Inspection visit
Health inspection
Citations
13 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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F924 - Equip corridors with firmly secured handrails on each side
Put firmly secured handrails on each side of hallways.
F584 - Safe Environment
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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F775 - The facility must—
Keep complete, dated laboratory records in the resident's record.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
FAQ · About this visit
Common questions about this visit
What happened during the March 31, 2025 survey of Millcreek Rehabilitation and Nursing LLC?
This was a inspection survey of Millcreek Rehabilitation and Nursing LLC on March 31, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Millcreek Rehabilitation and Nursing LLC on March 31, 2025?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
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.
SourceView on CMS Care Compare
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.