Mill Creek

In the surveyor’s words

From the most serious findings on record at Mill Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Oct 5, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF607Oct 5, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 5, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 6, 2023

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 9 residents reviewed for elopement. (Resident #1) The facility did not prevent Resident #1, a resident who was cognitively impaired with increased exit seeking behaviors, from eloping from the facility. This failure could place the residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 5/25/2023 at 4:55 p.m. […]

• No harm, potential for more than minimal, patternF684Dec 10, 2025

  Based 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. […]