Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 during CMS and state inspections, most recent first.
Untreated Toe Skin Tears in a Resident with Diabetes: A resident with DM and insulin use had three scabbed skin tears on the left 2nd, 3rd, and 4th toes that were observed by the surveyor and confirmed by the wound care nurse, but they were not documented in progress notes, skin assessments, incident records, or the care plan, and there were no treatment orders in place. An LVN said she knew about the wounds for 1 to 2 weeks but did not report or document them, and the DON and Administrator stated the resident should have had orders addressing the toe wounds.
Infection control practices were not followed on hall 200 when a CNA handled soiled linens without gloves, failed to perform hand hygiene after glove removal and between glove changes, and feces was observed on a resident room floor. During hydration services, another CNA did not perform hand hygiene before or after entering resident rooms, touched bedside tables and the ice scoop with ungloved hands, brought a resident’s used cup into the soiled utility room, and then returned the same contaminated cup to the resident; the surveyor intervened before the resident drank from it.
Incomplete DNR Forms for Two Residents: Two residents listed as DNR had invalid OOH-DNR paperwork. One resident’s form lacked proper witness dating and showed a witness signature entered after the relative’s signature, while another resident’s form had scribbled-over printed name entries. Both residents had impaired cognition but were able to state they did not want CPR, and the DON and Administrator confirmed the forms were not completed correctly.
A resident with DM and insulin use had 3 scabbed skin tears on the left 2nd, 3rd, and 4th toes, but the care plan did not address those wounds or include wound care interventions. The resident said she was not aware of any toe skin issues and that no wound care was being done. An LVN, the Wound Care Nurse, the DON, and the Administrator all confirmed the toe wounds should have been care planned, while the existing plan only included daily foot checks for diabetes-related concerns.
A resident with weakness, diabetes, and nail/skin candidiasis required extensive ADL assistance and had a care plan directing staff to inspect, clean, and trim nails. During observation, her nails were unclean, untrimmed, and jagged, with thick dark brown and yellow substance under the nails; she reported asking an RN to cut them more than a month earlier, but staff never returned to provide the care.
Unsafe Access to Razors in Resident Rooms: Two residents with severely impaired cognition were found with unsafe razor access, including one resident who retrieved a blue razor from a backpack and another who had an uncapped blue razor on a bedside dresser. Staff and leadership stated the residents should not have had razors, both care plans did not address restricted items, and the DON reported the facility had no policy addressing resident possession of razors or allowed items from home.
A resident's medical information, including name and medication details, was left unattended and visible on the nurse's station counter by an LVN, making it accessible to staff and visitors. This action violated facility policies requiring the confidentiality of resident records.
A resident with anxiety and other medical conditions did not receive timely pharmaceutical services when staff failed to ensure the acquisition and documentation of a prescribed Ativan dose. Nursing staff administered Ativan from the emergency kit but did not document it on the MAR, and the pharmacy did not receive the required prescription, resulting in the medication not being delivered. Facility procedures for ordering and documenting controlled substances were not followed.
A resident with anxiety, heart disease, and kidney disease experienced increased agitation and was administered Ativan by an LVN, but the nurse failed to document the event or medication administration in the EHR as required by facility policy. This lack of documentation was confirmed during staff interviews and record review.
A facility failed to accurately submit a PASRR Level 1 screening for a resident with a diagnosis of major depressive disorder. The PL1 was incorrectly marked as negative for mental illness, despite the resident's psychiatric assessment and medication orders indicating otherwise. The MDS nurse, responsible for PASRR forms, acknowledged the error, which was attributed to a lack of backup and oversight during a change in MDS coordinators. The DON and Administrator confirmed the risk of residents missing necessary services due to incorrect PASRR form completion.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease and diabetes, due to insufficient communication with the dialysis center and incomplete post-dialysis assessments. Despite physician orders, the facility's records often lacked necessary information, and staff interviews revealed a lack of follow-up and communication, posing potential risks to the resident's health.
A facility failed to properly label and store insulin vials, resulting in expired Novolin R and Lantus insulin being found in a medication cart. The vials were 59 and 69 days past their expiration, respectively. An LVN admitted the oversight might have occurred due to a resident's transfer, and the DON and Administrator confirmed the responsibility for monitoring expired medications.
