Inspection Reports for
Mills Nursing & Rehabilitation
500 BECK LANE, MAYFIELD, KY, 42066
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
97% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Mills Nursing & Rehabilitation.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Census: 101
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
A standard recertification inspection was conducted to assess compliance with regulatory requirements for continued certification.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the survey conducted from 07/07/2025 to 07/10/2025.
Report Facts
Survey Census: 101
Sample Size: 21
Supplemental Residents: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
An abbreviated survey was conducted to investigate complaint KY45040.
Complaint Details
Complaint KY45040 was investigated and found to have no deficiencies.
Findings
No deficient practices were identified during the complaint investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rita Henson | HSS | Completed the abbreviated survey investigating complaint KY45040. |
Inspection Report
Abbreviated Survey
Census: 98
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
An abbreviated survey investigating complaints KY00044125, KY00043688, and KY00043529 was initiated on 12/30/2024 and concluded on 01/02/2025.
Complaint Details
Investigation of complaints KY00044125, KY00043688, and KY00043529 found no deficient practices.
Findings
There was no deficient practice identified with Complaints KY00044125, KY00043688, and KY00043529.
Report Facts
Sample Size: 9
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 10, 2024
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to implement a comprehensive person-centered care plan and ensure adequate supervision to prevent accidents, specifically related to a resident fall resulting in serious injury and death.
Complaint Details
The complaint investigation substantiated that the facility failed to follow Resident #1's care plan, resulting in a fall with major injury and death. The facility also failed to maintain proper infection control practices for Residents #7 and #16.
Findings
The facility failed to follow the comprehensive care plan for Resident #1, resulting in a fall from a wheelchair without leg rests and improper positioning, causing severe injuries and death. Additionally, the facility failed to maintain an effective infection prevention and control program, including improper hand hygiene during wound care and perineal care for other residents.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan meeting all resident needs, resulting in Resident #1 falling from a wheelchair due to missing leg rests and improper positioning.
F 0689: The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents, leading to Resident #1's fall and subsequent fatal injuries.
F 0880: The facility failed to maintain an infection prevention and control program, including improper hand hygiene by staff during wound dressing changes and perineal care for Residents #7 and #16.
Report Facts
Sampled residents: 29
Brief Interview for Mental Status (BIMS) score: 0
Date of survey completed: May 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #3 | Nurse Assistant (Non Certified) / State Registered Nurse Assistant (SRNA) | Named in failure to follow care plan leading to Resident #1's fall |
| LPN #7 | Licensed Practical Nurse | Named in assessment and reporting of Resident #1's fall |
| ADON | Assistant Director of Nursing | Named in improper hand hygiene during wound dressing change |
| SRNA #2 | State Registered Nurse Aide | Named in improper hand hygiene during perineal care |
| Director of Nursing | Director of Nursing | Named in investigation and corrective actions |
| Medical Director | Medical Director | Named in ordering hospital evaluation after Resident #1's fall |
| Administrator | Administrator | Named in facility response and education after Resident #1's fall |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 10, 2024
Visit Reason
The investigation was conducted due to a complaint regarding a resident fall resulting in serious injury and death, and concerns about medication record keeping, food storage, and infection control practices.
Complaint Details
The investigation was triggered by a complaint related to a resident fall resulting in serious injury and death, and concerns about medication administration and record keeping, food safety, and infection control practices.
Findings
The facility failed to implement a comprehensive care plan for a resident, resulting in a fall with major injuries and death. Additionally, the facility failed to maintain accurate controlled substance records, store food properly, and follow infection prevention and control protocols.
Deficiencies (5)
F 0656: The facility failed to implement a comprehensive person-centered care plan for Resident #1, resulting in a fall due to improper wheelchair positioning and missing leg rests, causing serious injury and death.
F 0689: The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for Resident #1, leading to a fall with major injury and death.
F 0755: The facility failed to maintain accurate controlled substance records and reconcile narcotic counts, with multiple medications missing for several residents.
F 0812: The facility failed to store food in a sanitary manner, with opened bags of grated parmesan cheese found unsealed, unlabeled, and undated in the refrigerator.
F 0880: The facility failed to maintain an infection prevention and control program, with staff observed not performing hand hygiene appropriately during wound care and perineal care.
