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Complaint Investigation

Millington Healthcare Center

March 27, 2025 · Millington, TN · 5081 Easley Avenue
Citations 3
CMS Rating 2/5
Beds 85
Provider ID 445425
Healthcare Facility
Millington Healthcare Center
Millington, TN  ·  View full profile →
Inspection Summary

MILLINGTON HEALTHCARE CENTER in MILLINGTON, TN — inspection on March 27, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF602
Minimal harm or Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of Some Resident #17 was experiencing uncontrolled pain as evidenced by the Resident's restlessness and trembling affected

Review of the medical record revealed Resident #17 was readmitted to the facility on [DATE], following hospital discharge with diagnoses that included a right below the knee amputation on [DATE].

On [DATE], Resident #17's physician orders included Hydrocodone every 6 hours as needed for a moderate pain level of ,d+[DATE] and Ibuprofen 800 milligrams (mg) every 8 hours as needed for a mild pain level of , d+[DATE].

445425

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445425 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Millington Healthcare Center 5081 Easley Avenue Millington, TN 38053

During a telephone interview on [DATE] at 12:15 PM, the Administrator was asked how the facility reconciled controlled substances prior to [DATE], to ensure that all medications delivered to the facility were handled properly and accounted for.

The Administrator was unable to answer the question and stated, That would be a DON [Director of Nursing] question .

445425

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445425 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Millington Healthcare Center 5081 Easley Avenue Millington, TN 38053

Review of the facility policy titled, Charting and Documentation, revised 7/2017, revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Medications administered .

Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .must electronically sign the resident's eMAR immediately after administration .

Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility .Late entries in the medical record shall be dated at the time of entry and noted as a late entry .

2.

Review of the medical record revealed Resident #6 was readmitted on [DATE], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms.

Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was cognitively intact and required use of a wheelchair for mobility.

Review of the physician's orders dated 1/2/2025 for Resident #6 revealed Carbidopa Levodopa ER (extended release) oral tablet 25-100 milligram (mg) give 1 tablet by mouth every three hours for Parkinson's Disease, Entacapone 200 mg give 1 tablet by mouth every 3 hours for Parkinson's Disease, Ropinirole Hydrochloride (HCL) 0.5 mg give 1 tablet by mouth 3 times a day for Parkinson's, Tizanidine HCI 4mg give 1 tablet by mouth 3 times a day for Contracture, and Gabapentin 800 mg give 1 tablet by mouth 3 times a day for Parkinson's Disease.

Review of the physician's orders dated 2/18/2025, Resident #6 Carvidopa 50-200 mg give 1 tablet by mouth four times a day for Parkinson's Disease, Diazepam 2mg give 1 tablet by mouth three times a day for Anxiety disorder and muscle spasms.

Review of the Medication Admin (Administration) Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately:

445425

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445425 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Millington Healthcare Center 5081 Easley Avenue Millington, TN 38053

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLINGTON, TN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MILLINGTON HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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