Miletree Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spencer, West Virginia.
- Location
- 825 Summit Street, Spencer, West Virginia 25276
- CMS Provider Number
- 515182
- Inspections on file
- 16
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Miletree Center during CMS and state inspections, most recent first.
A dietary aide was observed handling food trays, pushing a cart, and using a telephone without changing gloves or performing hand hygiene before returning to the tray line. This breach in infection control procedures was confirmed by the regional dietary manager and had the potential to impact multiple residents.
A resident with worsening incontinence-associated dermatitis (IAD) on the buttocks was not reported to the physician, legal representative, or dietician as required. Documentation showed the wound was deteriorating, but notification sections were left blank and there was no evidence in the medical record that appropriate parties were informed. The DON confirmed the lack of notification.
A resident's quarterly MDS assessment did not accurately reflect the use of an antianxiety medication, Buspar, as required in the medication section. This omission was confirmed by the DON during a review of unnecessary medications.
A resident's pre-admission screening did not reflect their current diagnosis of Major Depressive Disorder, as the PASARR form indicated no major mental illness while other documentation showed the diagnosis. The Administrator confirmed the screening was not updated to match the resident's current condition.
Two residents did not have all of their medical diagnoses included in their care plans, with missing conditions such as paraplegia, acute embolism, panic disorder, chronic hepatitis C, MRSA history, and others. The DON confirmed that the care plans were incomplete after record review.
A resident's care plan was not revised after an antidepressant (Celexa) was discontinued, and the care plan also incorrectly listed a diagnosis of Parkinson's Disease, which the resident did not have. These issues were confirmed by the DON during a record review.
A resident with depression and schizophrenia was prescribed Prozac 40mg daily, but staff did not document required behavior or side effect monitoring for this psychotropic medication. The DON confirmed the absence of such monitoring during the survey.
A resident with a physician order for a puree diet was served crackers by a kitchen aide, which the resident then crumbled into her soup before surveyor intervention. Documentation confirmed that only residents on a Dysphagia Advanced diet may have crackers, not those on a puree diet. The facility did not ensure food was served in the correct consistency as ordered.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents. One resident's POST form was incomplete, lacking a documented choice for medically assisted nutrition, while another resident's hospital transfer forms contained incorrect transfer dates due to a system issue. These deficiencies were confirmed by facility leadership during the survey.
A resident was not provided with breakfast or lunch trays on a specific day, as confirmed by both a nurse aide and an LPN. The facility's posted meal times were not adhered to for this resident, and the incident was substantiated by staff during a follow-up investigation.
The facility failed to accurately assess three residents, leading to deficiencies in documenting dental status and restraint use. A resident reported dental issues not reflected in their MDS, while two residents had physician's orders for seatbelt restraints that were not documented. The DON confirmed these inaccuracies, indicating lapses in record-keeping and assessment practices.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific health needs. A resident's care plan did not include a diabetes diagnosis, another lacked information on restraint use, and a third had unimplemented fall interventions and meal intake monitoring. Additionally, a resident's dental care needs were not addressed, with the DON admitting to not arranging a dental consult. These issues highlight significant gaps in care planning and implementation.
The facility failed to maintain nutritional standards for two residents, resulting in significant weight loss and inadequate documentation of meal intake. One resident experienced a 10.91% weight loss over four months, with recommendations for snacks and appetite stimulants not implemented. Another resident's meal percentages were inconsistently documented, complicating weight loss monitoring. The DON acknowledged the documentation gap.
The facility failed to document medication refrigerator temperatures on several dates in June and July 2024. A tour revealed missing records for specific PM shifts, contrary to the facility's policy requiring twice-daily checks. The DON confirmed the oversight.
A resident reported significant dental issues, including broken teeth and discomfort, but the facility failed to assist in obtaining dental care. Despite a care plan addressing oral health risks, there was no documentation of dental consultations. The DON acknowledged awareness of the issue but did not document or arrange for care, leading to the deficiency.
