Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Millington Healthcare Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment experienced unmanaged pain due to the facility's failure to administer prescribed pain medications and to assess and address pain appropriately. One resident, post-amputation, did not receive ordered Hydrocodone and suffered uncontrolled pain, leading to agitation, a fall, and serious injury. Another resident with a hip fracture after a fall did not receive pain medication before hospital transfer, despite clear signs of distress. Staff did not follow up on unavailable medications or document pain management interventions, resulting in actual harm.
Two residents with severe cognitive impairment experienced preventable incidents due to inadequate supervision and failure to implement effective interventions. One resident, recently amputated and dependent on staff, exhibited new behaviors of trying to climb out of bed that were not documented or addressed, leading to an unwitnessed fall with serious injury. Another resident eloped from the facility after being mistaken for a visitor, as her risk was not identified and her photo was not in the elopement binder. In both cases, the facility did not follow its own policies for risk identification, documentation, and intervention.
An LPN diverted controlled and non-controlled medications from multiple residents, as evidenced by law enforcement's discovery of numerous resident-labeled blister packs and controlled drug records in the LPN's possession. The facility failed to maintain required documentation and was unable to account for the disposition of many medications, impacting residents with a range of medical and cognitive conditions.
Nursing staff failed to demonstrate required competencies, including immediate reporting of abuse allegations, accurate documentation of controlled substances, and timely administration of medications as ordered. A CNA delayed reporting an abuse allegation, while multiple LPNs did not properly document or administer medications according to policy and physician orders, resulting in discrepancies and late medication passes. The DON confirmed these failures were due to staff not following established procedures despite prior education.
A facility failed to maintain accurate systems for recording, reconciling, and accounting for controlled medications, resulting in an LPN diverting large quantities of scheduled and non-scheduled drugs from numerous residents. Law enforcement discovered the LPN in possession of blister packs and loose pills, many of which were missing all or most of their contents. Medication audits revealed ongoing discrepancies between medication records and actual counts, and interviews with leadership confirmed that the drug destruction process was not properly followed, allowing the diversion to go undetected.
Administration failed to ensure proper medication management, resulting in undetected drug diversion by an LPN, lack of timely pain control for two residents with significant medical needs, and inadequate systems for controlled substance reconciliation and documentation. The DON and Administrator were unaware of missing medications and did not have effective oversight or communication processes in place.
Multiple residents did not receive their medications as scheduled, and medication administration was not accurately or promptly documented by nursing staff, including agency and PRN nurses. Residents reported missed or late medications, and audit reports confirmed that medications were often given hours after the prescribed times or not documented at all. Staff interviews revealed difficulties in keeping up with medication administration and documentation requirements.
A resident, who was cognitively intact and had multiple medical conditions, reported to a nurse that a staff member had inappropriately touched him. Although the nurse reported the allegation to administration promptly, it was discovered that the resident had first disclosed the incident to a CNA the previous night, who failed to report it immediately as required by policy. The delay in reporting the allegation to administration resulted in noncompliance with the facility's abuse prevention policy.
A resident with multiple chronic conditions received Midodrine twice daily on dialysis days instead of the prescribed once daily dose, due to an incorrectly transcribed and scheduled order. The error was not identified by staff, and the medication was administered even after an elevated blood pressure reading was recorded and not re-checked.
Failure to Provide Appropriate Pain Management Resulting in Actual Harm
Penalty
Summary
The facility failed to provide appropriate pain management consistent with professional standards of practice for two residents who required such services. One resident, who was severely cognitively impaired and dependent on staff for all care, was readmitted after a right below-the-knee amputation. Upon admission, this resident's pain was assessed as moderate to severe, and physician orders included Hydrocodone for moderate pain and Ibuprofen for mild pain. Despite these orders, the facility did not administer Hydrocodone as needed for pain, resulting in the resident experiencing uncontrolled pain, as evidenced by restlessness, trembling, and new behaviors such as attempting to climb out of bed. The resident subsequently sustained an unwitnessed fall with a head injury, leading to hospitalization and diagnosis of subarachnoid hemorrhage and a periorbital fracture. The facility lacked a system to assess and address pain in residents with cognitive impairment, and there was no documentation of pain management interventions in the care plan. Another resident, also with severe cognitive impairment and dependent on staff, sustained an unwitnessed fall. Later, the resident exhibited intense pain through verbal complaints and nonverbal cues such as hollering, grimacing, and guarding the right hip and femur. The practitioner was not immediately notified, and the resident did not receive pain medication. A STAT x-ray was ordered and obtained hours later, revealing a periprosthetic fracture. The resident was transferred to the hospital without having received pain medication prior to transfer. Documentation did not reflect administration of pain medication, and staff interviews confirmed that pain management was not provided during the period of distress. Interviews with staff and review of records revealed multiple failures, including lack of follow-up when pain medications were not available, inadequate pain assessment for cognitively impaired residents, and insufficient documentation of pain management. Staff were aware that pain medications were not delivered or available, but did not take appropriate steps to resolve the issue or utilize available emergency supplies. The facility's policies required documentation and communication regarding pain management, but these were not followed, resulting in actual harm to both residents.
