Millcreek Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 23, 2024

  Based on review of facility policy, clinical and hospital records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide attempt by overdose, from appropriating a significant number of prescription medications that resulted in an overdose of the prescription medications that were provided during medication administration by the facility for one (Resident R234) of three residents reviewed with a history of suicide attempts, and resulted in an Immediate Jeopardy situation. Findings include: Review of a facility policy entitled Medication Administration dated 10/30/23, indicated that staff will remain at bedside with the resident until all medications are taken. […]

• Actual harm, isolatedF686May 6, 2022

  Based on review of clinical records, facility documentation, facility policies, and staff interviews, it was determined that the facility failed to follow professional standards regarding pressure ulcer prevention measures, that resulted in actual harm of a Stage III (full-thickness loss of skin) pressure ulcer for one of ten residents reviewed (Resident R83) and failed to make certain weekly skin assessments were being performed for two of ten residents reviewed (Residents R83 and R164). […]

• No harm, potential for more than minimal, patternF628Jan 23, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of eight residents reviewed for hospitalization (Residents R1, R56, R58, and Closed Record Resident CR149). Findings include: Review of a facility policy entitled Transfer or Discharge, Facility - Initiated, dated January 2026, indicated that should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: basis for the transfer or discharge, contact information of the practitioner responsible for the care of the resident, resident representative… […]

• No harm, potential for more than minimal, patternF554Feb 23, 2024

  Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 25 residents reviewed (Resident R102). Findings include: Review of facility policy entitled Resident Self-Administration of Medication dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. […]

• No harm, potential for more than minimal, patternF655Feb 23, 2024

  Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 25 residents reviewed (Residents R10, R79, R124, and R117). Findings include: A facility policy entitled, Care Plans dated 10/30/2023, revealed that A copy of the care plan will be provided to the resident and/or family/responsible party. […]