Millington Healthcare Center

F-F602

4. The facility Administration facility failed to ensure staff provided appropriate pain management consistent with professional standards of practice for Resident #9 and #17 and a safe environment to prevent accidents for Resident #17.

a. Resident #9 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including Dementia, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Resident #9's Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed the Resident was rarely understood, exhibited short-term and long-term memory problems, and was assessed by staff with severe cognitive impairment.

On [DATE REDACTED] at 1:15 AM, Resident #9 sustained an unwitnessed fall, and later at 9:15 AM, Resident #9 began to exhibit verbal complaints and nonverbal cues of intense pain, hollering out when her right leg was moved, grimacing, and guarding her right hip and femur (thigh bone). The practitioner was not immediately notified of Resident #9's pain and the Resident did not receive pain medication. An x-ray was ordered at 11:31 AM and was obtained approximately 2 hours later at 1:32 PM. The x-ray revealed Resident #9 suffered a periprosthetic fracture (fracture that occurs around or near an orthopedic implant). Resident #9 was transferred to the hospital at approximately 3:40 PM.

Resident #9 did not receive pain medication to address her pain prior to leaving the facility.

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Review of the admission assessment dated [DATE REDACTED] at 6:30 PM, revealed Resident #17 was experiencing pain rated as 5, which frequently caused difficulty sleeping and led to limitations of day-to-day activities. Level of Harm - Minimal harm or Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of potential for actual harm care.

Residents Affected - Some Resident #17 was experiencing uncontrolled pain as evidenced by the Resident's restlessness and trembling of the extremity. Resident #17 developed a new behavior of climbing out of bed on [DATE REDACTED] and on [DATE REDACTED]. Resident #17 sustained an unwitnessed fall with head injury, was transferred to the hospital and diagnosed with subarachnoid hemorrhage and a periorbital fracture. The facility failed to have a system in place to assess pain of residents with cognitive impairment and appropriately address the pain.

c. During an interview on [DATE REDACTED] at 9:41 AM, the DON confirmed Resident #17 did not receive Hydrocodone as ordered by the physician for pain rated 4 or greater.

During an interview on [DATE REDACTED] at 3:43 PM, the DON reviewed the orders from the hospital for Resident #17 that documented to pick up the ordered Hydrocodone at a local pharmacy in front of the facility. The DON stated, I would have said, whoa, I could have the family go get it and use it .she [LPN D] could have called me, and I could have given her direction .something would have happened, even if I called a Nurse Practitioner .she could have put in something [for pain]. They call me for a million things .night and day, but

they didn't call me for this. The DON stated, I found out Monday when she went out.

During an interview on [DATE REDACTED] at 5:20 PM, when the Immediate Jeopardy template for Pain Management was presented to the Administrator and DON, the Administrator was asked was she aware of the issue with Resident #17 not receiving Hydrocodone for pain from [DATE REDACTED]-[DATE REDACTED]. The Administrator stated she had just been made aware when she returned from her trip (was not in the facility during the survey from [DATE REDACTED] through [DATE REDACTED] due to a pre-planned trip).

During an interview on [DATE REDACTED] at 1:33 PM, the DON confirmed Resident #9 experienced a fall with periprosthetic femur fracture, did not receive pain medication on [DATE REDACTED], and the nursing staff should have called the Nurse Practitioner (NP) to get an order for pain medication.

Refer to

F-F697

5. The facility Administration failed to ensure the facility had a system of recording, accurate reconciliation, and accounting for all controlled medications, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and the facility's medication schedule, and failed to ensure controlled substances were in date and no discrepancies were identified for Residents #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, #37, #38, #41, and #42 reviewed for drug diversion, controlled substance reconciliation, and administration of medications.

During a telephone interview on [DATE REDACTED] at 12:15 PM, the Administrator was asked how the facility reconciled controlled substances prior to [DATE REDACTED], 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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The Administrator was asked if she was aware that LPN M had unlimited access to controlled substances without having to have a second nurse to sign with her. The Administrator stated, .No, I was not .I thought it Level of Harm - Minimal harm or was always two nurses . The Administrator was asked if, as the Administrator, she expected that someone potential for actual harm was tracking the controlled substances. The Administrator stated, .Yes, I just expect that to be the DON's responsibility to make sure those [controlled] substances are safe . Residents Affected - Some

During an interview on [DATE REDACTED] at 3:43 PM, the DON was asked when the narcotic E-kit should be reconciled if a medication is taken out of it. The DON stated, When it's taken out. The DON confirmed she identified the narcotic E-kit on the C Hall Medication Cart was expired on [DATE REDACTED] when she audited the cart at the time of

the drug diversion by Licensed Practical Nurse (LPN) M. The DON stated, .I have since it expired been trying to get it in here .

