Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mill Creek Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Dirty Resident Rooms and Bathrooms: Multiple occupied resident rooms had heavy dirt, hair, dust, food particles, and debris in corners, along baseboards, under beds, behind doors, and in bathrooms, including buildup around toilets, sinks, and walls. The housekeeper said daily cleaning had been completed but the same conditions remained on recheck, and she reported lacking a proper mop to remove the buildup. The ADM later stated the rooms did not meet facility standards and that dirty resident rooms were unacceptable.
The facility did not provide or document information to several residents or their responsible parties about the right to accept or refuse medical or surgical treatment when making decisions about advance directives, such as Full Code or Do Not Resuscitate status. This deficiency was confirmed by staff interviews and affected both cognitively intact and impaired residents.
The facility did not offer the Prevnar 20 (PCV20) pneumococcal vaccine to residents as required by updated CDC and ACIP guidelines. Instead, only the PPSV23 vaccine was offered, and documentation did not reflect that PCV20 was presented as an option, even when residents declined PPSV23. Staff interviews confirmed a lack of awareness regarding the need to offer PCV20, and the facility's immunization policy did not specify the required vaccine brands.
A resident was found self-administering a nasal spray medication at bedside without a physician's order, assessment, or care plan in place. Nursing staff and the DON were unaware of the resident's self-administration, and no evaluation of the resident's ability to manage their own medication had been conducted.
A resident who was totally dependent on staff and a mechanical lift for transfers did not have access to their wheelchair for an extended period after returning from the hospital. Staff did not ask if the resident wanted to get out of bed and were unaware the wheelchair was missing, resulting in the resident being unable to attend group activities or leave their room.
Confidential medical information, including names and dialysis schedules, was posted in public view near nurses' stations, making it accessible to residents and visitors. The DON confirmed that this information should not have been displayed where unauthorized individuals could see it.
A resident with dementia and COPD was admitted to hospice care for late-onset Alzheimer's disease, but the facility did not complete the required Significant Change in Status MDS assessment following the hospice admission. The Administrator confirmed that this assessment should have been completed within the specified timeframe.
A housekeeping cart containing a spray cleaner and a flammable spray deodorizer was left unlocked and unattended outside a resident's room, with several residents nearby. The cart's lock had been broken for several days, and although the issue was reported to management, it had not been addressed. The chemicals inside the cart could cause irritation or were flammable, according to their SDS.
A resident with chronic lung disease was found receiving continuous oxygen therapy without a cautionary oxygen sign posted outside the room and without an active physician order for the therapy. Staff interviews revealed the sign was not moved when the resident changed rooms, and the DON confirmed the lack of a current order for continuous oxygen use.
The facility did not consistently maintain or document communication with the dialysis center for two residents with ESRD, resulting in missing and incomplete dialysis communication forms. Nursing staff sent forms with residents and received post-dialysis information from the dialysis center, but gaps in documentation and scanning into the electronic medical record were identified, with the DON unable to account for the missing records.
A resident with multiple chronic conditions and documented oral health issues did not receive dental services as ordered by the physician. Despite orders for a dental referral following findings of cavities and oral pain, the referral was not processed due to a breakdown in the facility's order handling process, resulting in the resident not being seen by a dentist.
A resident who was dependent on staff for toileting and mobility was left in soiled briefs from the overnight shift through breakfast service, despite requesting incontinence care. Staff delayed care, citing meal tray delivery procedures, and the resident declined to eat until cleaned. The DON confirmed residents should be clean before meals and that this practice was unacceptable, highlighting a lapse in maintaining resident dignity.
Surveyors found that an electrical outlet cover in a resident's room was partially detached and not reported for repair, despite staff awareness. Additionally, two residents' clothing was observed to be dirty and improperly stored in overflowing bags and piles, rather than in appropriate containers or laundry bags, indicating lapses in maintaining a clean and homelike environment.
A resident who was dependent on staff for all ADLs and required a mechanical lift for transfers was not provided timely incontinence care despite requesting assistance before daylight. The resident remained in a soiled brief with a large amount of stool until after breakfast trays were passed, as staff reported they were not to perform care during meal service. The DON confirmed that residents should not be left in soiled briefs for extended periods.
Survey results were placed in a lobby area that was secured by a locked door, requiring staff assistance for residents to access. Multiple residents reported being unaware of the survey results' location or unable to access them, and the Administrator confirmed that the lobby was always locked and required staff to unlock it for resident entry.