The facility failed to maintain proper infection control practices, as evidenced by improper storage of a used bath basin and bed pan in a resident's room, and uncovered transport of clean personal items on a linen cart. The DON confirmed these deficiencies, which were attributed to staff oversight.
The facility failed to ensure dignified meal service by delaying assistance to dependent residents and allowing staff to stand while feeding a resident. The DON confirmed these practices were inappropriate.
A facility failed to notify the ombudsman of a resident's multiple hospital transfers. The resident was transferred to an acute care facility three times, but the DON revealed that the staff responsible for notifications mistakenly thought the requirement only applied to discharges, not transfers.
A facility failed to provide bed hold notices for a resident transferred to an acute care facility on three occasions. The resident was transferred on specific dates, and upon review, it was found that no bed hold notices were documented. The DON confirmed that these notices were not completed.
A facility failed to transmit a Minimum Data Set (MDS) upon the discharge of a resident. The MDS Discharge Return Not Anticipated was completed but not transmitted within the required timeframe, exceeding 120 days. The Clinical Reimbursement Coordinator acknowledged the oversight and was unsure why the MDS was not transmitted.
A facility failed to provide adequate ADL care for a resident, who was observed to be unkempt with oily hair and facial hair. Despite not rejecting care, the resident received only two showers in the last 30 days. The DON confirmed the resident did not receive all scheduled showers, indicating a deficiency in maintaining personal hygiene.
A resident expressed a lack of participation in activities, despite their care plan indicating the importance of group activities. The resident participated in only eight activities during a 48-day stay. The Activity Director acknowledged the resident's infrequent attendance and lack of one-to-one visits, with no further documentation provided.
The facility failed to follow physician's orders for two residents regarding the release of seatbelt restraints every two hours for repositioning. Documentation was missing from the Treatment Administration Record for specific dates and times, as confirmed by the DON. This indicates a failure to adhere to the prescribed care plan.
A resident reported constant severe pain, but the facility failed to provide adequate pain management. Despite having prescriptions for pain medications, the resident's pain was not consistently addressed, and there were no defined parameters for PRN medication use. Staff interviews revealed that medication administration was based on subjective assessments rather than structured guidelines.
A facility failed to maintain an accurate medical record for a resident's transfer to an acute care facility. The transfer form incorrectly stated the transfer date, which was confirmed by the DON during an interview.
Failure to Maintain Infection Control During Food Service
Penalty
Summary
A deficiency was identified when a dietary aide failed to follow proper infection control procedures while serving food from the tray line in the resident dining room. The aide was observed wearing the same gloves while pushing a tray cart, using the telephone, and then returning to handle food items on the tray line without changing gloves or performing hand hygiene. This lapse in infection control was confirmed by the regional dietary manager, who acknowledged that gloves should have been removed and hand hygiene performed before resuming food service tasks. The incident was observed during a random opportunity and had the potential to affect more than an isolated number of residents, given the facility's census of 56 at the time.
Failure to Notify Physician, Responsible Party, and Dietician of Worsening MASD
Penalty
Summary
The facility failed to notify a resident's legal representative, attending physician, and dietician regarding a worsening Moisture-Associated Skin Damage (MASD) area, specifically Incontinence Associated Dermatitis (IAD), located on the resident's intergluteal cleft. Documentation from a Skin and Wound Evaluation indicated the wound was in-house acquired, measured 39.5 cm2, and was deteriorating, with denuded skin due to exposure to bodily fluids. Notification sections for the physician, responsible party, and dietician were left blank, and there was no evidence in the electronic medical record or progress notes that these parties were informed. The Director of Nursing confirmed that the facility could not provide documentation of the required notifications.
Inaccurate MDS Assessment for Medication Use
Penalty
Summary
A review of records for one resident revealed that the facility failed to provide an accurate Minimum Data Set (MDS) assessment. Specifically, the quarterly MDS assessment did not indicate the use of an antianxiety medication, Buspar, in the section related to medications. This omission was confirmed by the Director of Nursing (DON) during an interview after being notified of the discrepancy. The deficiency was identified during a review of five residents under unnecessary medications, with the facility census at 56 residents at the time.
