Inspection·April 11, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 residents (Resident #1) reviewed for medical record confidentiality. Residents Affected - Few The facility failed to ensure LVN A kept Resident #1's medical information confidential. LVN A left an Emergency Kit Charge Slip, dated 04/05/25, with Resident #1's name and listed the medications with administration dosage and route on the nurse station counter and in view for staff, visitors, and others. This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors. Findings include: Record review of Resident #1's face sheet, dated 04/08/25, indicated a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included anxiety (feeling of fear, dread, and uneasiness), heart disease, and kidney disease. During an observation of a picture provided by family member B on 04/08/25 indicated there was an Emergency Kit Charge Slip, dated 04/05/25, completed by LVN A attached to other unknown papers on the ledge of the nurse's station. Resident #1's name was visible and the Emergency Charge Slip indicated Tramadol (used to treat moderate to moderately severe pain in adults) 50 mg PO and Ativan (used to treat anxiety disorders) 0.5 mg PO. During an interview on 04/08/25 at 2:40 p.m., LVN A indicated she left Resident #1's Emergency Kit Charge Slip on the nurse's station to take back to the medication room and place it with the emergency medications. She said she did not recall leaving Resident #1's information on the nursing counter on 04/05/25. During an interview on 04/09/25 at 12:35 p.m., Family Member B said the picture of Resident #1's Emergency Kit Charge Slip was taken on 04/06/25 at 2:30 p.m. During an interview on 04/11/25 at 9:10 a.m., the RDCS said Resident #1's Emergency Kit Charge Slip, dated 04/05/25, should not have been left on the nurse counter. She said all resident records were confidential. Record review of the facility's Resident Rights policy, dated 2002 (revised 2016), indicated 1. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 675338 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)