A resident with a seizure disorder did not receive scheduled doses of Valproic Acid due to being at dialysis, and the facility failed to notify the physician of these missed doses. Nursing staff either did not recall the resident or assumed the physician was aware, while the Unit Manager and NP were unaware of the issue. The physician knew about the scheduling conflict, but the facility's leadership expected proper notification and administration of medications.
A resident with a seizure disorder missed five doses of Valproic Acid due to being at dialysis during scheduled administration times. Nurses documented the absence but did not notify the physician. The physician was aware of the scheduling conflict but did not consider the missed doses harmful. The facility expected medications to be given as ordered and deviations to be communicated.
A resident was not assessed by a medical professional before being repositioned after falling out of a wheelchair in a transportation van. The driver moved the resident despite instructions not to, leading to a serious injury. The resident had multiple diagnoses and required full assistance with transfers.
A facility failed to use an occupant restraint system correctly during transport, leading to a resident's severe injury and subsequent death. The driver did not follow the manufacturer's instructions, resulting in the resident sliding out of the wheelchair when the brakes were applied suddenly.
Dirty Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in 3 of 36 resident rooms on 1 of 2 halls reviewed. Observations of three occupied rooms showed heavy buildup of dirt, hair, dust, food particles, and other debris in room corners, along baseboards, under beds, behind doors, around windows, and in bathrooms. In one room, the bathroom had heavy buildup in all corners, a dark brown stain around the toilet base, missing seal around the toilet base, and red and brown matter on the wall above the commode grab bar. In another room, heavy dirt and hair were observed along baseboards and corners, with raised matter on the wall, debris under the bed, white splatter on the door, and heavy buildup in the bathroom around the sink, toilet, and walls. In the third room, heavy dirt and dust were observed behind baseboards and corners, with raised red matter along a baseboard, heavy buildup around the wardrobe base, and a missing section of baseboard exposing packed dust, hair, food, and paper particles. The rooms were occupied by residents who were unable to be interviewed during the observations. The housekeeper assigned to the hall stated her daily duties included trash removal, bathroom cleaning, dusting, wiping surfaces, and cleaning floors, including under beds and behind dressers and window units. She confirmed that the daily cleaning in the affected rooms had been completed, but when the rooms were reobserved later the same day, the same issues remained. She also stated she lacked a proper mop to remove debris buildup and had told her supervisor this was a concern. She further stated that some of the debris in one bathroom felt firmly in place but could be removed with a scraping tool and rag. The Administrator later observed the same rooms and stated the cleanliness did not meet facility standards. The Administrator said daily housekeeping responsibilities included trash removal, cleaning overbed tables, bathrooms, nightstands if needed, sweeping under beds, and mopping from the window to the door. She stated she did not conduct monthly room inspections and relied on reports from the Housekeeping Director, who was on vacation during the survey period. She also stated she was not aware that the affected residents' rooms were not clean and said it was unacceptable to have dirty resident rooms.
Failure to Inform Residents of Rights Regarding Advance Directives
Penalty
Summary
The facility failed to provide information to residents or their responsible parties regarding the right to accept or refuse medical or surgical treatment when formulating advance directives. This deficiency was identified for four out of six sampled residents. For each of these residents, there was no documentation in the medical record indicating that information about the right to accept or decline treatment was provided prior to making decisions about advance directives, such as Full Code or Do Not Resuscitate status. Interviews with the Social Worker confirmed that the facility did not inform or document informing the residents or their responsible parties of these rights. The affected residents included both cognitively intact and severely cognitively impaired individuals, with some decisions made by responsible parties. The lack of documentation and communication was consistent across all reviewed cases, regardless of the resident's cognitive status or advance directive choice.
Failure to Offer Prevnar 20 Vaccine per Updated Guidelines
Penalty
Summary
The facility failed to offer the Prevnar 20 (PCV20) pneumococcal conjugate vaccine to residents in accordance with the most recent recommendations from the CDC and ACIP. Record reviews for four residents revealed that while the facility either administered or offered the PPSV23 vaccine, there was no documentation that the PCV20 vaccine was offered or administered, nor was there evidence that residents had received PCV20 prior to admission. In cases where residents declined the PPSV23 vaccine, the declination forms did not indicate that PCV20 was also offered as an option. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's practice was to offer only the PPSV23 vaccine to residents and that staff were unaware of the requirement to offer PCV20 in accordance with updated ACIP guidelines. The facility's immunization policy, last revised in 2019, did not specify the brand of pneumococcal vaccine to be offered, and staff reported that Prevnar 20 had never been offered to residents.