Removal Plan
- Root Cause Analysis was completed.
- Facility-wide audit of all residents with pain medication orders included confirmation the ordered pain medication was available on-site.
- Order request was sent to the pharmacy for a resident needing a re-fill of pain medication; resident received medication from the E-kit until the re-fill arrived.
- Pain Assessment/Management In-service training records were reviewed, including sign-in sheets and cross-referenced with current nursing staff including agency nursing.
- All nurses currently working had received pain assessment and management in-service training.
- Nursing staff were interviewed to describe the training received related to pain assessment, monitoring, and management.
- Training was conducted in person as well as electronically via the online training software.
Failure to Prevent Falls and Elopement Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to implement effective interventions and provide adequate supervision to prevent falls and elopement for two residents with severe cognitive impairment. One resident, who had recently undergone a right below-knee amputation and was dependent on staff for all care, began exhibiting new behaviors of attempting to climb out of bed. These behaviors were not documented in the clinical notes or addressed in the care plan, and the only interventions listed were to encourage the resident to use the call light, ensure proper footwear, and keep items within reach. Staff interviews confirmed that the resident was confused, in significant pain, and at high risk for falls, yet the care plan was not updated to reflect the new behaviors or increased risk. The resident subsequently sustained an unwitnessed fall resulting in a head injury, subarachnoid hemorrhage, and orbital fracture, and was transferred to the emergency department. The resident was later discharged to hospice and expired. Another resident with severe cognitive impairment and a history of wandering behaviors eloped from the facility through the front door. The resident was not identified as an elopement risk on admission, and the care plan did not include interventions for wandering or elopement. The resident was able to leave the building by telling the receptionist she was a visitor, as her picture was not included in the elopement binder used to identify at-risk residents. Staff only noticed the resident was missing when she was not at her usual location, and after a search, the resident was found at a nearby pharmacy approximately 12 minutes later. The receptionist, who was new to the facility, was unaware that the resident was not a visitor and allowed her to exit the building. Policy reviews revealed that the facility's procedures required identification of hazards and risks, implementation of appropriate interventions, and monitoring for effectiveness, but these were not followed in the cases described. Documentation and communication failures contributed to the lack of timely and effective interventions for both residents. The facility did not adequately assess, document, or respond to changes in resident behavior or risk, resulting in one resident sustaining actual harm and another eloping from the facility.
Widespread Diversion of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically the diversion of resident medications, including controlled substances, by a staff member. An LPN was found to have diverted medications from 13 residents over a period of time, as evidenced by law enforcement's discovery of numerous resident-labeled blister packs, both empty and partially full, in the LPN's possession. The medications included Schedule II, IV, and V controlled substances, as well as non-scheduled drugs, which were found in the LPN's car and home during a law enforcement investigation. The LPN was arrested and charged with multiple counts related to unlawful possession and intent to distribute controlled substances. The facility's policies required strict controls over the handling, storage, and documentation of controlled substances, including reconciliation at the end of each shift and proper documentation of medication disposition. However, the facility was unable to provide key documentation such as Pharmacy Electronic Shipping Manifests and Controlled Drug Record forms for many of the diverted medications. The Director of Nursing (DON) acknowledged that the facility's investigation was hampered by missing paperwork and that the LPN had been responsible for removing narcotics from the cart, particularly after residents expired or were discharged. The DON also stated that the facility's usual process for handling discontinued or expired medications involved logging and securing them until destruction, but much of the documentation was unavailable due to the law enforcement investigation. The affected residents had a range of medical conditions, including diabetes, anxiety, chronic pain, dementia, and other serious diagnoses, and many were prescribed controlled substances for pain, anxiety, or seizures. Some residents were cognitively intact and able to report missed medications, while others were severely cognitively impaired or had expired during their stay. The diversion of medications was substantiated by the physical evidence collected by law enforcement, which included hundreds of pills and numerous blister packs labeled with residents' names, as well as controlled drug record forms. The facility's inability to account for the medications and documentation contributed to the deficiency.
