Mill Creek Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mill Creek Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 29, 2024

  Based on observations, record review, and staff, Medical Director and Transportation Agent staff (Driver #1, Supervisor #1, Supervisor #2) interviews, the facility failed to have Resident #1 assessed by a medical professional before repositioning the resident after he was thrown forward out of his wheelchair while inside a contracted transportation van. On 03/20/24 Driver #1 for the Transportation Agent applied the van brakes suddenly to avoid a collision and Resident #1 slid out of his wheelchair onto the floor of the contracted transportation van. Driver #1 repositioned Resident #1 back into his wheelchair before the Resident was assessed by an emergency professional. […]

• Immediate jeopardy, isolatedF689May 29, 2024

  Based on observations, record review, and staff, Medical Director, Regional Nurse Consultant and Transportation Agent (Driver #1, Supervisor #1 and Supervisor #2) interviews, the facility failed to utilize an occupant restraint system, complete with a shoulder restraint and lap belt, per manufacturer's instructions for Resident #1 who slid out of his wheelchair during transport in a contracted transportation van. Driver #1 applied a shoulder restraint under the armrest of the wheelchair and across the lap of Resident #1 for transport, but did not apply a lap restraint. When Driver #1 applied brakes to avoid hitting a car, Resident #1's buttocks slid out of his wheelchair with his left leg bent forward, and his right leg extended straight out in front. […]

• Immediate jeopardy, isolatedF880Nov 16, 2023

  Based on observations, staff and Medical Director interviews, and record reviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 2 of 6 residents whose blood glucose levels were checked (Residents #168 and #58). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA) approved disinfectant in accordance with the manufacturer of the glucometer creates a high likelihood of exposing residents to the spread of blood borne infections. […]

• No harm, potential for more than minimal, widespreadF655Jun 23, 2022

  Based on record review, resident and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission for 4 of 5 new admissions reviewed Resident # ' s 154, 146, 9 and 201). The findings included: a. Resident #154 was admitted to the facility on [DATE]. On 6/20/22 at 11:45 AM, during an interview with Resident #154, he stated he was getting his antibiotics so he could go out and smoke. Intravenous antibiotics were observed hanging in a bag and being administered to Resident #154. A record review revealed no evidence a baseline care plan was completed for Resident #154. On 6/23/22 at 3:30 PM an interview was conducted with Nurse #2 who stated the Unit Manager completed the baseline care plans. […]

• No harm, potential for more than minimal, widespreadF812Jun 23, 2022

  Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen and in 1 of 2 nourishment rooms by not ensuring food items were not stored on the floor; by not ensuring food items were dated and labeled; by not maintaining the food service equipment in clean and debris-free condition; dishware were stacked clean and in good condition; by not ensuring staff were wearing hair coverings and chin guards for facial hair during food preparations; and by not preventing cross contamination of cleaned dishware when using the dishwashing machine. Findings included: 1a. […]