Mills Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mills Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656May 10, 2024

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs for one (1) of 29 sampled residents, Resident #1 (R1). On [DATE], Nurse Assistant (NA) #3 (Non Certified) failed to implement R1's Comprehensive Care Plan related to ensuring there were leg rests on the wheelchair and that the resident was positioned correctly in the wheelchair in regards to the pommel cushion. (A pommel cushion is designed to promote proper positioning by preventing residents from sliding forward in the wheelchair and features a raised center section that helps keep legs supported). […]

• Immediate jeopardy, isolatedF689May 10, 2024

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of 29 sampled residents (Resident (R1)). On [DATE], Nurse Assistant (NA) #3 (Non Certified) pushed R1 in her wheelchair from her room. However, NA #3 failed to place the leg rests on the wheelchair and failed to ensure the resident was positioned correctly in the wheelchair in regards to the cushion. R1 fell face first onto the floor. The facility transferred R1 to the emergency room (ER) for evaluation. […]

• Immediate jeopardy, isolatedF657Oct 14, 2023

  Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the resident's Person-Centered Comprehensive Care Plan for one (1) of six (6) sampled residents reviewed for elopement (Resident #1). Interviews with facility staff revealed Resident #1 frequently searched for and asked staff about the whereabouts of family members. However, this behavior was not reflected in Resident #1's care plan. Additionally, the Administrator stated the resident frequently left the facility with his/her family, which was a trigger for the resident to leave the facility unsupervised; however, the resident's care plan was not revised to reflect the Administrator's concerns. […]

• Immediate jeopardy, isolatedF689Oct 14, 2023

  Based on interview, record review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed for elopement risk (Resident #1). The facility assessed Resident #1 to be at risk for elopement on 08/22/2023. Staff observed the resident to wander throughout the facility searching for his/her family members; however, the staff were not alerted to provide increased supervision to the resident as this was the resident's normal behavior. Therefore, on 09/17/2023, the resident exited the facility undetected by staff. The resident was found approximately six hundred (600) feet outside of the facility by a citizen in the community. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based on observation, interview, and facility document and policy review, the facility failed to store and prepare foods under proper sanitary conditions and failed to ensure food preparation equipment was clean. The deficiency had the potential to affect all residents who received food from the kitchen.The findings include: A facility policy titled, Food Storage: Cold, dated October 2019, revealed, It is the center policy to insure [sic] all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines for the FDA [Food and Drug Administration] Food Code. The policy revealed, 5. […]