Mill Run Care Center: Medication Error - OH
Resident 69 had been hospitalized from August 8 through August 12 for metabolic encephalopathy and acute kidney failure. Hospital records show the patient received their last dose of Eliquis, a blood thinner prescribed for atrial fibrillation, at 8:41 A.M. on August 12 before discharge back to the nursing home.
The medication never made it onto the facility's orders.
Nursing staff didn't notice the omission until August 15, when a physician finally ordered Eliquis 5 mg twice daily over the phone at 7:01 P.M. The resident received their first dose that evening at 9:00 P.M., according to medication administration records.
The resident has multiple heart conditions including chronic diastolic heart failure, atrial fibrillation, coronary artery disease and hypertension. Their care plan specifically calls for "administering medications per physician orders" and monitoring for chest pain.
Hospital discharge summaries clearly listed Eliquis 5 mg twice daily on the medication list. The resident's discharge assessment confirmed they were cognitively intact and receiving anticoagulant therapy for active heart failure.
Federal inspectors reviewed the case after receiving a complaint. The Director of Nursing admitted during a September 4 interview that staff "did not complete a thorough and accurate medication reconciliation upon the resident's readmission."
Eliquis prevents blood clots that can cause strokes in patients with atrial fibrillation, a heart rhythm disorder. The medication requires consistent dosing to maintain therapeutic levels in the bloodstream.
The resident had been admitted to Mill Run initially on July 10, then readmitted on August 12 following the hospital stay. They were discharged home on August 19, one week after the medication error was discovered and corrected.
Mill Run Care Center houses 53 residents. Inspectors reviewed three recent admissions and found medication reconciliation failures affected one resident.
The facility's own care plan for Resident 69 acknowledged their "altered cardiovascular status related to chronic heart failure, hypertension, atrial fibrillation and coronary artery disease." Staff were specifically directed to administer medications per physician orders and monitor for chest pain.
Hospital records show meticulous documentation of the resident's medication schedule during their four-day stay. The after-visit summary included detailed timing of the final Eliquis dose before discharge.
But when the resident returned to their nursing home bed on August 12, that critical medication disappeared from their daily routine.
The error went undetected for 72 hours. No one cross-checked hospital discharge orders against the facility's medication list. No one questioned why a heart patient with atrial fibrillation suddenly had no anticoagulant on their chart.
The resident spent three days without protection against the blood clots their heart condition makes more likely.
Federal regulations require nursing homes to ensure residents are "free from significant medication errors." The inspection classified this violation as causing "minimal harm or potential for actual harm."
The Director of Nursing confirmed to inspectors that Eliquis wasn't ordered until August 15, three days after the resident's return. By then, therapeutic blood levels had likely dropped, potentially leaving the resident vulnerable to clot formation.
Medication reconciliation is supposed to happen every time a resident moves between care settings. Hospital pharmacists prepare detailed discharge medication lists. Nursing home staff are expected to review those lists and ensure continuity of care.
At Mill Run, that safety net failed.
The resident's medical record shows a complex cardiac history requiring careful medication management. They had been diagnosed with major depressive disorder alongside their heart conditions, adding to the importance of consistent pharmaceutical care.
Hospital staff had maintained the resident on twice-daily Eliquis throughout their stay for metabolic encephalopathy and kidney failure. The medication continued right up until discharge, with the final documented dose at 8:41 A.M. on departure day.
Then silence for three days, until someone finally noticed the gap and called in the missing prescription.
The complaint that triggered the federal investigation remains numbered 2600930 in state records. Inspectors found the medication error affected few residents, but confirmed Mill Run's failure to protect even one patient from significant pharmaceutical mistakes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mill Run Care Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MILL RUN CARE CENTER in HILLIARD, OH was cited for violations during a health inspection on September 10, 2025.
Resident 69 had been hospitalized from August 8 through August 12 for metabolic encephalopathy and acute kidney failure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.