Cycle 1
Health 2024-03-07 · Fire 2024-03-07
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Millington, TN
Millington Healthcare Center
1-star overall rating with 1-star inspections with $231,516 in total fines with 11 recent health deficiencies
5081 Easley Avenue, Millington, TN
(901) 873-3290
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellington Health Care Services
Operator or chain grouping
Approved since
2001-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,992
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9947
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.24
Baseline 24.39% · Performance 20.16% · Measure score 5.24 · Achievement 2.73 · Improvement 5.24
Healthcare-associated infections
3.01
Baseline 8.14% · Performance 7.04% · Measure score 3.01 · Achievement 2.66 · Improvement 3.01
Total nurse turnover
6.50
Baseline 43.55% · Performance 37.10% · Measure score 6.50 · Achievement 6.50 · Improvement 2.95
Adjusted total nurse staffing
1.98
Baseline 2.59 hours · Performance 3.38 hours · Measure score 1.98 · Achievement 1.07 · Improvement 1.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 12.58% · Lower 95% interval 8.2% |
| Discharge to community | 53.32% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 43.17% · Lower 95% interval 44.37% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.14% |
95.27%
3.9 pts better
|
Numerator 115 · Denominator 116 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 116 |
| Discharge self-care score | 49.33% |
53.69%
4.4 pts worse
|
Numerator 37 · Denominator 75 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 45 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 4.31% |
2.29%
2 pts worse
|
Numerator 5 · Denominator 116 · Adjusted rate 3.19% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 7.48% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 107 |
| Discharge function score | 52% |
56.45%
4.5 pts worse
|
Numerator 39 · Denominator 75 |
| Transfer of health information to provider | 94.44% |
95.95%
1.5 pts worse
|
Numerator 34 · Denominator 36 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 41 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 1.47% |
25.2%
23.7 pts worse
|
Numerator 1 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.6
1.3 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 12.1% |
89.9%
77.8 pts worse
|
93.4%
81.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 16.7% · Q3 15.4% · Q4 10.6% · 4Q avg 12.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.5% |
94.5%
12 pts worse
|
95.5%
13 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.6%
2.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.5% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
11.8%
5 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 8.1% · Q4 16.1% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 14.4% |
6.2%
8.2 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 20.0% · Q3 18.5% · Q4 8.8% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.6% |
32.2%
4.4 pts worse
|
19.6%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 32.1% · Q3 33.3% · Q4 36.7% · 4Q avg 36.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
18.1%
2.8 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 11.4% · Q3 16.3% · Q4 20.0% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.8% |
19.9%
0.9 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
15.3%
3.2 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.4% · Q3 24.1% · Q4 9.4% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.7% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.9%
0.3 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.4% · Q4 3.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
20.2%
1.7 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 26.1% · Q3 21.7% · Q4 15.1% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 12.1% |
5.4%
6.7 pts worse
|
5.1%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 11.6% · Q3 14.9% · Q4 15.9% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 5.3% |
79.6%
74.3 pts worse
|
81.7%
76.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 4.4% · Q3 4.6% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.2%
1.5 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.6%
0.6 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 2.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 9.9% |
79.8%
69.9 pts worse
|
79.7%
69.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 9.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
22.2%
1.6 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.3% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-26 · Fire 2022-04-26
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-12 · Fire 2020-02-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-02-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-18
D · Potential for more than minimal harm
2020-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-18
D · Potential for more than minimal harm
2020-02-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-18
B · Minimal harm
2020-02-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-03-18
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-24
G · Actual harm
2025-03-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-03-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-03-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-03-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-03-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-25
E · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-06
D · Potential for more than minimal harm
2023-03-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-03-17
G · Actual harm
2022-04-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-01
F · Potential for more than minimal harm
2020-02-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-18
D · Potential for more than minimal harm
2020-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-18
D · Potential for more than minimal harm
2020-02-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-03-18
D · Potential for more than minimal harm
2020-02-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-03-18
Penalties and ownership
What sits behind the stars
$203,873
2025-03-27
Fine
Fine · fine $203,873
Fine
$22,750
2024-03-07
Fine
Fine · fine $22,750
Fine
$1,748
2023-06-26
Fine
Fine · fine $1,748
Fine
$3,145
2023-06-05
Fine
Fine · fine $3,145
Fine
Ownership
Wellington Healthcare Services LP
5% Or Greater Direct Ownership Interest · Organization
Andrews, James
5% Or Greater Indirect Ownership Interest · Individual
Andrews, James
Operational/Managerial Control · Individual
Andrews, James
Corporate Director · Individual
Andrews, James
Corporate Officer · Individual
Andwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Teresa
W-2 Managing Employee · Individual
Elkins Road Associates LLC
General Partnership Interest · Organization
Kelman, Moshe
Corporate Officer · Individual
Nicks Speaks, Felicia
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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#2
Ave Maria Home
Bartlett, TN
2-star overall rating with 2-star inspections with $27,921 in total fines with 5 recent health deficiencies
#3
Signature Healthcare Of Memphis
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4-star overall rating with 4-star inspections with $7,901 in total fines with 3 recent health deficiencies
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