Millcreek Rehabilitation and Nursing

Inspectors wroteBased on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that allegations of neglect were reported immediately to the State Survey Agency. Specifically, the facility did not report an incident where a resident was not secured while being transported in a facility van. Resident Identifier:

Inspectors wroteBased on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that a resident's environment remained free of accident hazards. Specifically, a resident's wheelchair was not secured during transport. Resident Identifier: 1 and 2. It was determined the provider's non-compliance with the requirements of participation caused potential harm However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented on 3/27/26, educated and retrained all staff members who transport residents. [...]

Inspectors wroteBased on interview and record review, for 1 of 43 sampled residents, the facility, in response to an allegations of abuse, neglect, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, a resident sustained a fall in a wheelchair while being transported in the facility van and the facility did not investigate the incident or report the incident to the SSA. This was determined to have occurred at an Immediate Jeopardy level. Resident identifier: 47 and 50. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 43 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident fell backwards while being transported in a facility van due to not being secured properly and the resident sustained an injury to the head/neck. This was determined to have occurred at an Immediate Jeopardy level. Also, a resident with multiple falls did not have interventions in place to prevent additional falls. Resident identifiers: 1, 47, and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); [...]

Inspectors wroteBased on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure resident's were free from abuse. Specifically, a resident reported that another resident groped his genitals and attempted to penetrate his anus without his consent to the sexual activity. This deficient practice was found to have occurred at a Harm level. Additionally, a resident's capacity to consent to sexual activity assessment was not completed prior to the resident engaging in sexual activity. Resident identifiers 23, 49, and 112.

Inspectors wroteBased on interview and record review it was determined, for 5 of 43 sampled residents, that the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, the State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. Specifically, an allegation of sexual abuse was not reported to the SSA, APS, or local law enforcement within 2 hours after the facility became aware of the allegation, an allegation of sexual abuse was not reported to the APS within 2 hours after the facility became aware of the allegation, and an injury sustained in the transportation van was not reported to the SSA and APS within 2 hours of the incident. Resident identifiers 23, 50, 112, 113, and 114.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 43 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident that received dialysis did not have a care plan, a resident that vaped THC (Tetrahydrocannabinol) did not have a care plan, and a resident with frequent falls did not have care plan interventions implemented. Resident identifiers: 1, 33, and 58.

Inspectors wroteBased on interview and record review it was determined, for 3 of 43 sampled residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, 3 residents did not have laboratory reports filed in their medical record. Resident identifiers: 33, 37, and 49.

Inspectors wroteBased on observation, interview, and record review it was determined that, for 4 of 43 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, and readily accessible and failed to protect resident-identifiable information from being released to the public. Specifically, one resident did not have a physician's rationale for an on-going use of a PRN (as needed) psychotropic medication located in the medical record and 3 residents had another resident's name or documents located in their medical records. Resident identifiers: 49, 59, 164, and 214.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 43 sampled residents, that the facility failed to 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. Specifically, there was direct food contact with bare hands and 2 residents who had indwelling medical devices or wounds and did not have Enhanced Barrier Precautions (EBP) in place. Resident identifiers: 22 and 58.

Inspectors wroteBased on observation and interview, the facility failed to ensure that all corridors were equipped with firmly secured handrails. Specifically, 3 handrails throughout the facility were found to be loose which created a resident safety hazard.

Inspectors wroteBased on interview and record review it was determined for 1 of 43 sampled residents that the facility did not promote and facilitate the resident right to self-determination through support of the resident choice. Specifically, a resident who was assessed as not requiring supervision with smoking was not allowed access to the secured outside smoking patio after 9:00 PM unless it was at the supervised smoking times of 11:00 PM or 3:00 AM. Resident identifier 33.

Inspectors wroteBased on observation and interview, it was determined that, for 1 of 43 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, a resident had a brown substance on the wall next to the toilet for the entire length of the survey. Resident identifier: 50.

Inspectors wroteBased on interview and record review it was determined, for 1 of 43 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, resident had routine orders for a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a hemoglobin A1c (HbA1c) every 6 months in February and August that were not completed. Resident identifier: 33.

Inspectors wroteBased on observation, interview, and record review it was determined that, for 1 of 43 sampled residents, the facility failed to provide each resident with food prepared in a form designed to meet individual needs. Specifically, 1 resident received a modified diet that was not approved by the physician. Resident identifier: 5.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 26 sampled residents that the facility did not provide the necessary assistance to ensure each resident maintained or improved their ability to perform activities of daily living, including eating. Specifically, a resident with swallowing issues was not provided one-to-one assistance while eating as ordered by the physician. Resident identifier: 10.

Inspectors wroteBased on observation and interview it was determined that the facility did not 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. Specifically, food was not covered when transported through the hallways.

Inspectors wroteBased on interview and observation, the facility did not provide a safe, clean, comfortable and homelike environment to residents. Specifically, resident wheelchairs and walkers were dirty and furniture was in disrepair. The facility shower room was not clean.

Inspectors wroteBased on interview and record review it was determined, for 2 of 42 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, not less than once every 12 months. Specifically, resident Annual Minimum Data Set (MDS) assessments were not completed. Resident identifiers:

Inspectors wroteBased on observation, interview, and record review it was determined, for 10 of 42 sampled residents, that the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. Specifically, 11 residents did not receive timely Quarterly Review Assessments. Resident identifiers: 4, 12, 15, 18, 19, 20, 22, 24 31, and 44.

Inspectors wroteBased on observation, interview and record review, it was determined, for 3 of 42 sample residents, the facility did not give the appropriate services to maintain or improve the resident's activities of daily living (ADL). Specifically, residents were observed to have greasy hair and dirty fingernails. Resident identifiers:

Inspectors wroteBased on observation and interview it was determined, for 1 of 42 sampled residents, that the facility did not ensure it was free of medication error rates of five percent or greater. Observations of 25 medication opportunities on 9/29/21 revealed two administration errors which resulted in an 8% medication error rate. Specifically, the nurse left the medication cart unlocked in a resident care area and a resident was not properly positioned to receive medication. Resident identifier: 3.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the back splash area behind the steam table was dirty, the flooring around the drain near the stove had paint peeling up and the cement was chipped, and sausage patties and pie dough in the freezer were open to air.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, reusable resident medical equipment was not cleaned and disinfected according to manufacturers' instructions using an EPA registered disinfectant for healthcare settings prior to use on another resident. Resident identifiers: 22, 31, and 34.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 42 sample residents, that the facility did not provide adequate supervision and assistance devices to prevent accidents. Specifically, a resident that was assessed as an independent smoker was observed to ash on himself and had holes in his clothing. Resident indenter: 24.

Inspectors wroteBased on interview and record review it was determined, for 2 of 42 sample residents, that the facility did not ensure that residents were free of any significant medication errors. Specifically, insulin was not provided according to physician orders. Resident identifiers: 39 and 58.

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 of 42 sample residents, that the facility did not provide nor ensure each resident received food prepared in a form designed to meet individual needs. Specifically, residents with a physician's order for nectar thickened liquids received non-thickened foods. Resident Identifiers: 28 and 30.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 42 sample residents, that the facility did not provide specialized rehabilitation services. Specifically, a resident with orders for physical therapy did not receive therapy. Resident identifier: 58.

Inspectors wroteBased on observation, interview and record review, it was determined the facility did not ensure that outside services providing services to their residents met professional standards of practices for 1 of 42 sample residents. Specifically, a resident was not provided a podiatry and an Optometrist appointment as he requested. Resident identifier: 58.