Failure to Ensure Competent Nursing Staff and Timely Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff, including LPNs and CNAs, demonstrated the necessary competencies and skills to provide care that maximizes residents' well-being. One CNA did not immediately report an allegation of abuse made by a cognitively intact resident, instead waiting until the following day to inform facility staff, despite having attended an abuse in-service earlier in the month. This delay in reporting was acknowledged by the CNA during an interview, where she admitted to knowing the requirement to report immediately but failed to do so. Multiple LPNs did not properly document the administration of controlled substances for several residents. Discrepancies were found between the medication cards and the Controlled Drug Records for various medications, including Lacosamide, Oxycodone-Acetaminophen, Hydrocodone-Acetaminophen, Lorazepam, Tramadol, Alprazolam, Pregabalin, and Gabapentin. These discrepancies were confirmed by the LPNs during medication cart audits and interviews, with one LPN attributing the failure to sign out medications to being busy. The DON confirmed that the facility's policy requires controlled substances to be signed out when administered and acknowledged that staff were not consistently following this policy. Additionally, nursing staff failed to administer medications according to physician orders and scheduled times for several residents. Audit reports revealed that medications were often given hours late or not documented as administered at the correct times. In some cases, residents reported not receiving their medications as scheduled, and the DON acknowledged ongoing issues with timely medication administration, particularly when agency nurses were involved. The DON stated that the issue was not due to lack of education but rather staff performance, as staff had been repeatedly instructed and in-serviced on proper procedures.
Failure to Account for and Prevent Diversion of Controlled Substances
Penalty
Summary
The facility failed to maintain an effective system for recording, reconciling, and accounting for all controlled medications, which resulted in the diversion of both scheduled and non-scheduled prescription drugs by a staff LPN. The LPN was found in possession of numerous blister packs and loose pills belonging to multiple residents, including controlled substances such as Morphine, Hydrocodone, Lorazepam, Xanax, Gabapentin, and others. Law enforcement discovered these medications during a traffic stop and subsequent search of the LPN's vehicle and home, where a total of 1,929.5 pills were seized. The LPN admitted to taking medications from deceased patients at the facility, and the investigation revealed that the facility's drug destruction process was not properly followed, allowing the LPN to remove medications without detection. Medical record reviews and law enforcement findings identified that the LPN had diverted medications from at least 31 residents, including those with complex medical histories such as diabetes, renal failure, anxiety, chronic pain, and neurological disorders. Blister packs for these residents were found in the LPN's possession, often with all or most pills missing, indicating that the medications were not administered as ordered. In several cases, controlled substance records and medication administration records did not match the actual count of medications present, and discrepancies were confirmed by nursing staff during audits. The facility's policies required strict documentation and reconciliation of controlled substances, but these procedures were not effectively implemented or monitored. Interviews with facility leadership, including the DON and Administrator, revealed that the LPN had been entrusted with the responsibility of removing narcotics from medication carts for destruction, but oversight was lacking. The DON stated that she was unaware of how the LPN was able to divert medications without being detected and that the investigation was hampered by the lack of available documentation, as much of the evidence was in law enforcement custody. Observations during medication cart audits further confirmed ongoing discrepancies in controlled substance counts for multiple residents, demonstrating a systemic failure in the facility's pharmaceutical services and controlled substance management.
Failure to Ensure Medication Management, Pain Control, and Prevention of Drug Diversion
Penalty
Summary
Facility administration failed to provide adequate fiscal resources and personnel to meet resident needs, resulting in multiple deficiencies related to medication management, staff competency, and resident safety. Policies and job descriptions required the administration and nursing leadership to ensure proper handling, documentation, and reconciliation of controlled substances, as well as timely administration of medications per physician orders. However, the administration did not identify or prevent the diversion of resident medications by an LPN, which went undetected until law enforcement notified the facility. The DON confirmed that oversight systems were lacking, and the facility did not recognize missing controlled drug record sheets or medication discrepancies prior to external notification. Residents were not provided with appropriate pain management consistent with professional standards. One resident with dementia and a recent hip fracture did not receive pain medication after a fall, despite exhibiting clear signs of pain and cognitive impairment. Another resident with a recent below-the-knee amputation and severe cognitive impairment experienced uncontrolled pain and developed new behaviors, including climbing out of bed, which led to a fall and subsequent injuries. In both cases, staff failed to assess and address pain appropriately, and physician orders for pain medication were not followed. The DON and Administrator acknowledged that staff did not communicate or escalate these issues as required. The facility also lacked effective systems for recording, reconciling, and accounting for all controlled medications. There were failures to promptly identify drug diversion, ensure medications were administered according to orders and schedules, and maintain in-date controlled substances. Interviews revealed that the Administrator was unaware of the reconciliation process and that an LPN had unsupervised access to controlled substances. The DON admitted to ongoing issues with medication administration and documentation, attributing some failures to staff performance rather than lack of education. These deficiencies affected numerous residents reviewed for drug diversion and medication management.
