Millington Healthcare Center: Drug Diversion Failures - TN
The March 2025 inspection, triggered by a complaint, found that LPN M had been able to access the facility's narcotics without a second nurse present to co-sign. When inspectors asked the administrator whether she knew this was happening, she said she didn't. "I thought it was always two nurses," she told them.
It wasn't.
LPN M had already been identified by the time inspectors arrived, having diverted controlled substances at the facility. The inspection report does not specify what was taken or how long the diversion went on before anyone noticed. What it does document is what inspectors found when they looked at the broader system around that diversion: expired narcotics sitting on a medication cart, missed and inconsistent medication administrations, and records that couldn't be reconciled.
The narcotic emergency kit on the C Hall medication cart had expired. The Director of Nursing acknowledged she discovered it herself during the audit she conducted after the diversion came to light. She told inspectors she had been trying to get a replacement since she found it expired. When she found it, she didn't say.
Inspectors reviewed controlled substance records for 31 residents — numbers 8 through 42, with a few gaps — and found problems across all of them. The issues included medications not given according to physician orders, discrepancies that couldn't be accounted for, and controlled substances that were out of date.
The Director of Nursing described medication administration at the facility as "spotty." She said the problems were concentrated among agency staff and that the facility had been conducting additional training. Then she walked that back. After the diversion was identified, the facility provided education on controlled substance documentation. Staff didn't follow it. The DON told inspectors that wasn't an education problem. "This was a staff performance issue," she said.
When inspectors asked the administrator how the facility had been reconciling controlled substances before the diversion was discovered — the basic accounting process that should catch missing medications — she couldn't answer. She redirected the question. "That would be a DON question," she said.
The Director of Nursing, for her part, said the narcotic emergency kit should be reconciled when a medication is removed from it. She confirmed that wasn't happening consistently.
What the inspection describes is a facility where the two people responsible for overseeing medication safety had divided the responsibility in a way that left neither of them watching. The administrator assumed the DON was handling it. The DON was dealing with agency staff who weren't following documentation procedures even after being trained. The emergency narcotic kit sat expired on a cart in the hallway.
Nobody caught LPN M until after the diversion had already occurred.
The inspection report does not say how many doses were unaccounted for, which medications were diverted, or whether any resident went without a controlled substance they were prescribed because of what LPN M took. It does not say whether LPN M is still employed at the facility. Those details are not in the record inspectors produced.
What is in the record: 31 residents whose controlled substance histories couldn't be cleanly reconciled, a medication cart with an expired narcotic kit that the Director of Nursing had been meaning to replace, and an administrator who expected someone else was making sure the narcotics were safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Millington Healthcare Center from 2025-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 15, 2026 · Our methodology
MILLINGTON HEALTHCARE CENTER in MILLINGTON, TN was cited for violations during a health inspection on March 27, 2025.
When inspectors asked the administrator whether she knew this was happening, she said she didn't.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.