During an interview on [DATE REDACTED] at 3:38 PM, the DON acknowledged the facility was having issues with medications being administered as ordered. The DON stated medication administration was being spotty, and they were trying to conduct additional training for agency staff. The DON acknowledged nursing staff failed to follow the education and training related to controlled substance documentation that was provided

after the drug diversion was identified in [DATE REDACTED], when the controlled substances were not signed out when administered on [DATE REDACTED]. The DON acknowledged this was a staff performance issue, rather than an education issue.

Refer to

F-F755

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37532

Residents Affected - Some Based 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.

The findings included:

1. 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 REDACTED], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms.

Review of the Minimum Data Set (MDS) dated [DATE REDACTED], 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:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The Ropinirole HCl 0.5 mg scheduled for 5:00 AM was documented as administered at 9:24 AM.

Level of Harm - Minimal harm or The Tizanidine HCI 4 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. potential for actual harm

The Gabapentin 800 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. Residents Affected - Some

The Entacapone 200 mg give 1 tablet scheduled for 6:00 AM was documented as administered at 9:24 AM.

The Carbidopa- Levodopa 25-100 mg dose scheduled for 6:00 AM was documented as administered at 9:24 AM.

The Diazepam 2 mg scheduled for 6:00 AM was documented as administered at 9:24 AM.

The Ropinirole HCI 0.5 mg scheduled for 9:00 PM was documented as administered at 11:34 PM.

The Tizanidine HCI 4 mg scheduled for 9:00 PM was documented as administered at 11:33 PM.

The Entacapone 200 mg scheduled for 9:00 PM was documented as administered at 11:33 PM.

The Carbidopa-Levodopa 25-100 mg scheduled for 9:00 PM was documented as administered at 11:33 PM.

During an interview on 3/18/2025 at 2:26 PM, Resident #6 stated on Friday night 3/14/2025, the nurse did not give him his Parkinson's medicine as scheduled. Resident #6 stated, This problem comes and goes, depending on the number of agency nurses working.

During interview on 3/20/25 12:05 PM, the Director of Nursing (DON) confirmed the medication administration audit revealed Resident #6's medication was not administered as scheduled per the physician order and/or the medication administration was not documented timely and accurately.

3. Review of the medical records revealed Resident #9 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including Dementia, Diabetes, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee.

Review of a physician's order for Resident #9 dated 2/6/2025, revealed an order for Acetaminophen (for minor aches and pains) 325 mg, give 3 tablets by mouth two times a day.

Review of the fall Incident Report dated 2/21/2025 at 1:15 AM, revealed Resident #9 sustained an unwitnessed fall.

Review of the undated facility document titled MED (Medication) PASS TIME FRAMES revealed medications ordered two times a day should be administered from 7:00 AM-10:00 AM for the morning dose and 7:00 PM-10:00 PM for the evening dose.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of the Medication Admin Record (MAR) for Resident #9 dated 2/21/2025, revealed a 6 (indicated the resident was hospitalized ) was documented in the box where the 7:00 AM to 10:00 AM dose of Level of Harm - Minimal harm or Acetaminophen should have been documented. Resident #9 was not transferred to the hospital until potential for actual harm approximately 3:41 PM. Continued review revealed the MAR did not reflect documentation that Resident #9 received the Acetaminophen. Residents Affected - Some

Review of the E-INTERACT FORM dated 2/21/2025, revealed Resident #9 was transferred to the hospital at 3:41 PM.

During a telephone interview on 3/27/2025 beginning at 2:10 PM, Licensed Praqctical Nurse (LPN) was asked about her documentation of Acetaminophen on the Medication Administration Record (MAR) that documented a 6 which indicated the resident was hospitalized , and asked did that mean the medication was not administered. LPN L stated, I guess not. LPN L stated she did not remember what time Resident #9 was transferred to the hospital.

