Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mill Pond Health Campus during CMS and state inspections, most recent first.
A resident with ALS and multiple comorbidities used a ventilator, cough assist, and suctioning devices, but the facility did not develop a care plan addressing these respiratory devices. Staff were not in-serviced on the equipment, and the care plan lacked required entries, despite the resident's dependence on these devices and facility policy requiring care planning for such needs.
A resident with ALS and multiple comorbidities used a cough assist and airway clearance device brought from home, but the facility did not obtain physician orders or include these devices in the care plan. The DON and Corporate Nurse Consultant confirmed the absence of orders and documentation, despite the resident's ongoing use of the equipment.
A facility failed to obtain a physician order for a Tubigrip used on a resident's left arm to prevent skin tears and manage swelling. The resident, with a history of brain mass, early-onset Alzheimer's, and edema, had a dressing on her arm due to an injury. Despite staff and family confirming the use of the Tubigrip, the resident's record lacked a physician order, violating the facility's policy for medical orders.
A resident's nebulizer mask was repeatedly observed un-bagged on the bedside table, contrary to facility policy requiring it to be stored in a dated plastic bag. The resident, with a history of heart disease and kidney issues, had a physician's order for nebulizer treatments. Despite recent flu symptoms, the care plans lacked documentation of respiratory concerns. Clinical Support staff confirmed the mask should have been properly stored.
A facility failed to timely address a pharmacist's recommendations for a resident's medication regimen. The resident, with chronic kidney disease and heart failure, was on Midodrine. Recommendations to adjust dosage times to prevent supine hypertension were not initially followed, and documentation was lacking. The facility relied on state and federal regulations without a specific policy for addressing such recommendations.
The facility failed to properly label and dispose of prepared food items in the kitchen, as observed during a tour. A container of chicken salad lacked a label or use-by date, and several other food items were found with expired dates. The Business Office Manager and Dietary Manager acknowledged these issues, which could affect all residents receiving food from the kitchen.
A CRCA violated the facility's abuse and cell phone policies by posting a video on social media featuring a resident with severe cognitive impairment. The video included inappropriate gestures and captions. The CRCA was suspended and later terminated after admitting to the violation. Staff were previously educated on these policies during onboarding.
Failure to Develop Care Plan for Resident's Respiratory Equipment
Penalty
Summary
The facility failed to develop a care plan addressing the use of respiratory durable medical equipment, specifically a cough assist device and a suctioning device, for a resident diagnosed with amyotrophic lateral sclerosis (ALS), dysphagia, rheumatoid arthritis, depression, and anxiety. The resident, who was admitted from home and receiving hospice services, was cognitively intact but unable to speak, requiring substantial to maximal assistance with daily activities and was dependent on staff for transfers and mobility. The resident used a ventilator at night and had an airway clearance device at bedside, but the care plan did not include any problems, goals, or approaches related to these respiratory devices. Interviews with facility staff revealed that the resident had been using the respiratory equipment at home and continued to use them independently in the facility. Staff had not been in-serviced on the use of the cough assist device or the ventilator, and only one staff member was familiar with the ventilator. The care plan lacked entries for the respiratory devices, and although the hospice care plan indicated hospice was responsible for medical supplies, the facility did not include the devices in the resident's care plan as required by facility policy.
Failure to Obtain Physician Orders for Resident's Respiratory Devices
Penalty
Summary
The facility failed to obtain physician's orders or conduct an assessment for the use of a cough assist device and an airway clearance device (suctioning) for a resident diagnosed with amyotrophic lateral sclerosis (ALS), dysphagia, rheumatoid arthritis, depression, and anxiety. The resident, who was admitted from home and receiving hospice services, was cognitively intact but unable to speak, requiring substantial to maximal assistance with daily activities and dependent on staff for transfers and mobility. The resident communicated using a whiteboard and had a gastric tube for nutrition, with orders entered for her supplements. Despite the resident's use of a ventilator at night and the presence of an airway clearance device at bedside, there were no physician's orders for the cough assist or suctioning devices. Interviews with the DON and Corporate Nurse Consultant confirmed that the resident had brought the respiratory equipment from home and used them as needed, but the facility had not entered corresponding care plan entries or physician orders for these devices. The hospice care plan indicated hospice was responsible for medical supplies, but the facility lacked documentation and policy regarding the use of these respiratory devices.
Failure to Obtain Physician Order for Tubigrip Use
Penalty
Summary
The facility failed to obtain a physician order for the use of a Tubigrip on a resident's left arm, which was used as a preventive measure for skin tears and swelling. During an observation, the resident was seen with a dressing on her left arm, which she indicated had been there for a while due to an injury from banging it on the bed's side rail. The resident's medical history included a brain mass, early-onset Alzheimer's disease, and unspecified edema. The care plan did not include an intervention for the Tubigrip, despite the resident's risk for skin breakdown and need for assistance with mobility and transfers. Interviews with staff and a family member confirmed the use of the dressing/sleeve due to skin tears and swelling in the resident's left arm. However, the resident's record lacked documentation of a physician order for the Tubigrip. The facility's policy required physician notification for changes in condition or injuries, but this was not adhered to in this case. The Clinical Support Nurse confirmed the absence of a physician order for the Tubigrip, highlighting a deficiency in following the facility's policy for obtaining necessary medical orders.
