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Deficiency Records for Millcreek Manor
A list of the most recent deficiencies for Millcreek Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Millcreek Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-24 | 2024-08-16 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-23 | 2024-04-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-02-23 | 2024-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-23 | 2024-04-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-23 | 2024-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-04-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-23 | 2024-04-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-23 | 2024-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-23 | 2024-04-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-27 | 2024-03-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-27 | 2024-03-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-27 | 2024-03-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-27 | 2024-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-27 | 2024-03-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-24 | 2023-05-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-24 | 2023-05-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-05-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-24 | 2023-05-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-24 | 2023-05-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-03-24 | 2023-05-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-22 | 2023-04-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-06 | 2023-03-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-06 | 2022-06-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-06 | 2022-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-06 | 2022-06-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-12 | 2022-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-12 | 2022-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-12 | 2022-06-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | Not Fixed | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-02 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-02 | Not Fixed | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-16 | Not Fixed | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-16 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-16 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-16 | Not Fixed | Y |
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