4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE REDACTED] with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia.

a. Review of the physician's order for Resident #13 dated 2/6/2025, revealed the following:

Insulin Lispro (fast-acting insulin to lower blood glucose) 100 Units/ML, inject per sliding scale before meals for blood sugar (glucose) levels of:

71 - 150 mg/dL = 0 units

151 - 200 mg/dL = 2 units

201 - 250 mg/dL = 4 units

251 - 300 mg/dL = 6 units

301 - 350 mg/dL = 8 units

351 - 400 mg/dL= 10 units

401 mg/dL or above = 10 units recheck in one hour if blood sugar (glucose) has not gone down, notify the Nurse Practitioner (NP).

Continued review revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth four times a day for pain, Montelukast Sodium 10 mg, give 1 tablet by mouth one time a day for allergies, Ezetimibe 10 mg, give 1 tablet by mouth one time a day for Hyperlipidemia, Fluticasone Propionate Nasal Suspension 50 micrograms/actuation (mcg/act), 1 spray alternating nostrils two times a day for Allergic Rhinitis, and Sennosides-Docusate (Senna-S) 8.6-50 mg, give 2 tablets by mouth one time a say for Constipation.

b. Review of the MAR for Resident #13 dated 2/1/2025-2/28/2025, revealed the following medications were documented as being administered timely:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 On 2/26/2025 at 7:30 AM, Resident #13's blood glucose (sugar) was 233 milligrams per deciliter (mg/dL) and LPN L documented she administered 4 units of Lispro Insulin at 7:30 AM. Level of Harm - Minimal harm or potential for actual harm On 2/26/2025 at 12:00 PM, Resident #13's blood glucose was 264 mg/dL and LPN L documented she administered 6 units of Lispro Insulin at 12:00 PM. Residents Affected - Some

On 2/26/2025 at 11:00 AM, LPN L documented that she administered Resident #13's Norco.

Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 2/25/2025-2/27/2025 revealed the following medications were not documented as being administered accurately:

The Lispro Insulin scheduled on 2/26/2025 at 7:30 AM was documented as administered at 2:20 PM.

The Norco 7.5-325 mg scheduled on 2/26/2025 at 11:00 AM was documented as administered at 2:20 PM.

The Lispro Insulin scheduled on 2/26/2025 at 12:00 PM was documented as administered at 2:21 PM.

The Buspirone 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM.

The Montelukast Sodium 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM.

The Ezetimibe 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM.

The Fluticasone Propionate Nasal Spray scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM.

The Senna-S 8.6-50 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:53 AM.

Review of the MAR revealed the medications were administered timely, but review of the Medication Admin Audit Report revealed the medications were actually not accurately documented as administered timely.

Observation and interview in the Resident's room on 3/13/2025 at 9:20 AM, revealed Resident #13 was in bed and wearing oxygen. Resident #13 stated a night nurse (Named LPN Q) said he gave her medications while she was asleep, but she told him she couldn't take medications while she slept. Resident #13 stated, . come to find out the next morning there was a lot of people that didn't get their medication so he's not coming back .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview on 3/26/2025 at 12:46 PM, LPN L stated medication should be administered within an hour before and an hour after the time it was scheduled. LPN L reviewed the Medication Admin Audit Report Level of Harm - Minimal harm or and stated she gave Resident #13's 7:30 AM dose of Lispro Insulin before breakfast. LPN L stated, I know potential for actual harm because that's when I go down the hall and administer .sometimes there's just so much going on with that many patients it's hard to get it signed out. LPN L stated she administered Resident #13's 12:00 PM Lispro Residents Affected - Some and Norco right before the Resident left for Dialysis which was around 11:00 AM. When asked about the documentation that showed Resident #13 received her 7:30 AM at 2:20 PM and 12:00 PM dose of Lispro Insulin at 2:21 PM, LPN L stated, That's probably just when I was able to chart it [Lispro Insulin and Norco] .

5. Review of the medical records revealed Resident #16 was admitted to the facility on [DATE REDACTED], with diagnoses including Diabetes, Hypothyroidism, Gout and Cellulitis of Right Lower Limb.

Review of the physician's orders for Resident #16 dated 3/6/2025 revealed Levothyroxine Sodium Tablet 137 micrograms (MCG) Give 1 tablet by mouth one time a day for Hypothyroidism and Furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for edema.

