Mills Nursing & Rehabilitation

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. The Dining Services Director/ Cook(s) insures [sic] that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. A facility policy titled, Food Storage- Dry Goods, dated October 2019, revealed, It is the center policy to insure [sic] all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. The policy revealed, 5. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and facility document and policy review, the facility failed to report an allegation of abuse for 1 (Resident (R)33) of 1 sampled resident reviewed for abuse. Specifically, an allegation of abuse that Resident 33 made toward Resident 34 was investigated by the facility but not reported to the state agency.The findings include: A facility policy titled, Abuse Neglect and Exploitation Policy, dated 04/2026, indicated, Y. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. [exempli gratia], for example, law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. A Resident Face Sheet revealed the facility admitted R33 on 05/05/2023.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored in a sanitary manner. Observation of the kitchen, on 05/07/2024 at 9:10 AM, revealed two (2) opened bags of grated parmesan cheese were stored in the refrigerator and were not sealed, labeled, or dated. The findings include: Review of the facility's policy titled, Food Receiving and Storage, revised July 2014, revealed foods should be received and stored in a manner that complied with safe food handling practices. Observation of the reach in refrigerator, on 05/07/2024 at 9:10 AM, revealed two (2) opened bags of grated parmesan cheese that had were not sealed, labeled, or dated. During an interview with [NAME] #1, on 05/10/2024 at 8:07 AM, she stated opened containers or packages of food should have a label for identification of the food, and a date to indicate when the food item was opened to ensure the food had not expired. Further, [NAME] #1 stated all opened food containers or packages should be sealed properly. During an interview with [NAME] #2,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This affected Residents (R), R1, R46, R53, R54, R88, R91 and R403. On 05/10/2024, reconciliation of the controlled drugs, on the East Hall with Licensed Practical Nurse (LPN) #4, revealed narcotics and scheduled drugs had not been signed out on the narcotic sign out book as administered. The findings include: Review of the facility's policy titled, Controlled Substances, dated 08/22/2019 and revised 08/19/2023, revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Review of the facility's policy titled, Medication Administration, dated 01/21/2023 and revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two (2) of 29 sampled residents, Resident 7 (R7) and R16. Observation on 05/08/2024, of R7's left heel wound dressing change, revealed the Assistant Director of Nursing (ADON), removed the soiled dressing and failed to perform hand hygiene before donning clean gloves. After the dressing change, the ADON failed to wash her hands before exiting the room. Observation of perineal care (pericare), on 05/08/2024 for R16, revealed State Registered Nurse Aide (SRNA) #2, placed R16's dirty cloths on the resident's bedspread. SRNA #2 failed to wash her hands or perform hand hygiene. The SRNA pulled the resident's bed linens up, and pulled the bedside curtain open and did not wash her hands. The findings include. Review of the facility's policy titled Infection Prevention and Control Program, dated 09/03/2021 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure residents' grievances were thoroughly investigated to include a statement of findings with corrective actions taken for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member filed a grievance reporting concerns that the resident's debit card and his/her money were missing. The facility failed to thoroughly investigate the resident's grievance and did not resolve or provide corrective action related to the resident's concerns until 07/17/2023, when the Certified Nurse Aide (CNA) #10, was identified by local police, as the person who made unauthorized transactions using the resident's debit card. The findings include: Review of the facility's policy, Resident and Family Grievances, dated 01/02/2023 revealed the Grievance Official was responsible for overseeing the grievance process; receiving, and tracking grievances through to its conclusion. The staff member receiving the grievance would record the nature and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of the facility's policy it was determined the facility failed to protect residents from abuse for one (1) of forty-one (41) sampled residents (Resident #33). On 10/10/2023 at 6:25 PM, Resident #32 was sitting in a wheelchair at the East Nurses' Station and motioned for Resident #33 to come over. Resident #32 then touched Resident #33's breast above his/her clothes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 08/30/2022, revealed it was the facility's policy to provide protection for the health, welfare and rights of each resident. This would be done by developing and implementing policies that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident's property. Training on misappropriation included training for new and existing staff on activities that constituted abuse, neglect, misappropriation of resident's property, reporting procedures, resident abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's policies, and review of the Police Report it was determined the facility failed to protect residents from abuse related to misappropriation of resident property for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 reported that she/he was missing her/his debit card and cash from her/his wallet. Resident #9's daughter discovered a debit card that was in Resident #9's wallet was potentially used by a staff member. She reported this to the facility on [DATE] or 06/27/2023. The police investigation discovered the debit card was used by one of the facility's staff members. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 08/30/2022, revealed the facility would protect the rights of each resident from misappropriation of property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member informed staff he/she was missing his/her debit card. The facility failed to implement its policy by identifying, correcting, and intervening in situations where misappropriation of the resident's property was likely to occur. Further, the facility failed to ensure the allegations were thoroughly investigated when the allegations of misappropriation were reported on 06/28/2023. The facility's failure to protect and prevent further acts of misappropriation allowed staff to steal over $500.00 from Resident #9 and potentially other residents. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 08/30/2022 revealed it was the policy of the facility to provide protection for residents by developing and implementing written policies and procedures that prohibit and prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.