Deficiency Records for Mill Creek Center For Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Mill Creek Center For Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-12-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-16 | 2023-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-16 | 2023-12-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2023-12-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-12-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-16 | 2023-12-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-16 | 2023-12-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-22 | 2022-12-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-22 | 2022-12-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-19 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-08-30 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-06-23 | 2022-08-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-23 | 2022-08-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-23 | 2022-08-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-23 | 2022-08-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-23 | 2022-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-23 | 2022-08-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-23 | 2022-08-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-23 | 2022-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-23 | 2022-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-23 | 2022-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-23 | 2022-08-12 | N |
| Dispose of garbage and refuse properly. | Health | 2022-06-23 | 2022-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-23 | 2022-08-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-23 | 2022-08-12 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-19 | 2022-08-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-19 | 2022-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-19 | 2022-08-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-13 | 2021-07-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-13 | 2021-07-02 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-13 | 2021-07-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-13 | 2021-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-13 | 2021-07-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-25 | 2019-07-17 | N |
