Inspection Reports for Mill Creek Manor

The complaint investigation was conducted due to concerns about staff qualifications, resident care planning, neglect related to injuries of unknown origin including burns, medication administration without physician orders, failure to report to Health Care Personnel Registry, and failure to notify DSS and responsible parties of incidents requiring emergency medical evaluation.

The facility was found deficient in multiple areas including failure to ensure staff qualifications per Health Care Personnel Registry checks, failure to develop a care plan for a resident within 30 days of admission, neglect of a resident with injuries of unknown origin including burns, failure to obtain physician orders for wound care, failure to report injuries to the Health Care Personnel Registry timely, and failure to notify the county Department of Social Services and responsible parties of incidents requiring emergency medical evaluation and treatment.

The facility failed to ensure tuberculosis testing compliance for 2 of 5 sampled residents, lacked therapeutic diet menus for 3 residents with physician-ordered diets, and had multiple medication administration documentation deficiencies for all 5 sampled residents. Additionally, 2 of 3 residents in the Special Care Unit lacked required resident profiles within 30 days of admission and quarterly thereafter.

The facility was found to have multiple deficiencies including unsafe outside premises with a large pothole and pavement ruts, unclean and unrepaired walls, ceilings, floors, and furnishings, and inadequate exhaust ventilation in specified areas with several exhaust fans not working.

The facility failed to have a qualified food service supervisor who consulted with a licensed dietitian/nutritionist, failed to implement physician's medication orders for one resident, and lacked therapeutic diet menus for residents with physician-ordered therapeutic diets.

The survey found multiple deficiencies remain uncorrected, including unsafe outside premises with a large pothole and pavement ruts, poor housekeeping with stained floors and broken tiles, lack of required fire safety rehearsals on each shift quarterly, failure to maintain fire safety systems with holes allowing fire and smoke spread, and inadequate exhaust ventilation in specified areas with several non-working exhaust fans.

The complaint investigation was initiated by Iredell County Department of Social Services on 11/15/23 related to concerns about resident care including seizure management and dietary supervision.

The facility failed to have a qualified food service supervisor, failed to follow-up on a resident's seizure care and neurologist appointments, lacked therapeutic diet menus for residents with special diets, failed to clarify and properly administer insulin medication orders, failed to ensure medication availability and administration, and failed to complete required pre-admission screening and resident profiles for the Special Care Unit residents.

The facility was found to have multiple deficiencies including unsafe outside premises, poor housekeeping and maintenance issues, lack of fire safety rehearsals, failure to maintain fire safety and emergency equipment, improper storage of oxygen bottles, and inadequate exhaust ventilation in specified areas.

The facility failed to ensure referral and follow-up with the physician for one sampled resident regarding missed medications and failed to administer medications as ordered to two sampled residents, including medications to control blood sugars, serum phosphate levels, and chronic pain. Medication administration times were not adjusted for dialysis schedules, and missed medications were not properly communicated to the physician or pharmacy.

The facility failed to assure tuberculosis testing upon admission for 2 of 5 sampled residents, failed to notify the physician regarding refusals and missed labs related to Coumadin for 1 resident, and failed to administer medications according to physician orders for 2 residents, including missed doses of lorazepam and improper insulin administration.

Multiple deficiencies were cited including failure to maintain current sanitation and fire safety inspection reports, lack of hand grips in showers, obstructions in corridors and exits, non-functioning wanderer alarms, unsafe outside premises, poor housekeeping and furnishings, unsecured oxygen cylinders, improperly maintained fire extinguishers, lack of regular fire safety rehearsals, unsafe building equipment and emergency systems, use of prohibited portable electric heaters, and failure to maintain required exhaust ventilation systems.

The facility was found deficient in multiple areas including failure to ensure tuberculosis testing upon admission for sampled residents, failure to assure physician notification related to care coordination for a resident requiring a BiPAP machine and sleep study, failure to follow medication administration orders, failure to complete quarterly pharmaceutical reviews, and failure to follow up on pharmacist medication review recommendations.

The survey included a complaint investigation related to tuberculosis testing, staff qualifications, supervision, medication administration, resident rights, and infection control.

The facility failed to assure five of six sampled staff were tested for tuberculosis upon hire, failed to ensure two of seven sampled staff had no substantiated findings on the Health Care Personnel Registry prior to hire, failed to provide adequate supervision for residents in the Special Care Unit resulting in sexual activity, assaults, and elopements, failed to notify physicians of changes in resident conditions and missed medications, failed to provide required staff training including CPR and special care unit training, failed to maintain accurate medication administration and controlled substance records, and failed to maintain complete resident records and care plans.

