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Inspection visit

Health inspection

Monument Healthcare MillcreekCMS #4651398 citations on this visit
8 citations recorded

Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0757GeneralS&S Epotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0773GeneralS&S Dpotential for harm

    F773 - The facility must—

    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

  • 0779GeneralS&S Dpotential for harm

    F779 - File in the resident's clinical record signed and dated reports of

    Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0919GeneralS&S Epotential for harm

    F919 - Resident Call System

    Make sure that a working call system is available in each resident's bathroom and bathing area.

FAQ · About this visit

Common questions about this visit

What happened during the November 20, 2025 survey of Monument Healthcare Millcreek?

This was a inspection survey of Monument Healthcare Millcreek on November 20, 2025. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Monument Healthcare Millcreek on November 20, 2025?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.