Review of the quarterly MDS assessment dated [DATE REDACTED] revealed resident had a BIMS score of 15, which indicated Resident #16 was cognitively intact.

Review of the Medication Admin 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:

The Levothyroxine Sodium 137 MCG Give 1 tablet scheduled at 4:00 AM was documented as administered at 1:06 PM.

The Furosemide 20 mg Give 1 tablet scheduled at 5:00 AM was documented as administered on 3/14/2025 at 1:06 PM.

Observation and interview in the Resident's room on 3/13/2025 at 9:34 AM, revealed Resident #16 was in bed. Resident #16 stated there were times she did not receive her medications as scheduled especially on

the night shift and she would get the medications when the day shift nurse arrived.

During an interview on 3/26/2025 at 3:38 PM, the DON confirmed Resident #16's Levothyroxine that was due at 4:00 AM and the Furosemide that was due at 5:00 AM were documented as administered at 1:06 PM.

The DON stated, [Named LPN C] comes at 7 [7:00] AM and gave the meds that were due at 4 [4:00] and 5 [5:00] am because they were not administered by either Agency [an agency nurse] or [Named LPN Q], a prn nurse. The DON stated, .it's [medication administration] being spotty and we're trying to get every agency person in here for additional training and the ones who are not performing I'm not letting them come back.

6. Review of the medical records revealed Resident #24 was admitted to the facility on [DATE REDACTED], with diagnoses including Diabetes, Paraplegia, Schizophrenia, Narcolepsy, Insomnia, and Anxiety.

Review of the quarterly MDS assessment dated [DATE REDACTED], revealed resident had a BIMS score of 15, which indicated Resident #24 was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of the physician's orders for Resident #24 dated 3/6/2025, revealed Simethicone 125 mg give 1 tablet by mouth before meals and at bedtime for heartburn, Tamsulosin HCL 0.4 mg give 2 capsules by Level of Harm - Minimal harm or mouth at bedtime for enlarged prostate, Risperdal 1 mg give one tablet by mouth at bedtime for potential for actual harm Schizophrenia, Gabapentin 600 mg give 1 tablet by mouth three times a day for Polyarthritis, Clonazepam 1 mg give 1.5 tablets by mouth at bedtime for Anxiety, and Mesalamine Rectal Suppository 1000 mg, insert 1 Residents Affected - Some suppository rectally at bedtime for Constipation.

Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025-3/16/2025 revealed the following medications were not documented as being administered accurately:

The Simethicone 125 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM.

The Tamsulosin HCL 0.4 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM.

The Risperdal 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM.

The Gabapentin 600 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM.

The Clonazepam 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM.

The Mesalamine Suppository 1000 mg scheduled for 3/14/2025 at 9:00 PM, was documented as administered on 3/15/2025 at 12:01 AM.

7. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE REDACTED] with diagnoses including Dementia, Diabetes, Bipolar Disorder, Schizophrenia, Osteoarthritis, and Depression.

Review of the annual MDS assessment dated [DATE REDACTED] revealed Resident #38 was cognitively intact.

Review of the physician's orders for Resident 38 dated 3/6/2025, revealed Acetaminophen 650 MG give 2 tablets by mouth three times a day, Gabapentin (to treat seizures and nerve pain) 800 MG give 1 tablet by mouth three times a day, Ziprasidone (to treat Schizophrenia) 20 MG give 1 capsule by mouth at bedtime, Ziprasidone 80 MG, give 1 capsule by mouth at bedtime, and Lamictal (to treat seizures and bipolar disorder) 200 MG give one tablet by mouth at bedtime.

Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/15/2025 revealed the following medications were not documented as being administered accurately:

The Acetaminophen 650 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 1:44 AM.

The Lamictal 200 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:13 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 64 445425 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The Gabapentin 800 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:14 AM.

Level of Harm - Minimal harm or The Ziprasidone 20 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. potential for actual harm

The Ziprasidone 80 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. Residents Affected - Some

Observation and interview on 3/17/2025 at 12:20 PM, revealed Resident #38 sitting in her wheelchair in her room and the Resident stated, .didn't get our meds last night till 2:30 the next morning .agency nurse she didn't know what she was doing .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 64 445425