Millington Healthcare Center

In the surveyor’s words

From the most serious findings on record at Millington Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF697Mar 27, 2025

  Based on policy review, medical record review, hospital record review, observation, and interview, the facility failed to provide appropriate pain management consistent with professional standards of practice for 2 of 6 (Resident # 9 and #17) residents reviewed for pain management. The facility's failure to appropriately manage pain resulted in Immediate Jeopardy (IJ) on [DATE], when Resident #17 was readmitted to the facility following a right below the knee amputation on [DATE]. Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of care. Resident #17's pain level was assessed as a 5 (on a scale of 1 - 10 with 10 being the most severe) on admission. […]

• Immediate jeopardy, isolatedF600Dec 15, 2022

  Based on policy review, review of a facility incident report, medical record review, observation and interview, the facility failed to ensure a resident was free from neglect when the facility staff neglected to provide adequate supervision for a vulnerable resident (Resident #3) who exited the facility unsupervised and without staff knowledge. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #3, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, was missing for an undetermined amount of time when she walked approximately 218 feet from the facility, and was found at a nearby pharmacy. […]

• Immediate jeopardy, isolatedF610Dec 15, 2022

  Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of neglect/elopement were thoroughly investigated for 1 of 5 sampled residents (Resident #3) reviewed for wandering/elopement behaviors. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #3, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, was missing for an undetermined amount of time and was later found at a nearby pharmacy approximately 218 feet from the facility. […]

• Immediate jeopardy, isolatedF689Dec 15, 2022

  Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 5 sampled residents (Resident #3) reviewed for elopement/wandering behaviors. The facility's failure to ensure residents at risk for wandering/elopement behaviors were adequately supervised resulted in Immediate Jeopardy when Resident #3, who had severe cognition impairment and was at risk for wandering, exited the facility without staff knowledge through the front door, walked approximately 218 feet and was found by staff in a nearby pharmacy after an undetermined amount of time. […]

• Actual harm, isolatedF689Mar 27, 2025

  Based on policy review, medical record review, facility investigation, and interview, the facility failed to implement effective interventions and supervision to prevent falls and incidents of elopement for 2 of 5 (Resident #17 and #5) sampled residents reviewed for accidents. Resident #17 had severe cognitive impairment and was dependent upon staff for assistance with all aspects of care. On [DATE] and [DATE], Resident #17 had undocumented new behaviors of attempting to climb out of the bed, then on [DATE], Resident #17 sustained an unwitnessed fall with a head injury which resulted in actual HARM. […]