A facility failed to maintain accurate medical records for a resident with end-stage renal disease, documenting incorrect dialysis days in the TARs. Despite physician orders indicating dialysis on Tuesdays, Thursdays, and Saturdays, the resident actually received treatment on Mondays, Wednesdays, and Fridays. Staff interviews confirmed the discrepancy, and the DON acknowledged the error, emphasizing the need for accurate chart audits.
Untreated Toe Skin Tears in a Resident with Diabetes
Penalty
Summary
The facility failed to ensure that Resident #2 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices. Resident #2 was a cognitively intact female with diagnoses including type 2 diabetes, weakness, edema, candidiasis of skin and nails, and a periprosthetic fracture around the left knee joint. Her MDS indicated she was receiving insulin and was at risk for pressure ulcers and injury. On the care plan dated 11/06/2025, the resident had diabetes interventions that included inspecting feet daily for open areas, sores, pressure areas, blisters, edema, or redness. The record showed that Resident #2 had three scabbed skin tears on the left 2nd, 3rd, and 4th toes, but these wounds were not care planned and there were no treatment orders in place for them in the November and December 2025 orders. The facility’s incident and accident records did not list the toe wounds, and progress notes, weekly head-to-toe assessments, and a nursing skilled assessment did not document the abrasions or skin tears. During observation, the surveyor identified the three scabbed skin tears on the resident’s left toes, and the wound care nurse later confirmed their presence. During interviews, LVN B stated she had been aware of the toe wounds for approximately 1 to 2 weeks but did not report them, document them in a nurse’s note, complete a nursing skin assessment, initiate interventions, or notify the doctor or treatment nurse. She said she assumed the wound care nurse was already aware of the wounds. The wound care nurse stated she was responsible for weekly and as-needed skin assessments and that diabetic residents’ feet should be assessed daily by all nursing staff. She also stated that if a resident had a skin tear or abrasion to the foot, she would notify the resident, doctor, family representative, DON, and charge nurse and complete the related documentation and treatment orders, but none of that had been done for Resident #2’s toe wounds. The DON and Administrator stated that skin assessments should be completed accurately and that the resident should have had orders addressing the care needed for the toes.
Infection Control Lapses During Linen Handling and Hydration Services
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for hall 200. During an observation of hall 200, CNA A disposed of soiled linens without gloves, did not perform hand hygiene after the linens were disposed of, and then put on gloves to adjust Resident #33’s brief and clothing. CNA A removed her gloves and put on new ones without performing hand hygiene between glove changes. During another observation, a dime-sized amount of light brown feces was seen on the floor of a resident room. In a separate observation of hydration services on hall 200, CNA B did not wash or sanitize her hands before entering or after exiting resident rooms, touched residents’ bedside tables with ungloved hands, handled the hydration cart ice scoop in a way that touched the inside of residents’ cups, and handled residents’ used insulated cups while providing ice and water. CNA B also entered Resident #2’s room while the resident was on enhanced barrier precautions, carried out trash and the resident’s used insulated cup, placed the used cup in the soiled utility room, and later brought the same cup back to the resident. Resident #2’s straw contained pink and dark brown debris, and the surveyor intervened before the resident drank from the cup. Interviews confirmed the observed practices. CNA A stated she should have worn gloves when disposing of soiled linens and should have used hand hygiene before putting on gloves and after removing them. CNA B stated she should have performed hand hygiene before entering and after exiting resident rooms, should not have touched the ice scoop to the inside of the resident’s cup, and should not have brought the used cup into the soiled utility room and then back to the resident. The DON, Regional Director of Clinical Services, Administrator, and LVN C all stated that staff were expected to follow hand hygiene and infection control practices, including using gloves with soiled linen, sanitizing before entering resident rooms and between rooms, and disposing of feces properly. Facility policy required hand hygiene before donning gloves and immediately after removing them, and the serving drinking water procedure stated the ice scoop should not touch the water pitcher.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had valid advance directive documentation for their DNR status. Resident #21, an older female admitted with diagnoses including hypertension, cerebral infarction, and unspecified dementia, was listed as DNR on the face sheet, care plan, and physician order. Her OOH-DNR form showed the adult child signature in the qualified relative section, but Witness #1 had no date and Witness #2 signed and dated the form two days after the qualified relative signature, indicating the signature was not witnessed. Resident #21’s record also showed moderate cognitive impairment with a BIMS score of 10 out of 15, though she was able to make herself understood and stated during observation and interview that she did not want CPR and wanted to pass peacefully. The facility’s admission packet stated that an OOH-DNR must be properly executed to be valid, and the back-page instructions required two competent adult witnesses who witnessed the signature in section A. The DON confirmed the current advance directive for Resident #21 was not completed and that the witness dates did not support a witnessed signing. Resident #31, an older male admitted with emphysema and adult failure to thrive, was also listed as DNR on the face sheet, care plan, and physician order. His OOH-DNR form contained scribble and written-over letters in two separate printed name areas, with the last two letters of his first name altered and darker than the rest of the name. Resident #31 had moderately impaired cognition with a BIMS score of 12 out of 15 and stated during observation and interview that he did not want CPR and wanted to die in peace. The DON and Administrator both confirmed the DNR form was not completed correctly and that written-over letters should have been corrected properly or rewritten.