Failure to Assess and Document Resident's Ability to Self-Administer Medication
Penalty
Summary
A cognitively intact resident was observed with fluticasone propionate nasal spray on their bedside table, which they reported using independently for nasal congestion over the past month or two. There was no documentation of a physician's order for the nasal spray, nor was there an assessment or care plan addressing the resident's ability to self-administer medications. Nursing staff were unaware of the resident's use of the medication at bedside, and the DON confirmed that no assessment for self-administration had been completed for this resident.
Failure to Ensure Wheelchair Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure the accessibility of a wheelchair for a resident who was totally dependent on staff and a mechanical lift for transfers. The resident, who had diagnoses including osteomyelitis, cerebral infarction, and diabetes mellitus, was cognitively intact and previously used a wheelchair to attend group activities. After returning from a hospital stay, the resident reported not having access to his wheelchair and had not attended out-of-room activities since his return. Multiple observations confirmed that the wheelchair was not present in the resident's room or bathroom over several days. Interviews with nursing assistants revealed that none of them had asked the resident if he wanted to get out of bed, and they were unaware that the wheelchair was missing from the room. The resident's wheelchair was eventually found in a storage room, labeled with his name, after the issue was brought to the attention of the Interim Rehabilitation Director. The lack of staff awareness and failure to ensure the resident's wheelchair was accessible resulted in the resident not being reasonably accommodated for his needs and preferences.
Confidential Medical Information Posted in Public Areas
Penalty
Summary
Surveyors observed that confidential medical information for three residents was posted on 8.5 x 11-inch sheets of paper on the walls behind and next to both nurses' stations in the 100 and 200 halls. The posted documents, dated 3/12/25, included the residents' names, details about their dialysis treatments, scheduled days, departure times, and procedure times, all in large, typed print with additional handwritten notes. These signs were visible and readable to both residents and visitors from the front of the nurses' station countertops. During an interview, the Director of Nursing confirmed that the medical information was displayed in public view and acknowledged that it should not have been accessible to anyone other than nursing staff due to HIPAA regulations.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was admitted to hospice services. The resident, who had diagnoses including dementia and chronic obstructive pulmonary disorder, was admitted to hospice with Alzheimer's disease with late onset. Record review showed that after the resident's admission to hospice, the required Significant Change in Status MDS assessment was not completed. During an interview, the facility's Administrator confirmed that the assessment should have been completed within fourteen days of the resident's admission to hospice, but it was not done.
Unsecured Housekeeping Cart with Chemicals Left Accessible
Penalty
Summary
A housekeeping cart on the second floor was observed with its side door partially ajar and lacking a working lock, positioned outside a resident's room with three residents nearby and no staff present. The cart contained a spray cleaner and a spray deodorizer. The housekeeper responsible for the cart confirmed that the lock had broken over the weekend and, although she had reported the issue to the Environmental Manager, it had not yet been repaired. She stated she was aware of the requirement for a working lock but continued to use the cart as it was the only one available on the floor, keeping it close as she moved between rooms. Review of the Safety Data Sheets for the products inside the cart revealed that the spray cleaner could cause eye irritation, while the spray deodorizer contained flammable propanol and could cause irritation to the eyes, nose, and throat. The Housekeeping Manager, who had been at the facility for two weeks, acknowledged being informed of the broken lock but had not yet notified maintenance. The Administrator emphasized the importance of having a working lock on all housekeeping carts due to the chemicals stored inside.
Failure to Post Oxygen Signage and Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic lung disease and hypertension by not posting cautionary signage outside the resident's room to indicate that supplemental oxygen was in use. During an observation, the resident was found receiving continuous oxygen via nasal cannula from an oxygen concentrator, but there was no sign outside the room to alert staff and visitors to the presence of oxygen. Staff interviews revealed that the resident had recently moved rooms and the oxygen in use sign was not transferred with him. Additionally, the facility did not have an active physician order for the resident's continuous oxygen therapy, despite the care plan specifying oxygen administration at 3 liters per minute and the resident reporting ongoing use of oxygen. The DON confirmed that the previous order for as-needed oxygen had been discontinued and acknowledged that a new order for continuous oxygen should have been entered into the facility's system, including instructions for the flowrate. The DON also stated that the facility physician needed to be notified to write an order when continuous oxygen therapy was initiated based on an outside physician's recommendation.
