Mill Pond Health Campus
MILL POND HEALTH CAMPUS in GREENCASTLE, IN — inspection on August 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/19/25 at 5:05 p.m., the Corporate Nurse Consultant indicated the equipment was her preference to use.
She had brought them from home and used them as needed.
The hospice care plan indicated that hospice was responsible for medical supplies.
The facility had not entered a care plan for the cough assist device or the suctioning device.A current facility policy, revised 8/21/24, titled, 48 Hour Baseline Care Plan Guidelines, provided by the Corporate Nurse Consultant on 8/19/25 at 5:11 p.m., included the following: Procedure .5.
Any changes to the residents care will be care planned accordingly until the comprehensive care plan is developed and then will be included on the comprehensive care plan.This citation relates to Intake 2584408.3.1-35(a) 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155736 08/19/2025
Mill Pond Health Campus 1014 Mill Pond Lane Greencastle, IN 46135
During an interview on 8/19/25 at 2:18 p.m., the Director of Nursing (DON) indicated there should have been physician orders regarding the resident's cough assist device and airway clearance device (suctioning).
The resident had used the devices as needed.
The resident had been using the respiratory equipment at home and had used them in the facility on her own.
The resident's care plan lacked an entry regarding her respiratory devices.
During an interview on 8/19/25 at 5:05 p.m., the Corporate Nurse Consultant indicated the equipment was her preference to use.
She had brought them from home and used them as needed.
The hospice care plan indicated that hospice was responsible for medical supplies.
The facility had not entered a care plan or physician orders for the cough assist device or the suctioning device.No policy was provided prior to the exit conference.
The Corporate Nurse Consultant indicated there was no specific policy regarding physician orders.
This citation relates to Intake 2584408.3.1-37(a)
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.