Failure to Care Plan Toe Skin Tears
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with diabetes and other medical conditions, including measurable objectives and timeframes, for 3 scabbed skin tears on the left 2nd, 3rd, and 4th toes. The resident was re-admitted to the facility with diagnoses including type 2 diabetes, weakness, lack of coordination, edema, candidiasis of skin and nails, and a periprosthetic fracture around the left knee joint. The quarterly MDS indicated the resident was cognitively intact with a BIMS score of 15 and was receiving insulin injections for blood sugar control. Record review of the resident’s care plan showed that the skin tears on the left foot toes had not been care planned and that no wound care treatment interventions were listed for those areas. The existing care plan addressed diabetes mellitus and included an intervention to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness, but it did not specifically address the 3 toe wounds. During observation, the resident had 3 scabbed skin tears on the left 2nd, 3rd, and 4th toes, and the resident stated she was not aware of any skin issues on her toes and that no one was doing wound care on her feet. Interviews confirmed the lack of a care plan for the toe wounds. The LVN stated the resident had not had a care plan addressing the 3 skin tears and that infection could be a risk if they were not care planned. The Wound Care Nurse stated she was responsible for updating wound care plans and that the toe wounds should have been care planned, while the DON stated she was responsible for initiating wound care plans and that the resident should have had a care plan for the 3 left foot toes to ensure wound care treatment. The Administrator stated nursing staff, as a team, were expected to care plan residents’ needs to ensure needed treatment was received.
Failure to Provide Nail Care for a Resident Needing ADL Assistance
Penalty
Summary
The facility failed to ensure a resident who required extensive assistance with ADLs received appropriate nail care. Resident #2 was a re-admitted female with diagnoses including periprosthetic fracture around the left knee prosthesis, weakness, candidiasis of the skin and nails, lack of coordination, edema, and type 2 diabetes. Her MDS indicated a BIMS score of 15 and extensive assistance needs for personal hygiene. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and for diabetes, to cut nails straight across, never cut corners, and file rough edges with an emery board. During observation and interview, Resident #2's nails were not clean, trimmed, or cut. Her right middle fingernail was sharp, uneven, and jagged edged, four nails were approximately 1 cm long, and all nails had a thick dark brown and yellow substance underneath. Resident #2 stated she liked her fingernails cleaned and cut, said they had never been that long before, and reported she had asked a nurse to cut them more than a month earlier but staff never came. The DON, Administrator, and Regional Director of Clinical Services each stated staff should have cleaned, trimmed, and cut the resident's nails as requested and as stated in the care plan.