Failure to Maintain Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for two residents with end stage renal disease who required regular dialysis. For both residents, there were active physician orders and care plans specifying the need for communication with the dialysis center using a designated form. However, record reviews revealed significant gaps and incomplete documentation of dialysis communication forms. For one resident, only 23 forms were located over several months, with 5 incomplete and none available for an entire month. For the other resident, only a few completed forms were found for two months, and the last scanned forms in the electronic medical record were from several months prior. Nursing staff reported that they completed the top portion of the dialysis communication form and sent it with the resident, while the dialysis center typically returned their own printed post-dialysis information instead of completing the facility's form. Both sets of documents were sent to medical records, but there was no process for retaining copies on the unit. The Director of Nursing confirmed the facility's responsibility for ensuring completion and proper documentation of dialysis communication forms, but was unable to explain the missing or incomplete records, noting that scanning into the electronic medical record was the responsibility of medical records staff, who were unavailable for interview.
Failure to Provide Dental Services as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide dental services as ordered by the physician for a resident with multiple medical diagnoses, including COPD, diabetes, and Crohn's disease. The resident's oral evaluation revealed red and inflamed oral tissue, heavy plaque buildup, and cavities, with recommendations for dental cleaning and assistance with oral hygiene. Despite a dental referral order being placed by the physician due to cavities and subsequent oral pain, there was no documentation that the resident was referred to or seen by a dentist as ordered. The process for handling referral orders required the nurse to confirm the physician's order in the electronic health record, print it, and deliver it to the Appointment Scheduler. However, due to the physician confirming the order directly, the nursing staff were unaware of the referral, and it was not processed as required. The Appointment Scheduler confirmed that no dental referrals for the resident were received or scheduled during the relevant period, despite the presence of orders and ongoing oral health concerns. Interviews with staff and the resident confirmed that the resident had not received the necessary dental follow-up after the initial evaluation and subsequent complaints of oral pain. The facility had not provided onsite dental services for several months, and the breakdown in communication and order processing led to the failure to obtain timely dental care for the resident, as documented in the clinical record and staff interviews.
Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
A deficiency occurred when a resident with bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care. The resident reported needing to be changed before daylight and had requested assistance from the overnight nurse aide, who acknowledged the request but did not return to provide care. The resident remained in soiled briefs into the morning, resulting in a strong odor in the room. When the day shift arrived, the resident was given a breakfast tray but declined to eat until he was cleaned, stating he could not eat in that condition. The nurse aides on the morning shift indicated they could not provide incontinence care while meal trays were being passed and believed the overnight shift should have ensured the resident was clean before breakfast. Staff interviews confirmed that it was expected for residents to be clean and dry before breakfast, and the DON stated it was unacceptable for residents to be left in soiled briefs while being served meals. The resident expressed ongoing dissatisfaction with this pattern of care since admission, feeling neglected and undignified. The failure to provide timely incontinence care resulted in the resident being left in an unclean state during mealtime, directly impacting his dignity and comfort.
Unsecured Electrical Outlet and Improper Clothing Storage
Penalty
Summary
A deficiency was identified when an electrical outlet cover in a resident's room was observed to be partially separated from the wall, with two electrical cords plugged in and both devices functioning. The resident occupying the room had not left since returning from the hospital and was unaware of the outlet's condition. Despite the outlet's visible state, it was not reported to the maintenance department by staff, although a nursing assistant stated she had informed a staff nurse about the issue in February. The facility's protocol required staff to report such maintenance needs through a designated program, but this was not followed, resulting in the outlet remaining unrepaired during multiple observations. Additionally, the facility failed to ensure that residents' clothing was clean and stored properly for two residents on the 200 hall. Observations revealed large, clear plastic bags of dirty clothing overflowing and stored on the floor beneath vanities, as well as piles of clothing on top of vanities. One resident expressed a preference for dirty clothes to be placed in a container or laundry bag. The Environmental Services Director confirmed that laundry was done twice weekly and as needed, but indicated that dirty clothes would not accumulate if nursing assistants brought them to the laundry room as required. Nursing assistants were expected to participate in a shower assistant team responsible for transporting dirty laundry, but the observed conditions indicated this process was not consistently followed.