Failure to Update PASARR with Current Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Pre-admission Screening and Resident Review (PASARR) accurately reflected the resident's current mental health diagnosis. Documentation review showed that the pre-admission screening form indicated no major mental illness or suspected mental illness, while a separate diagnosis report listed Major Depressive Disorder, Single Episode, Unspecified. Staff interview with the Administrator confirmed that the pre-admission screening had not been updated to reflect the resident's current diagnosis at the time of admission. This deficiency was identified for one resident out of a facility census of 56, based on both documentation review and staff interview.
Care Plans Incomplete for Residents with Multiple Diagnoses
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included all current diagnoses for two residents. For one resident, the care plan did not address diagnoses such as non-Alzheimer's disease, paraplegia, transient paralysis, acute embolism and thrombosis of the lower extremity, obstructive and reflux uropathy, and retention of urine. For another resident, the care plan omitted multiple diagnoses, including panic disorder, dizziness, generalized muscle weakness, inflammatory liver disease, chronic viral hepatitis C, a history of MRSA, vestibular disorder, benign prostatic hyperplasia, urinary retention, obstructive sleep apnea, hypertension, hyperlipidemia, bilateral age-related nuclear cataract, dry eye syndrome, GERD, and constipation. These omissions were confirmed by the DON following record reviews.
Care Plan Not Updated After Medication Change and Incorrect Diagnosis Listed
Penalty
Summary
The facility failed to revise a resident's care plan after the discontinuation of a psychotropic medication and also listed an incorrect diagnosis in the care plan. Specifically, the care plan for a resident was not updated when Celexa, an antidepressant prescribed for depression, was discontinued. Additionally, the care plan incorrectly documented a diagnosis of Parkinson's Disease, despite the resident never having been diagnosed with this condition. These deficiencies were identified during a record review and confirmed by the Director of Nursing.
Failure to Monitor Side Effects and Behaviors for Antidepressant Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident who had diagnoses of depression and schizophrenia. The resident was prescribed Prozac 40mg daily for depression, but there was no documentation of behavior or side effect monitoring for this antidepressant as required. This deficiency was identified during a record review, and the DON confirmed that such monitoring was not being conducted or documented for the resident receiving Prozac. This lapse was noted for one out of four residents reviewed in the care area of hospitalizations, with the facility census at 56 at the time of the survey.
Resident on Puree Diet Served Incorrect Food Consistency
Penalty
Summary
A resident with a physician order for a puree diet was served crackers on her plate during a meal service. The incident occurred when a kitchen aide placed crackers on the resident's plate, which was verified by the Regional Dietary Manager. The resident then crumbled the crackers and added them to her soup, preparing to eat the mixture before a surveyor intervened. Documentation from speech therapy indicated that only residents on a Dysphagia Advanced diet may have crackers with soups, but this resident was on a puree diet, which does not permit crackers. The facility failed to ensure that food was prepared and served in the correct consistency as ordered by the physician.
Incomplete Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident, the Physician's Order for Scope of Treatment (POST) form dated 01/31/25 was found to be incomplete, specifically missing a documented choice in Section D regarding medically assisted nutrition options. This omission was confirmed by both the Administrator and the DON. For another resident, a review of transfer documentation revealed that the date on the second hospital transfer form was incorrect, listing an earlier year instead of the actual transfer date. The Administrator confirmed that the incorrect dates were due to a system issue. These findings were based on record reviews and staff interviews conducted during the survey process, affecting two of the 22 residents reviewed.
Failure to Provide Scheduled Meals to Resident
Penalty
Summary
The facility failed to provide at least three meals daily at regular times in accordance with resident needs, preferences, requests, and plan of care. Specifically, one resident did not receive a breakfast or lunch tray on a specified date, as confirmed by a facility-conducted Five-Day Follow-Up investigation. Both a nurse aide and an LPN acknowledged that the resident was not given a breakfast or lunch tray on that day. The posted meal times for residents were 7:15 AM for breakfast, 12:00 PM for lunch, and 5:15 PM for dinner. The administrator confirmed that the incident was substantiated by staff during the investigation.
