Mill Creek Nursing & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Feb 12, 2025

  Based on observation and interview, the facility failed to ensure thickener and flour were properly stored. This had the potential to affect three residents (#23, #33, and #73) that received pureed diets and 14 residents on mechanical diets. Facility census was 71. Findings include: A tour of the kitchen on 02/09/25 at 8:21 A.M. revealed two large square containers with the lids off. The containers were located on the bottom shelf of a table that held the immersion blender. One container was labeled flour and one was labeled thickener. No food was being blended or prepared at the time. On 02/09/25 at 8:55 A.M. Dietary Manager #210 verified the containers with flour and thickener were not properly covered.

• No harm, potential for more than minimal, isolatedF558Feb 12, 2025

  Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible. This affected two residents (Resident #17 and #66) of two residents reviewed for call light accessibility. The census was 71. Findings Include: 1. Record review revealed Resident #17 was admitted on [DATE] to the facility with diagnoses that included but not limited to hypertensive heart disease, polyarthritis, and general anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had moderately impaired cognition and required supervision of activities of daily living. […]

• No harm, potential for more than minimal, isolatedF695Feb 12, 2025

  Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to ensure oxygen was administered per physician orders and failed to ensure oxygen tubing was dated when initiated/changed. This affected two (#23 and #31) of eight residents reviewed for oxygen administration. The facility identified eight residents who received oxygen therapy. The facility census was 71. Findings include: 1. Review of the medical records for resident #23 revealed an admitted [DATE] with the following but not limited to diagnoses of: respiratory failure, Parkinson's disease, dysphagia, and pneumonia. Resident #23 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of 15 noted on 01/10/24. […]

• No harm, potential for more than minimal, isolatedF806Feb 12, 2025

  Based on observation, record review, and interview, the facility failed to honor Resident #185's food preferences. This affected one (Resident #185) of four residents reviewed for food and nutrition. Facility census was 71. Findings include: Review of the medical record revealed Resident #185 was admitted on [DATE] with diagnoses that included urinary tract infection, asthma, and type 2 diabetes. The Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #185 was cognitively intact. The MDS also revealed Resident #185 received a regular diet. The care plan dated 01/28/25 revealed Resident #185 had the potential for alteration in nutrition and hydration. Interventions included to honor food/beverage preferences as able and provide the diet as ordered. […]