Failure to Provide Timely Incontinence Care Upon Resident Request
Penalty
Summary
A resident with osteomyelitis and bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care upon request. The resident required a mechanical lift for transfers and was frequently incontinent, as documented in the care plan. On the morning of the survey, a strong odor of feces was noted coming from the resident's room. The resident reported having requested to be changed before daylight, but staff did not respond to his request in a timely manner. When incontinence care was finally provided, the resident was found with a saturated brief containing a large amount of soft stool, and the bottom sheet was soiled. The resident's skin was pink and intact, and the stool was not dried or stuck to the skin. Nurse aides interviewed stated that the resident was often left in this condition by the previous shift and that they were instructed not to perform patient care while breakfast trays were being distributed. The resident confirmed that he had asked the night shift aide for assistance, who acknowledged the request but did not return. The resident remained in a soiled brief until after breakfast trays were passed by the day shift. The Director of Nursing confirmed that residents should be clean and dry before the first shift and that it was unacceptable for residents to remain in soiled briefs for extended periods.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to make survey results easily accessible to residents, as required. On observation, the survey results binder was located in the lobby, which was secured by a locked door requiring a code for entry. During a Resident Council meeting, several residents stated they were unaware of the location of the survey results or that they were posted, and all reported being unable to access the lobby to review the binder. The Resident Council President was aware of the binder's location but also confirmed that residents could not access the lobby without staff assistance. An interview with the Administrator confirmed that the lobby door was always locked and residents needed staff to unlock it in order to view the survey results.
Failure to Notify Physician of Missed Anticonvulsant Doses
Penalty
Summary
The facility failed to notify the physician when an anticonvulsant medication, Valproic Acid, was not administered to a resident with a seizure disorder. The resident was admitted with diagnoses including stroke and epilepsy, and had a physician's order for Valproic Acid to be given every 8 hours. However, the medication was not administered on multiple occasions due to the resident being at dialysis during the scheduled administration times. Specifically, the medication was not given on five separate dates, and there was no documentation indicating that the physician was notified of these missed doses. Interviews with nursing staff revealed a lack of recollection regarding the resident and the missed doses. The nurses involved either did not remember the resident or assumed that the physician was aware of the situation. The Unit Manager and Nurse Practitioner were also unaware of the missed doses, while the physician was aware of the scheduling conflict with dialysis. The Interim Director of Nursing and the Administrator both stated that they expected medications to be administered as ordered and for the physician to be notified if they were not.
Failure to Administer Antiseizure Medication as Prescribed
Penalty
Summary
The facility failed to prevent a significant medication error by not administering antiseizure medication as prescribed to a resident with a seizure disorder. The resident, who had a history of stroke and epilepsy, missed five doses of Valproic Acid due to being at dialysis during the scheduled administration times. The medication was not given on multiple occasions, and the reasons documented included the resident being on leave of absence or at dialysis. Nurses involved did not recall the resident or the specific circumstances, and there was no evidence that the physician was notified of the missed doses. Interviews with the nursing staff, unit manager, nurse practitioner, physician, and pharmacist revealed a lack of communication and documentation regarding the missed doses. The physician was aware of the scheduling conflict with dialysis but did not believe the missed doses were harmful, as the resident did not experience seizures at the facility. The pharmacist indicated that missing a single dose would not have made the resident subtherapeutic. Despite this, the facility's expectation was that medications should be administered as ordered, and any deviations should be communicated to the physician.
Failure to Assess Resident by Medical Professional Before Repositioning After Fall
Penalty
Summary
The facility failed to have a resident assessed by a medical professional before repositioning the resident after he was thrown forward out of his wheelchair while inside a contracted transportation van. The incident occurred when the van driver applied the brakes suddenly to avoid a collision, causing the resident to slide out of his wheelchair onto the floor of the van. Despite instructions from her supervisor not to move the resident and to call 911, the driver repositioned the resident back into his wheelchair before emergency medical services arrived. The resident complained of significant pain and was later diagnosed with an acute impacted oblique left femoral fracture with edema and bleeding around the left knee at the hospital. The resident involved had multiple diagnoses, including end-stage renal disease, diabetes mellitus, and cerebrovascular accident, and required 100% assistance with transfers using a mechanical lift. The resident was non-ambulatory, unable to stand, non-weight bearing, and unable to sit without full back and head support. On the day of the incident, the resident was being transported back to the facility from a dialysis appointment when the accident occurred. The driver initially reported that she did not move the resident, but later admitted to repositioning him due to his complaints of pain and panic. Interviews with the driver, supervisors, and facility staff revealed that the driver moved the resident despite being instructed not to do so. The facility was not aware that the resident had been moved before EMS arrived, and the medical director confirmed that the resident should have remained in place to avoid the risk of further injury. The facility's failure to ensure that the resident was assessed by a medical professional before being moved led to the resident suffering a serious injury, highlighting a significant deficiency in the facility's handling of the situation.