Failure to Accurately Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain accurate and timely medical records related to medication administration for six sampled residents. Facility policies required that all services provided, including medication administration, be documented in the resident's medical record immediately after administration. However, review of medical records, medication administration audit reports, and interviews revealed that medications were not consistently administered or documented according to physician orders and facility policy. In several cases, medications were documented as given hours after their scheduled times, and in some instances, there was no documentation that medications were administered at all. For example, one resident with Parkinson's Disease and other conditions had multiple medications scheduled for specific times, but the audit report showed these were documented as administered several hours late. The resident reported not receiving medications as scheduled, particularly when agency nurses were on duty. Another resident with dementia and diabetes had a medication marked as not given due to hospitalization, even though the transfer to the hospital occurred hours after the scheduled dose, and the nurse could not recall the timing of the transfer or medication administration. Additional residents with complex medical needs, including diabetes, schizophrenia, and other chronic conditions, also experienced delays in medication administration, with documentation showing medications given well outside the prescribed time frames. Interviews with residents and staff confirmed these discrepancies. Residents reported not receiving medications on time, especially during night shifts or when agency staff were present. Staff interviews revealed challenges in administering and documenting medications within the required time frames, often due to workload or unfamiliarity with procedures. The Director of Nursing acknowledged that medications were not administered or documented as scheduled and attributed some issues to agency and PRN nurses. These findings demonstrate a pattern of inaccurate and untimely documentation of medication administration, contrary to facility policy and professional standards.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
Facility staff failed to ensure that an allegation of abuse involving a resident was reported to administration immediately, as required by facility policy. The policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than two hours after the allegation is made. In this case, a resident with a history of diabetes, HIV, depression, and encephalopathy, who was cognitively intact, reported to a nurse that a staff member had inappropriately touched him. The nurse promptly reported the allegation to the administrator and initiated further steps, including arranging for the resident to be transported to the emergency room. However, it was later revealed through interviews that the resident had initially reported the same allegation to a Certified Nursing Assistant (CNA) the night before. The CNA did not immediately report the allegation, stating that she was unable to find the nurse in charge at the time and subsequently delayed reporting until the following day. The CNA acknowledged awareness of the requirement to report such incidents immediately and expressed regret for not doing so. Interviews with other staff, including the Registered Nurse and Chief Nursing Officer, confirmed the expectation that abuse allegations must be reported within two hours. The administrator also confirmed that the incident was investigated after being reported by the nurse, but the initial delay by the CNA in reporting the resident's allegation constituted a failure to follow the facility's abuse prevention policy.
Significant Medication Error in Administration of Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of Midodrine, a medication used to raise blood pressure. According to the physician's order, the medication was to be given once a day, 30 minutes prior to dialysis on Monday, Wednesday, and Friday. However, review of the Medication Administration Records for February and March 2025 showed that the resident received Midodrine twice a day on those days, rather than the prescribed once daily dose. This error was confirmed by both the Director of Nursing and the Nurse Practitioner, who acknowledged that the order was transcribed and scheduled incorrectly. The resident involved had multiple diagnoses, including diabetes, dependence on renal dialysis, hypothyroidism, anxiety, bipolar disorder, and insomnia, and was cognitively intact. On one occasion, the resident's blood pressure was recorded as elevated at 177/95, and there was no documentation that this elevated reading was re-checked. Despite the high blood pressure, Midodrine was administered less than an hour later. The error in medication administration was attributed to incorrect transcription and lack of verification of the order, as well as a failure to monitor and respond appropriately to elevated blood pressure readings.
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Illustrative
What surveyors actually found near you
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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 Millington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Gate Rehab & Healthcare Center | 7.4 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Memphis | 9.8 mi | ★★★★★ | 4 | 0 |
| Ave Maria Home | 9.8 mi | ★★★★★ | 0 | 0 |
| The Kings Daughters And Sons | 10.4 mi | ★★★★★ | 1 | 0 |
| Rainbow Rehab And Healthcare | 10.4 mi | ★★★★★ | 0 | 0 |
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