Report Facts
Residents sampled: 29
Resident #1: 1
Controlled drug discrepancies: 7
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #3 / SRNA #3 | Nurse Assistant / State Registered Nurse Assistant | Named in fall incident for failing to use leg rests and properly position resident in wheelchair |
| LPN #7 | Licensed Practical Nurse | East Unit Charge Nurse who responded to fall incident |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation and provided statements regarding fall incident and medication policies |
| Medical Director | Medical Director | Provided orders for emergency treatment after resident fall |
| Administrator | Facility Administrator | Provided statements regarding fall incident and corrective actions |
| LPN #4 | Licensed Practical Nurse | Involved in controlled substance reconciliation with discrepancies |
| RN #2 | Registered Nurse | Provided statements on medication administration and signing out controlled substances |
| RN #4 | Registered Nurse | Provided statements on medication administration and signing out controlled substances |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed failing to perform hand hygiene during wound dressing change |
| State Registered Nurse Aide #2 | State Registered Nurse Aide | Observed failing to perform hand hygiene during perineal care |
| Staff Development Coordinator | Staff Development Coordinator | Provided statements on staff education and infection control |
| Director of Culinary Services | Director of Culinary Services | Provided statements on food storage policies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 14, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident grievances, abuse, misappropriation of resident property, and elopement incidents at Mills Nursing & Rehabilitation.
Complaint Details
The complaint investigation involved Resident #9's grievance about missing debit card and cash, abuse and misappropriation by staff, and Resident #1's elopement incident. Resident #9's grievance was substantiated with findings of staff theft. Resident #1's elopement was confirmed with inadequate supervision and environmental controls.
Findings
The facility failed to thoroughly investigate a resident's grievance regarding missing debit card and cash, failed to protect residents from abuse and misappropriation of property by staff, and failed to provide adequate supervision to prevent elopement of a cognitively impaired resident. The facility implemented corrective actions including staff education, care plan revisions, and enhanced monitoring.
Deficiencies (6)
F 0585: The facility failed to ensure residents' grievances were thoroughly investigated and resolved, specifically regarding a missing debit card and cash for Resident #9.
F 0600: The facility failed to protect residents from abuse, including inappropriate touching between residents and misappropriation of Resident #9's property by a staff member.
F 0602: The facility failed to protect Resident #9 from misappropriation of property by a staff member who used the resident's debit card without consent.
F 0607: The facility failed to implement its abuse policy by not thoroughly investigating allegations of misappropriation and failing to reimburse Resident #9 for stolen cash.
F 0657: The facility failed to review and revise Resident #1's person-centered comprehensive care plan to reflect frequent wandering and elopement risk, resulting in Resident #1 eloping undetected.
F 0689: The facility failed to provide adequate supervision and maintain a safe environment to prevent elopement of Resident #1, who exited the facility undetected and was found 600 feet away.
Report Facts
Unauthorized transactions: 5
Total theft amount: 422.86
Resident #9 missing cash: 166
Distance Resident #1 eloped: 600
BIMS score Resident #9: 15
BIMS score Resident #1: 3
Number of residents sampled: 41
Number of residents reviewed for elopement: 6
Date of survey completion: Oct 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #10 | CNA | Identified by police as staff member who misappropriated Resident #9's debit card. |
| Licensed Practical Nurse #6 | LPN | Identified CNA #10 in police photograph related to Resident #9's debit card misuse. |
| Social Service Director | SSD | Responsible for grievance process and investigation of Resident #9's missing debit card. |
| Director of Nursing | DON | Involved in investigation and corrective actions for Resident #9 and Resident #1 incidents. |
| Assistant Director of Nursing | ADON | Involved in grievance investigation and care plan reviews. |
| Administrator | Administrator | Oversaw investigations and corrective actions related to Resident #9 and Resident #1. |
| Unit Manager #1 | Unit Manager | Notified Resident #1's guardian and physician after elopement. |
| Maintenance Director | Maintenance Director | Responsible for door checks, wanderguard system, and elopement drills. |
| Staff Development Coordinator | SDC | Provided staff education on elopement prevention and documentation. |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 4
Date: Jul 19, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in accurately coding resident assessments, developing comprehensive care plans, providing appropriate respiratory care, and ensuring proper food storage practices.
Deficiencies (4)
F 0641: The facility failed to ensure one resident's Minimum Data Set assessment was accurately coded to reflect hospice services.
F 0656: The facility failed to develop and implement a comprehensive care plan addressing dental care needs for one resident with missing teeth.
F 0695: The facility failed to store a resident's nebulizer mask properly when not in use, increasing risk of contamination.
F 0812: The facility failed to date a pan of pudding and a pitcher of tomato juice in the refrigerator as required by food safety standards.
Report Facts
Residents receiving meals from kitchen: 86
Number of sampled residents: 19
Nebulizer treatments ordered: 4
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