Millington Healthcare Center

Inspectors wroteBased on policy review, medical record review, hospital record review, observation, and interview, the facility failed to provide appropriate pain management consistent with professional standards of practice for 2 of 6 (Resident # 9 and #17) residents reviewed for pain management. The facility's failure to appropriately manage pain resulted in Immediate Jeopardy (IJ) on [DATE], when Resident #17 was re-admitted to the facility following a right below the knee amputation on [DATE]. Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of care. Resident #17's pain level was assessed as a 5 (on a scale of 1 - 10 with 10 being the most severe) on admission. [...]

Inspectors wroteBased on policy review, medical record review, facility investigation, and interview, the facility failed to implement effective interventions and supervision to prevent falls and incidents of elopement for 2 of 5 (Resident #17 and #5) sampled residents reviewed for accidents. Resident #17 had severe cognitive impairment and was dependent upon staff for assistance with all aspects of care. On [DATE] and [DATE], Resident #17 had undocumented new behaviors of attempting to climb out of the bed, then on [DATE], Resident #17 sustained an unwitnessed fall with a head injury which resulted in actual HARM. [...]

Inspectors wroteBased on facility policy review, personnel file review, medical record review, facility document review, Law Enforcement Investigation review, hospital order review, and interview, the facility failed to ensure the residents' rights to be free from misappropriation of residents' property for 13 of 13 (Resident #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #26, #28, and #30) sampled residents reviewed for misappropriation of resident property by means of diversion of resident medications including, but not limited to, controlled substances from [DATE] through [DATE]. On [DATE] facility Licensed Practical Nurse (LPN) M was arrested for drug diversion of the 13 residents' medications and controlled substances.

Inspectors wroteBased on policy review, job description review, personnel record review, facility investigation review, in-service record review, medical record review, observation, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being. [...]

Inspectors wroteBased on policy review, Pharmacy Services Agreement, Law Enforcement Investigation, facility investigation, medication reconciliation document review, medical record review, facility document review, observation, and interview, the facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medication, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and per facility policy, and failed to ensure controlled substances were in date and no discrepancies were identified for 31 of 57 (Residents #6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 38, 41, and 42) sampled residents reviewed for controlled substance reconciliation, drug diversion, and medication administration.

Inspectors wroteBased on policy review, document review, medical record review, Law Enforcement Investigation review, observation, and interview, the Administration failed to assure the provision of appropriate fiscal resources and personnel to meet the needs of the residents. Administration failed to ensure residents' medications were timely and accurately reconciled and free of misappropriation, failed to ensure competent nursing staff documented controlled substances when administered and administered medications per the physician's order and the facility's medication schedule; and failed to ensure available medications weren't expired.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to maintain accurate medical records related to medication administration for 6 of 6 (Resident #6, 9, 13, 16, 24, and 38) sampled residents reviewed for medication administration.

Inspectors wroteBased on policy review, medical record review, facility investigation, observation, and interview, facility staff failed to ensure an allegation of abuse was reported to Administration immediately for 1 of 6 (Resident #1) sampled residents reviewed for allegations of abuse and neglect.

Inspectors wroteBased on policy review, American Heart Association website: www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure, medical record review, and interview, the facility failed to ensure residents were free of significant medication errors for 1 of 5 (Resident #13) sampled residents reviewed for medication administration.

Inspectors wroteBased on policy review, observations, and interview, the facility failed to ensure food was handled, prepared, and served under sanitary conditions when 2 of 6 dietary staff (Dietary Aide #1 and Dietary Aide #3) failed to remove their gloves and perform hand hygiene after leaving the dirty side of the dishwasher and before removing clean dishes from the clean side of the dishwasher, when 1 of 6 dietary staff (Dietary Aide #2) failed to cover food when transporting food through the hallway, and when the facility failed to test the sanitizing solution level of the low temperature dishwasher daily. The facility had a census of 66 with 63 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to implement a comprehensive care plan for 2 of 18 (Resident #21 and #70) sampled residents reviewed for care planning.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow the facility policy for monitoring weights and failed to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 8 sampled residents (Resident #54) reviewed for nutrition and the facility failed to follow the RD recommendations timely and obtain reweight assessments for a weight change for 1 of 8 sampled residents (Resident #24) reviewed for nutrition. The facility's failure to monitor weights and follow the RD recommendations for nutritional interventions resulted in Actual Harm when Resident #54 had a severe weight loss.

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee and Essential Healthcare Personnel Screening Logs, Employee Schedules, assignment sheets, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 8 of 71 staff members (Dietary Aide #1, Dishwasher #1, [NAME] #1 and #2, Dietary Helper #1, the Assistant Dietary Manager, Housekeeper #1 and Physical Therapy Assistant (PTA) #1) failed to complete screenings for the detection of COVID-19 prior to working on 4 of 4 days (4/15/2022, 4/16/2022, 4/17/2022 and 4/19/2022) reviewed for screenings. This had the potential to affect the 70 residents residing in the facility.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when staff failed to provide privacy for 2 of 4 sampled residents (Resident #56 and #59) reviewed during wound care.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide reasonable accommodations to meet the residents' needs for the use of a call light for 3 of 70 sampled residents (Resident #46, #57, and #69) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to perform complete neurological (neuro) checks for residents that had unwitnessed falls for 1 of 8 sampled residents (Resident #27) reviewed for falls.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to obtain orders for oxygen for 1 of 6 sampled residents (Resident #68) reviewed for oxygen.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure pureed food was prepared and served under sanitary conditions as evidenced by an unclean deep fryer, ice build-up in freezers, carbon build-up on skillets, pureed foods not served at an appropriate temperature, no temperature logs for 1 of 2 nutrition freezers (A/B Nutrition Room), and a black substance in 1 of 3 ice machines (A/B Nutrition Room). The facility had a census of 75 residents with 75 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a comprehensive care plan was developed for an indwelling urinary catheter for 1 of 21 sampled residents (Resident #53) reviewed.

Inspectors wroteBased on Certified Nursing Assistant (CNA) job description, observation, and interview, the facility failed to ensure the availability of water at the bedside for 1 of 7 sampled residents (Resident #23) reviewed for nutrition.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a bedrail was maintained in good working order for 1 of 76 residents (Resident #1) reviewed with bedrails.