Unsafe Access to Razors in Resident Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when a blue razor was found in Resident #33’s possession and an uncapped blue razor was found on Resident #6’s bedside dresser. Resident #33 was a female admitted with diagnoses including hemiplegia, hemiparesis affecting the right dominant side, candidiasis, and aphasia. Her quarterly MDS indicated a BIMS score of 7, showing severely impaired cognition, and she required substantial to maximal assistance with toileting, personal hygiene, showering/bathing, lower body dressing, and partial to moderate assistance with upper body dressing. Her care plan did not address items she could not keep in her room. During observation, Resident #33 asked a CNA to shave her face. The CNA looked for a razor in the bedside dresser, did not find one, and the resident then retrieved a clear packaged blue razor from her backpack and handed it to the CNA. The CNA stated the resident should not have had the razor and discarded it in a sharps container after use. Staff interviews indicated the resident should not have had access to razors, and the DON stated the facility did not have a policy addressing residents having razors or what items residents were or were not allowed to bring from home. Resident #6 was a male re-admitted with diagnoses including hypertensive heart disease without heart failure, paranoid schizophrenia, intermittent explosive disorder, Alzheimer’s disease, and unspecified dementia with mood disturbances. His quarterly MDS indicated a BIMS score of 7, showing severely impaired cognition, and his care plan did not address items he could not keep in his room. During observation, an uncapped blue razor was found on top of his bedside dresser. Staff interviews stated he relied on staff to shave him, that he should not have access to razors, and that staff were responsible for ensuring razors were secured. The DON, regional director of clinical services, and Administrator all stated the facility did not have a policy in place addressing resident possession of razors or allowed items from home.
Failure to Maintain Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to maintain the confidentiality of a resident's medical information. The LVN left an Emergency Kit Charge Slip, which included the resident's name and details of prescribed medications (Tramadol 50 mg PO and Ativan 0.5 mg PO), on the nurse's station counter. This document was left in plain view, accessible to staff, visitors, and others, rather than being properly secured in the medication room as intended. The LVN later stated she did not recall leaving the information on the counter. The incident was substantiated by a photograph provided by a family member, showing the Emergency Kit Charge Slip visible on the nurse's station ledge. Interviews with facility staff confirmed that resident records are considered confidential and should not be left unattended or visible in public areas. The facility's policies on resident rights and confidentiality require that all resident information be safeguarded to protect privacy.
Failure to Ensure Timely Acquisition and Documentation of Prescribed Ativan
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition and administration of Ativan, a medication prescribed for anxiety. The resident, an elderly female with diagnoses including anxiety, heart disease, and kidney disease, was admitted with moderate cognitive impairment. Physician orders were in place for Ativan 0.25 mg every 12 hours as needed for agitation, and the care plan included monitoring the effectiveness of psychotropic medications. On the day of increased agitation, nursing staff obtained Ativan from the emergency kit, halved the tablet, and administered the dose, but did not document the administration on the medication administration record (MAR). Further review revealed that the order for Ativan was faxed to the pharmacy, but the required written prescription for the controlled substance was not received by the pharmacy, resulting in the medication not being delivered. The facility's medication binder did not contain the order or fax confirmation, and the process for reconciling and following up on medication orders was not completed as required. Interviews with staff confirmed that the necessary follow-up to ensure the medication was received did not occur, and the facility's procedures for ordering and documenting controlled substances were not followed.
Failure to Document Resident Agitation and Medication Administration
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a progress note or nurse note regarding a resident's increased agitation on a specific date, despite administering Ativan for anxiety. The Medication Administration Record (MAR) indicated that the medication was given, but there was no corresponding documentation in the electronic health record (EHR) about the resident's condition or the administration of the medication. The resident involved was an elderly female with diagnoses including anxiety disorder, heart disease, and kidney disease. Her care plan required monitoring and recording of behavioral or mood problems, as well as the effectiveness of psychotropic medications. Facility policy required documentation of all services provided, changes in condition, and medication administration. During interviews, staff confirmed that documentation should have occurred for the resident's increased agitation and the administration of Ativan, but this was not completed.
Failure to Accurately Submit PASRR Screening
Penalty
Summary
The facility failed to accurately submit a PASRR Level 1 (PL1) screening for a resident admitted with a diagnosis of mental illness. Specifically, the PL1 screening for a resident was marked as negative for mental illness, intellectual disability, and developmental disability, despite the resident having a diagnosis of major depressive disorder. This oversight was identified during a review of the resident's records, which showed a psychiatric assessment diagnosing major depressive disorder and multiple physician orders for medications treating this condition. The MDS nurse, who was responsible for completing PASRR forms, acknowledged that the PL1 form was incorrectly documented by the previous MDS nurse. The current MDS nurse had been in-serviced on PASRR form completion but had no backup to double-check the forms. The Director of Nursing (DON) and the Administrator confirmed that the MDS nurse was responsible for PASRR forms and that the incorrect completion of these forms could result in residents missing out on necessary services. The Regional Care Coordinator explained that the MDS nurse and the resident's family were responsible for completing the PL1 upon admission. The interdisciplinary team was supposed to review admission paperwork and update the PL1 if new diagnoses were noted. However, the paperwork was not submitted timely when the psychiatric group added diagnoses. The Regional Care Coordinator noted that the local authority would review the resident's status to determine if they qualified for additional services.
Inadequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident requiring such services, as evidenced by a lack of ongoing communication with the dialysis facility and insufficient post-dialysis assessments. The resident, a male with end-stage renal disease and type 2 diabetes mellitus, was admitted to the facility and required dialysis treatments. Despite having a physician's order for post-dialysis assessments and communication with the dialysis center, the facility did not consistently document or complete these assessments. Observations and interviews revealed that the resident attended dialysis sessions three times a week, but the facility's Dialysis Communication Records were often incomplete or missing. For several dates in July, August, and September, the records lacked necessary information from the dialysis nurse and post-dialysis assessments by the facility nurse. This included critical assessments for bruit/thrill, signs of infection, bleeding at the graft/shunt site, and changes in skin integrity. The absence of this documentation indicates a failure to monitor the resident's condition adequately after dialysis treatments. Interviews with facility staff, including the DON and an LVN, highlighted a lack of follow-up and communication between the facility and the dialysis center. The DON acknowledged the risk of complications from dialysis procedures if nurses were unaware of the treatment details or did not perform complete assessments. The facility's policy required a Dialysis Communication Record to be completed and returned with the resident, but this protocol was not consistently followed, leading to potential risks for the resident's health and safety.
Expired Insulin Vials Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional principles, as observed in one of the medication carts. Specifically, a multi-dose vial of Novolin R insulin and a multi-dose vial of Lantus insulin were found to be expired by 59 and 69 days, respectively. These vials were still present in the medication cart for Hall 200, which serves residents in Rooms 100 - 112B. The deficiency was identified during an observation and interview with an LVN, who confirmed that the insulin vials should have been removed from the cart after being opened for 30 days. The LVN admitted that the expired vials might have been overlooked due to a resident's transfer from Hall 200 to Hall 100. The LVN stated that she was responsible for checking the medication carts daily for expired medications and that the DON double-checked the carts. Interviews with the DON and the Administrator revealed that the nurses were responsible for monitoring the medication carts daily, with the DON and pharmacy consultant providing additional oversight. The DON acknowledged that the expired insulin vials were possibly overlooked during the resident's transfer. The facility had an undated form indicating the discard time frames for insulin, which were not adhered to in this instance.
Inaccurate Documentation of Dialysis Days
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of dialysis days. The resident, who was cognitively intact and diagnosed with end-stage renal disease and type 2 diabetes mellitus, was supposed to receive dialysis on Mondays, Wednesdays, and Fridays. However, the physician orders inaccurately indicated dialysis on Tuesdays, Thursdays, and Saturdays. This discrepancy was consistently documented in the Treatment Administration Records (TARs) for July, August, and September 2024, where staff recorded dialysis on the incorrect days. Interviews with the resident and staff, including an LVN, the ADON, and the DON, confirmed that the resident actually received dialysis on Mondays, Wednesdays, and Fridays. The DON and ADON acknowledged the incorrect documentation and stated that it was the administrative nursing responsibility to audit charts for accuracy. The Interim Administrator also emphasized the expectation for clinical records to be accurate, highlighting the risk of providing incorrect care due to inaccurate information.
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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.
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Nursing homes near Silsbee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silsbee Oaks Health Care Llp | 1.3 mi | ★★★★★ | 9 | 0 |
| Paradigm At The Pines | 2.4 mi | ★★★★★ | 18 | 1 |
| Village Creek Rehabilitation And Nursing Center | 6.1 mi | ★★★★★ | 16 | 3 |
| Paradigm At Kountze | 7.7 mi | ★★★★★ | 5 | 0 |
| Jefferson Nursing And Rehabilitation Center | 16 mi | ★★★★★ | 0 | 0 |
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