Improper Storage of Nebulizer Mask for Resident
Penalty
Summary
The facility failed to ensure proper storage of a nebulizer mask for a resident, identified as Resident 19, who was receiving respiratory care. During multiple observations on different days, the nebulizer mask was found un-bagged and sitting on the resident's bedside table. This was contrary to the facility's policy, which required nebulizer masks to be stored in a plastic bag marked with the date and the resident's name when not in use. The Clinical Support staff confirmed that the mask should have been bagged and dated for storage. Resident 19 had a history of atherosclerotic heart disease and stage 4 chronic kidney disease. The resident's medical records indicated a physician's order for nebulizer treatments with ipratropium-albuterol solution every four hours as needed, which was administered once for congestion. Despite the resident's recent flu and productive cough, there was no documentation of shortness of breath or respiratory concerns in the care plans. The failure to properly store the nebulizer mask was observed by the Clinical Support staff, who acknowledged the oversight.
Failure to Address Pharmacist's Recommendations for Medication Regimen
Penalty
Summary
The facility failed to address a pharmacist's recommendation regarding a resident's medication regimen in a timely manner. Resident 22, who has diagnoses including hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, was receiving Midodrine, an anti-hypotensive medication. A pharmacy recommendation dated April 29, 2024, suggested adjusting the dose times and hold parameters for Midodrine. However, the document was marked with 'Leave alone' on May 2, 2024, without any physician documentation to justify this decision. The Clinical Support staff could not find any rationale for this statement during an interview on March 3, 2025. Further pharmacy recommendations on June 24, 2024, and July 22, 2024, advised avoiding the evening dose of Midodrine after the evening meal or within four hours of bedtime to prevent supine hypertension. Although the task was marked as completed, the June 24 medication administration record (MAR) showed the medication was given between 6:00 p.m. and 10:00 p.m., lacking specific administration times. By July, the evening dosage times were adjusted to 4:00 p.m. to 6:00 p.m. The Executive Director stated that pharmacy recommendations should be addressed before the next medication regimen review, but the Clinical Support could not locate a specific policy for addressing these recommendations, indicating reliance on state and federal regulations.
Improper Food Labeling and Disposal in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and disposal of prepared food items, as observed during a kitchen tour. A plastic container of prepared chicken salad was found in the walk-in refrigerator without a label or use-by date. The Business Office Manager, who was present during the tour, was unable to determine when the chicken salad was prepared or how long it had been stored. Dietary Services Assistant 8 mentioned that prepared food should be discarded after four days, indicating a lack of adherence to this guideline. Additionally, several containers of prepared food items, including poppy seed dressing, lemonade, apple raspberry juice, blue Gatorade, and thickened liquid, were found in the refrigerator with expired use-by dates. The Business Office Manager acknowledged that these items should have been discarded. The Dietary Manager later confirmed that prepared food items should be labeled with a use-by date and discarded after three days, as per the facility's policy on leftover food storage. This failure to follow proper food storage and labeling procedures had the potential to affect all 50 residents receiving food from the kitchen.
Staff Violation of Abuse and Cell Phone Policies
Penalty
Summary
The facility failed to ensure that a staff member adhered to its abuse and cell phone use policies, resulting in a deficiency related to the protection of residents from abuse. A Certified Resident Care Assistant (CRCA) posted a video on a social media platform featuring an unidentifiable resident in the restroom. The video included a caption that was inappropriate and disrespectful, and the CRCA was seen making a grimacing face and an offensive hand gesture. This incident was reported to the Executive Director, and the CRCA was immediately suspended pending an investigation. The investigation revealed that the CRCA admitted to violating the facility's abuse policy. The resident in the video, identified as Resident B, had severe cognitive impairment due to conditions such as depression, generalized anxiety disorder, and Alzheimer's disease. Interviews with various staff members, including the Dementia Care Director and the Director of Health Services, indicated that they were unaware of any previous disciplinary issues with the CRCA. The staff were educated on cell phone usage and social media posting during their onboarding training. The facility's policies on cell phone use and abuse were reviewed, highlighting that personal cell phones and electronic devices are prohibited in work areas, and unauthorized recording of residents is not allowed. The CRCA's actions were deemed a poor choice, and she was terminated from her position. The incident was documented in an Episodic Event form, and the facility took immediate steps to educate current staff members on the relevant policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greencastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Towers Health Care Center | 1.3 mi | — | 10 | 0 |
| Hickory Creek At Sunset | 1.4 mi | — | 7 | 0 |
| Waters Of Greencastle, The | 1.4 mi | — | 12 | 0 |
| Aperion Care Summerfield | 9.3 mi | — | 0 | 0 |
| Cloverleaf Of Knightsville | 15.3 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.