C-
55/100Mill Creek Center for Nursing and Rehabilitation Inspection Report, Violations & Safety Grade (Winston-Salem, North Carolina)
4911 Brian Center Lane, Winston-Salem, North Carolina 27106
Phone: 3367445674
CMS Overall:2/5
Overview & Bed Count
Certified Beds
66
Avg Residents/Day
56.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Forsyth
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing2/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | North Carolina Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.51 | 0.62 | -0.11 |
| Total Nurse Hours per Resident per Day | 3.57 | 3.87 | -0.30 |
| CMS Staffing Rating | 2/5 | 2.7/5 | - |
| Nursing Staff Turnover | 65.4% | 48.7% | - |
Health Citation History
28 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-28 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2025-04-14 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2025-04-14 | Resident Rights Deficiencies | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | C – Minimal Harm Potential |
| 2025-01-07 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-01-07 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-05-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2024-05-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2023-11-16 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | J – Immediate Jeopardy |
| 2023-11-16 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2023-11-16 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2023-11-16 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2023-11-16 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2023-11-16 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2023-11-16 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2023-11-16 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-11-16 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D – Moderate Harm Potential |
Fire Safety Citation History
23 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-28 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2026-05-28 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2026-05-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2025-04-14 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2025-04-14 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2025-04-14 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-04-14 | Egress Deficiencies | Meet other general requirements. | D – Moderate Harm Potential |
| 2025-04-14 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-04-14 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2025-04-14 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2023-11-16 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2023-11-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2023-11-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-11-16 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2023-11-16 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2023-11-16 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
| 2023-11-16 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2023-11-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | D – Moderate Harm Potential |
Total Penalties & Fines
$16,452
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-05-29 | Fine | $16,452 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Winston-Salem area at no cost.
Find Safe, Vetted Facilities Near Winston-Salem
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Winston-Salem area at no cost.
Find Safe, Vetted Facilities Near Winston-Salem
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.