassisted. RN #235 verified Resident #23 did not have a personal alarm in place to her wheelchair. Interview on 09/07/23 at 11:20 A.M. with STNA #248 revealed she assisted in making recommendations for which residents need alarms. STNA #248 stated Resident #23 required a personal alarm while in bed only. Interview on 09/07/23 at 11:31 A.M. with ADON #500 revealed a facility staff nurse evaluated residents with alarms on a quarterly basis. ADON #500 reviewed Resident #23's chart and identified a form titled Side Rail Assessment, dated 07/01/23. ADON #500 stated this form was used to assess side rail use and alarm use. ADON #500 pointed to one question on the Side Rail Assessment which asked if alarm was adhered to a firm surface to alert staff of residents' unassisted attempts to get up, to which 'N' was marked. ADON #500 stated that 'N' indicated that no alarm was currently being used. ADON #500 stated if there was an alarm used, there was a space underneath the question to circle whether the alarm was used in wheelchair, chair and/or bed. ADON #500 verified no alarm use was noted on the form and stated the nurse who completed the assessment on 07/01/23 must have missed the alarm. ADON #500 further verified Resident #23's fall plan of care did not identify Resident #23 to need or use a personal alarm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 7 of 9 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 09/07/2023 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. 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 nutrition related to an eating, chewing, and/or swallowing disorder, cognitive impairment, and high risk for aspiration. Interventions included elevating the resident's head of bed 30 to 45 degrees unless contraindicated. Observation on 09/06/23 at 11:03 A.M. with Registered Nurse (RN) #231 revealed Resident #22 was lying almost flat while her tube feed was running at 40 milliliters per hour. RN #231 paused the tube feed, went through the process of flushing the tube, and stated to an unidentified nursing assistant that she would leave the tube feed disconnected so the nursing assistant could assist the resident in getting up for the lunch meal. RN #231 entered Resident #22's bathroom and began washing her hands. Resident #22 began coughing. RN #231 ran out of the bathroom and raised the head of Resident #22's bed. Interview on 09/06/23 at 11:21 A.M. with RN #231 verified Resident #22's head of bed was not elevated as it should have been. RN #231 reported an aide had provided care to Resident #22 about an hour prior and probably did not raise the head of the bed back up afterwards. RN #231 reported she would monitor to ensure Resident #22's head of bed remained elevated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 8 of 9 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 09/07/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 removed the plastic cover to a bowl of oatmeal and a cup of juice. STNA #248 exited the room and did not perform hand hygiene before returning to the hall cart. Interview on 09/05/23 at 9:06 A.M. with STNA #248 verified she did not perform hand hygiene after she touched Resident #03's feet with ungloved hands. STNA #248 stated she should have washed her hands with soap and water or used hand sanitizer, but she did not have any on her. Review of the policy titled Infection Prevention and Control Program, updated 05/2022, revealed employees shall wash their hands before and after each direct resident contact and before handling items which will come in contact with residents, such as food, clean linen, medications, etc. The policy further noted handwashing facilities are available throughout the facility, including in the bathroom of each resident room. Hands shall be washed at the site closest to the site where resident contact occurs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366031 If continuation sheet Page 9 of 9

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

FAQ · About this visit

Common questions about this visit

What happened during the September 7, 2023 survey of MILL MANOR CARE CENTER?

This was a inspection survey of MILL MANOR CARE CENTER on September 7, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MILL MANOR CARE CENTER on September 7, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 7, 2023