Mill Pond Health Campus: ALS Resident Care Plan Failures - IN
The resident, identified in inspection records only as Resident B, was admitted from her home and was already receiving hospice services when she arrived. She had amyotrophic lateral sclerosis, a progressive disease that destroys the nerve cells controlling muscle movement, along with difficulty swallowing, rheumatoid arthritis, depression, and anxiety. She communicated by writing on a whiteboard. She needed staff help to dress, move in bed, transfer, shower, and use the toilet. At night, she relied on a ventilator. During the day, she used a cough assist device and a suctioning machine she had brought from home.
None of that equipment appeared anywhere in her care plan. No problem statement. No goal. No approach for staff to follow.
When inspectors interviewed the Director of Nursing on August 19, the explanation offered was that the resident had been using the equipment at home and had continued using it at the facility on her own. Most staff, the director acknowledged, had never been trained on the cough assist device or the ventilator. One staff member who worked most days on her hall knew how the ventilator operated. One.
The Corporate Nurse Consultant, interviewed later the same afternoon, described the equipment as the resident's personal preference, brought from home, used as needed. The consultant pointed to the hospice care plan, noting that hospice was responsible for medical supplies. The facility, the consultant confirmed, had not written a care plan entry for the cough assist device or the suctioning machine.
That explanation did not satisfy inspectors. The facility's own policy, revised in August 2024, stated plainly that any changes to a resident's care would be care planned accordingly. A woman arriving with a ventilator, a cough assist device, and a suction machine, unable to speak, and dependent on staff for nearly every physical need, represented exactly the kind of situation that policy was written for.
The inspection was a complaint survey, triggered by a specific concern that brought investigators to the facility on August 19. Inspectors reviewed three residents for quality of care. Only one had respiratory equipment. That was enough.
The deficiency was cited at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than documented injury. But the gap between what the records showed and what the facility offered as explanation is worth sitting with. The resident had been there for more than a month. The admission assessment, completed six days after she arrived, documented her ventilator use and the airway clearance device at her bedside. The care plan was never updated.
For a resident who cannot speak, who writes her needs on a whiteboard, and who depends on equipment to breathe and clear her airway, a care plan is not a formality. It is the document that tells staff what she needs, how to respond, and what to do when something goes wrong. Without it, that knowledge lived with one employee who happened to work her hall most days.
The resident was on hospice. She had come to Mill Pond not to recover but to be cared for through the final stage of a disease that would eventually take her ability to breathe on her own. What the inspection found was a facility that accepted her, accepted her equipment, and then left the instructions for how to keep her safe unwritten.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mill Pond Health Campus from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
MILL POND HEALTH CAMPUS in GREENCASTLE, IN was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records only as Resident B, was admitted from her home and was already receiving hospice services when she arrived.
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.