Removal Plan
- The involved contracted transportation company contract was terminated in writing by the facility administrator.
- Education was provided in person by the Director of Plant Operations to the facility van driver and provided the education to the company-contracted van drivers to pull over, not move a resident if he/she slides down or falls out of their wheelchair, call 911, and wait for paramedics to assess the resident, as well as the risks of moving a resident prior to EMS arrival.
- A reiteration of education and return demonstration was completed again in the presence of the Director of Plant Operations.
- Drivers will not be allowed to transport any resident until education has been completed.
- Education will be tracked by the Director of Plant Operations or Maintenance Director with documented signatures.
- Newly hired transportation drivers will be required to receive the same education in orientation prior to any transportation.
Failure to Properly Secure Resident During Transport
Penalty
Summary
The facility failed to utilize an occupant restraint system according to the manufacturer's instructions for a resident during transport in a contracted transportation van. The driver applied a shoulder restraint under the armrest of the wheelchair and across the lap of the resident but did not apply a lap restraint. When the driver applied brakes to avoid hitting a car, the resident slid out of his wheelchair, resulting in severe pain and subsequent hospitalization. The resident was diagnosed with an acute impacted oblique left femoral fracture with edema and bleeding around the left knee, which later led to complications causing the resident's death. The incident occurred when the driver, who had been trained to use both a shoulder restraint and a lap belt, did not have a lap belt available in the van and used the shoulder restraint incorrectly. The driver stated that she secured the shoulder restraint under both armrests and across the lap of the resident because she thought it would be a choking hazard to use it across the shoulder. The driver also mentioned that the resident usually leaned forward during transport, which influenced her decision. The manufacturer's instructions clearly stated that both a shoulder belt and a lap belt should be used to secure the occupant properly. Interviews with the driver, supervisors, and facility staff revealed that the driver did not follow the manufacturer's guidelines for securing the resident. The contracted transportation van used for the transport did not come equipped with a lap belt, and the driver did not obtain one from another source. The facility's failure to ensure the proper use of the restraint system led to the resident's injury and subsequent death. The incident highlighted a significant lapse in adherence to safety protocols and proper training for transportation staff.
Removal Plan
- The involved contracted transportation company contract was terminated by the facility for noncompliance with not using an effective restraint system to safely secure a resident.
- Education of proper securement per manufacturer guidelines was provided to the one facility van driver by the Director of Plant Operations who is knowledgeable of the manufacturer guidelines for the single facility vehicle.
- A return demonstration was also completed to show full compliance and understanding.
- Other contracted van drivers will be educated by their company management who is knowledgeable on their specific vehicle's manufacturing guidelines.
- Re-education and return demonstration was completed by the facility and contracted van drivers by the Director of Plant Operations.
- Education included following the manufacturer's guidelines for the specific vehicle being used to prevent this event from reoccurring.
- Drivers will not be allowed to transport any resident until education has been completed.
- Newly hired transportation drivers will be required to receive the same education provided by the Director Plant Operations or Maintenance Director during orientation.
- The Administrator will be responsible for tracking the education.
- Facility will require return demonstrations of correct securement per the manufacturer's guidelines before transport and monitored by the Maintenance Director or designee.
- If stretcher transport is required, the facility will utilize the services of a medical transport company that specializes in stretcher transport.
- Residents with poor center of gravity will utilize the appropriate equipment for safe securement following the manufacturer guidelines.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winston-salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookridge Retirement Community | 1.2 mi | ★★★★★ | 1 | 0 |
| Salemtowne | 1.8 mi | ★★★★★ | 2 | 0 |
| Oak Forest Health And Rehabilitation | 3.1 mi | ★★★★★ | 0 | 0 |
| Arbor Acres United Methodist Retirement Community | 3.8 mi | ★★★★★ | 2 | 0 |
| Willow Valley Center For Nursing And Rehabilitatio | 4.5 mi | ★★★★★ | 10 | 1 |
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