Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with Alzheimer's and dementia fell and later died after a nurse assistant failed to follow the care plan, which required the use of leg rests and proper positioning in a wheelchair. The assistant did not check the care plan and improperly positioned the resident, leading to severe injuries.
A resident with Alzheimer's Disease fell and sustained fatal injuries after a Nurse Assistant failed to follow the care plan, which required the use of leg rests and proper positioning in the wheelchair. The NA did not review the care plan and was unaware of the necessary safety measures.
The facility failed to store food in a sanitary manner, as two opened bags of grated parmesan cheese were found in the refrigerator without being sealed, labeled, or dated. Interviews with kitchen staff and the Director of Culinary Services confirmed that the facility's protocol requires opened food containers to be labeled and sealed properly, and any unlabeled or improperly sealed food should be discarded.
The facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Discrepancies were found in the controlled substance drug count and the narcotic sign-out sheets for several residents. An LPN admitted to not signing out controlled substances during her morning medication pass, which was against the facility's policy. Interviews with other nursing staff and the DON confirmed that all medications should be signed out at the time of administration.
The facility failed to maintain an infection prevention and control program, leading to deficiencies in the care of two residents. An ADON did not follow proper hand hygiene during a wound dressing change, and an SRNA failed to adhere to infection control practices during perineal care. Both lapses were contrary to the facility's policies, highlighting the need for further staff education and reinforcement of infection control measures.
Failure to Implement Comprehensive Care Plan Leads to Resident's Death
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #1 (R1), who had multiple diagnoses including Alzheimer's Disease, anxiety disorder, and dementia. The care plan specified that R1 should be assisted in a standard wheelchair with a pommel cushion for proper positioning and bilateral elevating leg rests. However, on the day of the incident, Nurse Assistant (NA) #3 did not follow these instructions. NA #3 transferred R1 into the wheelchair without the leg rests and did not ensure the resident was correctly positioned with the pommel cushion. As a result, R1 fell face-first onto the floor while being propelled in the wheelchair, leading to severe injuries including a traumatic subarachnoid hemorrhage, multiple fractures, and ultimately, R1's death. The incident report and interviews with staff revealed that NA #3 had not adhered to the care plan, believing that the resident did not need the leg rests despite the care plan's clear instructions. NA #3 admitted to not checking the care plan and failing to position R1 correctly in the wheelchair. This negligence was corroborated by Licensed Practical Nurse (LPN) #7, who confirmed that the leg rests were not in place at the time of the fall and that R1 was not properly aligned in the wheelchair. Further interviews with the MDS Coordinator, Staff Development Coordinator, and Director of Nursing (DON) confirmed that the comprehensive care plans were intended to guide staff in providing care and were to be followed as written. The failure to implement the care plan as specified led to the tragic fall and subsequent death of R1. The facility's policies and staff training emphasized the importance of adhering to care plans, but these were not followed in this instance, resulting in a severe deficiency in care.
Removal Plan
- Education for staff on the importance of following the Comprehensive Care Plans as written
- Ensuring clinical staff was educated related to finding the Comprehensive Care Plans and implementing them
- Further education for staff on equipment usage, floor training, care plans, and documentation
- Audit and interview with staff to ensure all interventions were in place according to the care plan
Failure to Follow Care Plan Results in Resident's Fatal Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident. A Nurse Assistant (NA) pushed the resident in a wheelchair without attaching the leg rests and failed to position the resident correctly in the wheelchair. As a result, the resident fell face first onto the floor, sustaining severe injuries including a traumatic subarachnoid hemorrhage, multiple fractures, and ultimately expired in the hospital from these injuries. The resident had a history of Alzheimer's Disease, anxiety disorder, and other conditions that required specific care interventions, including the use of a pommel cushion and bilateral elevating leg rests. The NA did not follow the resident's care plan, which specified these interventions. The NA admitted to not reviewing the care plan or Kardex prior to the transfer and was unaware of the required safety measures. Interviews with staff revealed that the NA had been trained on proper transfer techniques and the importance of following care plans but failed to apply this knowledge. The Director of Nursing (DON) and other staff confirmed that the resident's care plan included the use of leg rests and proper positioning in the wheelchair, which were not followed at the time of the incident.
