Mill Creek

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (Resident #2) residents reviewed for quality of care. 1. The facility failed to identify and treat Resident #2's three scabbed skin tears on left 2nd toe,3rd toe, 4th toe. 2. The facility failed to ensure Resident #2 (diabetic) had orders in place to treat 3 scabbed skin tears on left 2nd toe, 3rd toe, 4th toe. These failures could place residents at risk of not receiving appropriate care, or treatment, leading to diabetic ulcers, infection, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 halls. 1. The facility failed to ensure CNA A did not handle soiled linen without gloves. 2. The facility failed to ensure CNA A used hand hygiene after she disposed of soiled linens. 3. The facility failed to ensure CNA A used hand hygiene between glove changes. 4. The facility failed to ensure feces were not on the floor. 5. The facility failed to ensure CNA B performed proper hand hygiene while entering and exiting residents' room on hall 200 while providing ice and water for hydration services. 6. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 10 residents (Resident #21 & #31) reviewed for advance directives. The facility failed to ensure Resident #21 who was listed as DNR (Do Not Resuscitate) had a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information and did not have the Witness sign and date after the qualified relative signature date. The facility failed to ensure Resident #31 who was listed as DNR had a valid Out-of-Hospital Do Not Resuscitate form that did not have scribble to correct the printed name twice. This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview, record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #2). The facility failed to develop Resident #2's comprehensive care plan that addressed 3 scabbed skin tears on left 2nd toe- 0.50 cm, 3rd toe- 1.20 cm x 1.00 cm, x 0.50 cm, left 4th toe- 1.30 cm x 0.40 cm. This failure could place residents at risk for not receiving necessary treatment and care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was given the appropriate treatment and services to a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #2) reviewed for activities of daily living. The facility failed to clean, trim, and clip Resident #2's nails. Resident #2 nails were not clean, trimmed, nor cut. Resident #2's middle finger on her right finger was sharp, uneven, and jagged edged, four nails (pinky and thumb on right hand and thumb and index finger) were approximately 1 cm in length, and all her nails had thick dark brown and yellow substance underneath fingernails. This failure could place residents at risk of activities of daily living decline, frustration, and decreased socialization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #33, Resident #6) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #33 did not have a blue razor. (Resident #33 pulled out of her backpack and handed it to CNA A to shave her face with.2. The facility failed to ensure Resident #6 did not have an uncapped blue razor on top of his bedside dresser. These failures could place residents at an increased risk for injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 residents (Resident #1) reviewed for medical record confidentiality. The facility failed to ensure LVN A kept Resident #1's medical information confidential. LVN A left an Emergency Kit Charge Slip, dated 04/05/25, with Resident #1's name and listed the medications with administration dosage and route on the nurse station counter and in view for staff, visitors, and others. This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Ativan (used to treat anxiety disorders) was acquired. This failure could place residents at risk of not receiving the therapeutic dosage of medication prescribed by the physician.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 8 residents (Resident #s 1) reviewed for pharmacy services. The facility failed to ensure Resident #1 had a 14-day limit for PRN Ativan (used to treat anxiety disorders). This failure could place residents at risk of receiving unnecessary psychotropic medications and of not receiving the intended therapeutic benefits of their psychotropic medications.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A documented a progress note or nurse note of Resident #1's increased agitation on 04/05/25. This failure could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on interview and record review, the facility failed to accurately submit a PL1 (PASRR Level 1 Screening) screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 of 5 residents reviewed for PASRR screenings. (Resident #7) The facility failed to submit a new PL1 screening when Resident #3 was diagnosed on [DATE] with Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily living) during her stay. This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed for dialysis. (Resident #36) * The facility did not have ongoing communication with the dialysis facility regarding dialysis care and services for Resident #36. * The facility did not have ongoing assessment of Resident #36's condition and monitoring for complications after dialysis treatments received at a certified dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 3 medication carts reviewed. (Hall 200 medication cart for Residents Rooms 100 - 112B) in that: A multi-dose vial of Novolin R insulin (used to lower blood sugar) with an open date of [DATE], had been expired for 59 days. A multi-dose vial of Lantus insulin (used to lower blood sugar) with an open date of [DATE], had been expired for 69 days. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with accepted professional standards and practices, the facility to maintain medical records on each resident that are accurately documented for 1 of 13 residents review for clinical records. (Resident #36) * The facility did not have an accurate physician order for Resident #36's dialysis days. * The facility did not have accurate information on the TAR for Resident #36. This failure could place residents at risk of incomplete clinical records and a decrease in staff knowledge regarding resident care.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status for 1 of 10 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's physician and psychiatrist were immediately notified after Resident #1 indicated he wanted to shoot or stab someone. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. 1. The facility failed to place Resident #1 on 1-1 or move him to a private room after he threatened to shoot or stab someone. 2. The facility failed to implement their abuse policy when they failed to report allegations of abuse. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on 1-1 supervision or move him to a private room after he threatened he wanted to shoot or stab someone. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 threatened to shoot or stab someone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan included supervision and interventions after he made threats of harm to others. This failure could place residents at risk of accidents, injuries, and death due to lack of appropriate interventions in place.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 of 13 residents reviewed for oxygen therapy. (Residents #4,18 and 28) *The facility did not administer Resident #4 and #18's oxygen as ordered, and the residents' tubing was not changed weekly as ordered. *The facility did not change Resident #28's oxygen tubing weekly as ordered. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse to the Administrator and the State Survey Agency, for 1 of 15 residents reviewed for reporting allegations of abuse. (Resident #103) The facility failed to report an allegation of physical abuse within 2 hours to the State Agency when Resident #103 reported to LD that a staff member slapped her in the face. This failure could place the residents at risk of abuse and neglect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) prior to admission and that individuals identified with MD are evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 13 residents reviewed for PASRR Assessments. (Residents #8) The facility failed to ensure Resident's #8's pre-admission screening and resident review (PASRR) Level l screening indicated a diagnosis of mental illness, although diagnosis was present upon admission. Thisese failures could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 residents reviewed for care plans. (Resident #4) The facility did not develop and implement a hospice care plan for Resident #4. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 19 Residents (Resident #17), who resided on Hall 200 and 1 of 2 halls (Hall 200) reviewed for accidents and hazards. The facility failed to ensure Resident #17 did not keep isopropyl alcohol (disinfectant) in her room. The facility failed to ensure residents' environment remained free from accident hazards as possible by securing chemicals on Hall 200. These failures could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable and attractive to 1 of 13 residents reviewed for food palatability. (Resident #28) The facility did not serve mashed potatoes that were palatable to Resident #28. This failure could place residents who ate food from the kitchen at risk of weight loss, alternate nutritional status, and diminished quality of life.