Mills Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to store and prepare foods under proper sanitary conditions and failed to ensure food preparation equipment was clean. The deficiency had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on interview and facility document and policy review, the facility failed to report an allegation of abuse for 1 (Resident (R)33) of 1 sampled resident reviewed for abuse. Specifically, an allegation of abuse that Resident 33 made toward Resident 34 was investigated by the facility but not reported to the state agency.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs for one (1) of 29 sampled residents, Resident #1 (R1). On [DATE], Nurse Assistant (NA) #3 (Non Certified) failed to implement R1's Comprehensive Care Plan related to ensuring there were leg rests on the wheelchair and that the resident was positioned correctly in the wheelchair in regards to the pommel cushion. (A pommel cushion is designed to promote proper positioning by preventing residents from sliding forward in the wheelchair and features a raised center section that helps keep legs supported). As NA #3 propelled R1 in the wheelchair, the resident fell face first onto the floor. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of 29 sampled residents (Resident (R1)). On [DATE], Nurse Assistant (NA) #3 (Non Certified) pushed R1 in her wheelchair from her room. However, NA #3 failed to place the leg rests on the wheelchair and failed to ensure the resident was positioned correctly in the wheelchair in regards to the cushion. R1 fell face first onto the floor. The facility transferred R1 to the emergency room (ER) for evaluation. R1 sustained injuries which included: [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored in a sanitary manner. Observation of the kitchen, on 05/07/2024 at 9:10 AM, revealed two (2) opened bags of grated parmesan cheese were stored in the refrigerator and were not sealed, labeled, or dated.

Inspectors wroteBased on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This affected Residents (R), R1, R46, R53, R54, R88, R91 and R403. On 05/10/2024, reconciliation of the controlled drugs, on the East Hall with Licensed Practical Nurse (LPN) #4, revealed narcotics and scheduled drugs had not been signed out on the narcotic sign out book as administered.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two (2) of 29 sampled residents, Resident 7 (R7) and R16. Observation on 05/08/2024, of R7's left heel wound dressing change, revealed the Assistant Director of Nursing (ADON), removed the soiled dressing and failed to perform hand hygiene before donning clean gloves. After the dressing change, the ADON failed to wash her hands before exiting the room. Observation of perineal care (pericare), on 05/08/2024 for R16, revealed State Registered Nurse Aide (SRNA) #2, placed R16's dirty cloths on the resident's bedspread. SRNA #2 failed to wash her hands or perform hand hygiene. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to review and revise the resident's Person-Centered Comprehensive Care Plan for one (1) of six (6) sampled residents reviewed for elopement (Resident #1). Interviews with facility staff revealed Resident #1 frequently searched for and asked staff about the whereabouts of family members. However, this behavior was not reflected in Resident #1's care plan. Additionally, the Administrator stated the resident frequently left the facility with his/her family, which was a trigger for the resident to leave the facility unsupervised; however, the resident's care plan was not revised to reflect the Administrator's concerns. On 09/17/2023, while ambulating throughout the facility independently, Resident #1 exited the facility without staff's knowledge. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed for elopement risk (Resident #1). The facility assessed Resident #1 to be at risk for elopement on 08/22/2023. Staff observed the resident to wander throughout the facility searching for his/her family members; however, the staff were not alerted to provide increased supervision to the resident as this was the resident's normal behavior. Therefore, on 09/17/2023, the resident exited the facility undetected by staff. The resident was found approximately six hundred (600) feet outside of the facility by a citizen in the community. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure residents' grievances were thoroughly investigated to include a statement of findings with corrective actions taken for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member filed a grievance reporting concerns that the resident's debit card and his/her money were missing. The facility failed to thoroughly investigate the resident's grievance and did not resolve or provide corrective action related to the resident's concerns until 07/17/2023, when the Certified Nurse Aide (CNA) #10, was identified by local police, as the person who made unauthorized transactions using the resident's debit card.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy it was determined the facility failed to protect residents from abuse for one (1) of forty-one (41) sampled residents (Resident #33). On 10/10/2023 at 6:25 PM, Resident #32 was sitting in a wheelchair at the East Nurses' Station and motioned for Resident #33 to come over. Resident #32 then touched Resident #33's breast above his/her clothes.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, and review of the Police Report it was determined the facility failed to protect residents from abuse related to misappropriation of resident property for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 reported that she/he was missing her/his debit card and cash from her/his wallet. Resident #9's daughter discovered a debit card that was in Resident #9's wallet was potentially used by a staff member. She reported this to the facility on [DATE] or 06/27/2023. The police investigation discovered the debit card was used by one of the facility's staff members.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member informed staff he/she was missing his/her debit card. The facility failed to implement its policy by identifying, correcting, and intervening in situations where misappropriation of the resident's property was likely to occur. Further, the facility failed to ensure the allegations were thoroughly investigated when the allegations of misappropriation were reported on 06/28/2023. The facility's failure to protect and prevent further acts of misappropriation allowed staff to steal over $500.00 from Resident #9 and potentially other residents.