Removal Plan
- Education for all nursing staff related to the need to follow the care plans
- Audit and interview with staff to ensure all interventions were in place according to care plan
- Education for NA #3/SRNA #3 related to ensuring the Care Plan was followed
Failure to Store Food in a Sanitary Manner
Penalty
Summary
The facility failed to ensure food was stored in a sanitary manner, as observed in the kitchen. Two opened bags of grated parmesan cheese were found in the refrigerator without being sealed, labeled, or dated. This observation was made during a survey at 9:10 AM. The facility's policy on food receiving and storage, which was revised recently, mandates that foods should be received and stored in compliance with safe food handling practices. However, the observed practice did not align with this policy. Interviews with kitchen staff and the Director of Culinary Services revealed that the facility's protocol requires opened food containers or packages to be labeled with the date they were opened and sealed properly. Cook #1 and Cook #2 both confirmed that opened food should be labeled and dated, and if not, it should be discarded. The Director of Culinary Services reiterated this policy, emphasizing that any unlabeled or improperly sealed food should be thrown away. The Administrator also stated that he expected food to be labeled, dated, and sealed as per the guidelines and policies. Despite these clear protocols, the deficiency was observed, indicating a lapse in adherence to the facility's food storage policies.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. During a narcotic count, discrepancies were found in the controlled substance drug count and the narcotic sign-out sheets for several residents. Specifically, medications such as Oxycodone, Alprazolam, Clonazepam, Lyrica, and Gabapentin were missing for residents with various diagnoses including paraplegia, spina bifida, vascular dementia, chronic pain syndrome, polyneuropathy, rheumatoid arthritis, type 2 diabetes mellitus, and anxiety. Licensed Practical Nurse (LPN) #4 admitted to not signing out controlled substances during her morning medication pass, stating it was quicker to administer the medications and sign them out later, which was against the facility's policy. This practice led to discrepancies in the drug count and the narcotic sign-out sheets for multiple residents, indicating a failure to comply with the facility's policies on medication administration and documentation of controlled substances. Interviews with other nursing staff, including Registered Nurses (RNs) and the Director of Nursing (DON), confirmed that all medications, including narcotics and controlled drugs, should be signed out at the time of administration on both the Medication Administration Record (MAR) and the narcotic sign-out sheet. The DON and the Administrator both emphasized that it was their expectation for staff to follow the facility's policies. The failure to adhere to these policies resulted in missing medications for several residents, highlighting a significant lapse in the facility's pharmaceutical services and controlled substance management.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to deficiencies in the care of two residents. For Resident 7, the Assistant Director of Nursing (ADON) did not follow proper hand hygiene protocols during a wound dressing change. The ADON removed the soiled dressing, failed to wash her hands before donning new gloves, and did not wash her hands after completing the dressing change and before exiting the room. This was contrary to the facility's policy on wound care and hand hygiene, which mandates thorough handwashing at specific steps during the procedure. The ADON acknowledged the lapse, attributing it to the pressure of being observed during the procedure, despite being the facility's Infection Preventionist responsible for ensuring compliance with infection control policies. For Resident 16, a State Registered Nurse Aide (SRNA) did not adhere to proper infection control practices during perineal care. The SRNA placed dirty cloths on the resident's bedspread, failed to wash her hands after removing soiled gloves, and proceeded to handle the resident's bed linens and open the bedside curtain without performing hand hygiene. The SRNA then disposed of the soiled items and only washed her hands after leaving the resident's room and entering the dirty utility room. This was in violation of the facility's perineal care policy, which requires handwashing before and after glove use and when handling soiled items. The SRNA later admitted to not having an open bag ready for the soiled cloths, which contributed to the lapse in proper procedure. Interviews with the Staff Development Coordinator and the Director of Nursing (DON) revealed that staff had been inserviced on correct handwashing techniques multiple times a year, and random spot checks were conducted to ensure compliance. However, the observed deficiencies indicated a need for further education and reinforcement of infection control policies. The Administrator also emphasized the expectation that all staff follow the established handwashing and infection control policies to prevent cross-contamination and ensure resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mayfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Acres Healthcare | 1.7 mi | ★★★★★ | 25 | 0 |
| Clinton-hickman County Nursing Facility | 18.6 mi | ★★★★★ | 0 | 0 |
| Lake Way Rehabilitation And Healthcare Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Clinton Place | 19 mi | ★★★★★ | 20 | 0 |
| Fulton Nursing And Rehabilitation, Llc | 19.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.