Millcreek Rehabilitation and Nursing

This section preserves official CMS inspection text matched to this facility from the current provider page source.

B6-INSP Inspections and official narratives P1 DIFF
CMS Health Deficiencies rows stay the citation spine. CMS Form 2567 inspection content is shown for this facility's cited F-tags and survey dates.
CMS scope and severity
Isolated
Pattern
Widespread
Immediate jeopardy
J 2
K
L
Actual harm
G 1
H
I
No harm, potential
D 6
E 6
F
Minimal harm
A
B
C
Shaded cells were cited in the latest survey cycle. Down and right is more serious.
Deficiency trend
Health deficiencies by cycle: 15, then 2, then 12 . Latest survey date: 2025-03-31.
Repeat citations
Tag Plain English Previous Latest Sev F0880 Provide and implement an infection prevention and control program. prior cycle latest cycle E CMS data shows 1 repeat deficiency tags between the latest two cycles.
Recent citations
Date Tag Category Sev Found how Corrected 2025-03-31 F0561 Resident Rights Deficiencies D complaint 2025-04-11 2025-03-31 F0584 Resident Rights Deficiencies D standard 2025-04-11 2025-03-31 F0600 Resident protection deficiencies G complaint 2025-04-11 2025-03-31 F0609 Resident protection deficiencies E complaint 2025-04-11 2025-03-31 F0610 Resident protection deficiencies J complaint 2025-04-11 2025-03-31 F0656 Resident Assessment and Care Planning Deficiencies E standard 2025-04-11 2025-03-31 F0689 Quality of Life and Care Deficiencies J complaint 2025-04-11 2025-03-31 F0770 Administration Deficiencies D standard 2025-04-11 2025-03-31 F0775 Administration Deficiencies E standard 2025-04-11 2025-03-31 F0805 Nutrition and Dietary Deficiencies D standard 2025-04-11 2025-03-31 F0842 Resident Assessment and Care Planning Deficiencies E standard 2025-04-11 2025-03-31 F0880 Infection Control Deficiencies E standard 2025-04-11 2025-03-31 F0924 Environmental Deficiencies E standard 2025-04-11
Official CMS inspection narrative
F0561 · 2025-03-31 · severity D
Official inspection narrative not available for this citation.
F0584 · 2025-03-31 · severity D
Official inspection narrative not available for this citation.
F0600 · 2025-03-31 · severity G
Official inspection narrative not available for this citation.
F0609 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
F0610 · 2025-03-31 · severity J
Official inspection narrative not available for this citation.
F0656 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
F0689 · 2025-03-31 · severity J
Official inspection narrative not available for this citation.
F0770 · 2025-03-31 · severity D
Official inspection narrative not available for this citation.
F0775 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
F0805 · 2025-03-31 · severity D
Official inspection narrative not available for this citation.
F0842 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
F0880 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
F0924 · 2025-03-31 · severity E
Official inspection narrative not available for this citation.
CMS Form 2567 inspection report text
The inspection text below is attributed to CMS Form 2567 records when a matching official source is available.
Inspection Report:
2025-03-31
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
13
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2025-03-31 | Tag F0584 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2025-03-31 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2025-03-31 | Tag F0770 | Administration Deficiencies | Severity: D
Provide timely, quality laboratory services/tests to meet the needs of residents.
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Survey: 2025-03-31 | Tag F0775 | Administration Deficiencies | Severity: E
Keep complete, dated laboratory records in the resident's record.
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Survey: 2025-03-31 | Tag F0805 | Nutrition and Dietary Deficiencies | Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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Survey: 2025-03-31 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2025-03-31 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
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Survey: 2025-03-31 | Tag F0924 | Environmental Deficiencies | Severity: E
Put firmly secured handrails on each side of hallways.
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Survey: 2025-03-31 | Tag F0561 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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Survey: 2025-03-31 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2025-03-31 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2025-03-31 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: J
Respond appropriately to all alleged violations.
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Survey: 2025-03-31 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2023-06-15 | Tag F0880 | Infection Control Deficiencies | Severity: D
Provide and implement an infection prevention and control program.
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Survey: 2023-06-15 | Tag F0676 | Quality of Life and Care Deficiencies | Severity: D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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Survey: 2021-09-30 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2021-09-30 | Tag F0636 | Resident Assessment and Care Planning Deficiencies | Severity: E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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Survey: 2021-09-30 | Tag F0638 | Resident Assessment and Care Planning Deficiencies | Severity: E
Assure that each resident’s assessment is updated at least once every 3 months.
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Survey: 2021-09-30 | Tag F0676 | Quality of Life and Care Deficiencies | Severity: E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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Survey: 2021-09-30 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2021-09-30 | Tag F0759 | Pharmacy Service Deficiencies | Severity: E
Ensure medication error rates are not 5 percent or greater.
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Survey: 2021-09-30 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
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Survey: 2021-09-30 | Tag F0805 | Nutrition and Dietary Deficiencies | Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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Survey: 2021-09-30 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2021-09-30 | Tag F0825 | Quality of Life and Care Deficiencies | Severity: D
Provide or get specialized rehabilitative services as required for a resident.
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Survey: 2021-09-30 | Tag F0840 | Administration Deficiencies | Severity: D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
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Survey: 2021-09-30 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.
Source rule. Official inspection text is quoted verbatim only when an official CMS Form 2567 source matches the CMS citation row. Citations without a matching official narrative remain labeled as not available.