Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Jefferson Nursing And Rehabilitation Center | 16 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.