The complaint investigation was initiated by the Iredell County Department of Social Services on November 30, 2018.

The facility failed to assure tuberculosis testing for 4 of 7 sampled staff, failed to ensure 2 of 8 sampled staff had no substantiated findings on the Health Care Personnel Registry prior to hire, failed to ensure 6 of 7 sampled staff were competency validated for Licensed Health Professional Support tasks, failed to provide diabetes care training to 3 medication aides prior to insulin administration, failed to notify the physician of medication not in the facility for 1 resident, failed to implement physician orders for weekly weights and blood pressures for 1 resident, failed to administer medications as ordered for 3 residents, and failed to provide required Special Care Unit staff orientation training to 1 staff member.

The facility failed to meet several physical plant and safety requirements including lack of fire detection devices in certain areas, outdated fire sprinkler system components, missing hand grips in bathrooms, loosely mounted handrails, improper storage of oxygen cylinders, electrical outlets without ground fault protection, locked exit doors without proper key access, malfunctioning warning devices, use of prohibited portable electric heaters, and non-functioning exhaust ventilation in the laundry.

The survey identified multiple deficiencies related to physical plant and safety code compliance, including improper installation of special locking exit doors without adequate fire detection, lack of combustion air for fuel-fired appliances, outdated and uncorrected fire safety inspection issues, missing hand grips in bathrooms, loose handrails on exterior ramps, unsafe storage and handling of medical oxygen cylinders, malfunctioning electrical outlets and exit signs, doors that do not close or latch properly, non-functioning warning devices for emergency exits, and a non-working exhaust fan in the laundry.

Complaint investigations were initiated by the Iredell County Department of Social Services on September 5, 2017 and October 20, 2017.

The facility failed to ensure proper physician order verification for oxygen use, accurate medication administration and documentation, and appropriate use of physical restraints including required assessments and consents for two residents. Deficiencies were found in medication order clarifications, medication administration accuracy, and restraint use protocols.

The facility failed to ensure referral and follow-up for 3 of 5 sampled residents with referrals for psychiatry, psychotherapy, gastrointestinal consults, and physical therapy. The facility also failed to administer medications as ordered for 4 of 5 sampled residents, failed to provide proper food storage and place settings, and failed to serve therapeutic diets as ordered. Additionally, the facility's medication administration records were inaccurate and incomplete for some residents, and the administrator failed to ensure proper oversight of healthcare referral, medication administration, nutritional services, and pharmaceutical care.

The visit included a complaint investigation triggered by reports of bedbug infestations and bites among residents. Staff and residents reported ongoing bedbug issues despite pest control treatments. Some residents showed evidence of bites and killed bedbugs. The pest control company had treated the facility but bedbugs persisted in some rooms.

The facility failed to maintain clean floors and furniture, with heavy dust buildup and presence of dead bedbugs in multiple rooms. Bedbug infestations persisted despite prior treatments, and some residents reported bites. The facility had staffing shortages affecting deep cleaning. Pest control measures had been taken but were not fully effective.

The facility failed to meet building code requirements for HVAC components penetrating the one-hour roof/ceiling assembly, had obstructions in corridors reducing required width, and failed to provide proper ventilation in certain areas, including non-operational exhaust fans in the 'A' Hall Chart Room and no mechanical exhaust ventilation in the 'A' Hall Spa Shower Room.

Multiple deficiencies were cited related to physical plant and safety issues including failure to meet building code requirements for HVAC penetrations, lack of current fire and sprinkler inspection reports, poor housekeeping with excessive particulate buildup, non-operational exhaust fans, malfunctioning door hardware, fire protection equipment not maintained safely, missing electrical cover plates, breaches in fire-rated construction, use of prohibited portable electric heaters, and lack of mechanical exhaust ventilation in certain areas.

The facility failed to ensure that one of six newly hired staff had no substantiated findings on the North Carolina Health Care Personnel Registry before hire. Staff C was hired despite having two substantiated findings of misappropriation of resident property. The facility submitted a plan of correction including immediate termination of Staff C and improved verification procedures.

Complaint investigation initiated on May 11, 2015 by the Iredell County Department of Social Services.

The facility was found to have multiple deficiencies including failure to assure criminal background checks for staff, competency validation for Licensed Health Professional Support tasks, training on care of diabetic residents, training on physical restraints, medication administration errors, inadequate supervision of residents with falls, and failure to maintain adequate medication administration records and supplies.