Millcreek Rehabilitation and Nursing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF610Mar 31, 2025

  Based on interview and record review, for 1 of 43 sampled residents, the facility, in response to an allegations of abuse, neglect, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, a resident sustained a fall in a wheelchair while being transported in the facility van and the facility did not investigate the incident or report the incident to the SSA. This was determined to have occurred at an Immediate Jeopardy level. […]

• Immediate jeopardy, isolatedF689Mar 31, 2025

  Based on observation, interview and record review it was determined, for 2 of 43 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident fell backwards while being transported in a facility van due to not being secured properly and the resident sustained an injury to the head/neck. This was determined to have occurred at an Immediate Jeopardy level. Also, a resident with multiple falls did not have interventions in place to prevent additional falls. […]

• Actual harm, isolatedF600Mar 31, 2025

  Based on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure resident's were free from abuse. Specifically, a resident reported that another resident groped his genitals and attempted to penetrate his anus without his consent to the sexual activity. This deficient practice was found to have occurred at a Harm level. Additionally, a resident's capacity to consent to sexual activity assessment was not completed prior to the resident engaging in sexual activity. Resident identifiers 23, 49, and 112. Findings included: HARM 1. […]

• No harm, potential for more than minimal, patternF609Mar 31, 2025

  Based on interview and record review it was determined, for 5 of 43 sampled residents, that the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, the State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. Specifically, an allegation of sexual abuse was not reported to the SSA, APS, or local law enforcement within 2 hours after the facility became aware of the allegation, an allegation of sexual abuse was not reported to the APS within 2 hours after the facility became aware of the allegation, and an injury sustained in the transportation van was not reported to the SSA and APS within 2 hours of the incident. […]

• No harm, potential for more than minimal, patternF656Mar 31, 2025

  2. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, and ascities. On 3/18/25 at 10:00 AM, an interview was conducted with resident 33. Resident 33 stated that he had a fistula in his left arm for dialysis access. Resident 33 stated that he went to dialysis 3 times a week on Monday, Wednesday and Friday. Resident 33 stated that staff did not use the arm with the fistula for blood pressure readings. Resident 33 stated that the nurse assessed the site. Resident 33 stated that he had no complications with the fistula, just bruising at the access site. […]