Inaccurate Assessments for Dental Status and Restraint Use
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in the documentation of dental status and the use of restraints. Resident #47 reported significant dental issues, including broken teeth, which were not accurately reflected in their Minimum Data Set (MDS) assessment. The MDS inaccurately indicated that the resident had no natural teeth or tooth fragments and no obvious dental issues, despite the resident's visible dental problems and their own report of discomfort. The Director of Nursing (DON) acknowledged the oversight and the absence of any notes or dental consultations in the resident's chart. Additionally, the facility failed to document the use of restraints for Residents #42 and #20 in their MDS assessments. Both residents had physician's orders for seatbelt restraints while in wheelchairs due to their inability to maintain an upright sitting position independently. However, the MDS for both residents did not reflect the use of these restraints. The DON confirmed that the MDS for both residents was incorrect and should have indicated the use of restraints, highlighting a lapse in accurate record-keeping and assessment practices.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific health needs. Resident #10's care plan did not include a diagnosis of diabetes mellitus, which was confirmed by the Director of Nursing (DON). Similarly, Resident #20's care plan lacked information regarding the use of restraints, which was also acknowledged by the DON. These omissions indicate a lack of thoroughness in the care planning process for these residents. Additionally, Resident #52's care plan was not properly implemented concerning fall interventions and meal intake monitoring. A fall mat, which was supposed to be placed on the left side of the bed, was missing, and meal intakes were not documented as required, hindering the dietician and physician's ability to monitor weight loss. Resident #47's dental care needs were not adequately addressed, as the resident reported significant dental issues, and the DON admitted to not having documented or arranged for a dental consult. These failures highlight significant gaps in the facility's care planning and implementation processes.
Failure to Maintain Nutritional Standards for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, as observed during the Long-Term Care Survey Process. Resident #9 experienced a significant weight loss of 10.91% over four months and 6% in one month. Despite a recommendation from the Registered Dietician to add snacks and consider an appetite stimulant, the facility did not implement these measures. The resident's meal intake records showed numerous days with no intake recorded or only 25% intake, and the physician's notes did not address the weight loss. The administrator acknowledged the lack of documentation regarding the resident's eating habits. Resident #52 also faced issues with nutritional management, as evidenced by significant weight fluctuations and inconsistent meal intake documentation. The care plan noted nutritional risk due to dementia, but meal percentages were frequently undocumented, making it difficult for the dietician and physician to monitor the resident's weight loss. The Director of Nursing admitted to not knowing why meal percentages were not documented, highlighting a gap in the facility's monitoring and documentation processes.
Failure to Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to record temperatures for the medication refrigerator, which was identified during a tour of the medication room. On July 10, 2024, at 9:25 AM, it was observed that the medication refrigerator temperatures were not documented for several dates in June and July 2024, specifically on June 26, 27, 28, and July 8, 2024, during the PM shifts. The facility's policy, revised on July 1, 2024, requires that refrigerators and freezers used to store medications and vaccines operate within an acceptable temperature range and be checked twice daily. The Director of Nursing confirmed the lack of documentation for the refrigerator temperatures.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility failed to assist residents in obtaining routine and emergency dental care, as evidenced by the case of a resident who reported significant dental issues. During an interview, the resident expressed that their teeth were in poor condition, with some broken off at the gums, and they were experiencing discomfort. The resident mentioned financial constraints as a barrier to accessing dental care, stating they could not afford it. An observation confirmed the resident's poor dental condition, and a review of their care plan revealed a focus on oral health risks due to being edentulous, with goals and interventions aimed at maintaining oral health. Despite the care plan, there was no documentation of dental consultations or notes addressing the resident's dental issues. The DON acknowledged the resident's dental condition and admitted to being aware of the problem but failed to document or arrange for a dental consultation. This lack of action and documentation contributed to the deficiency, as the resident continued to experience dental pain and discomfort without receiving the necessary dental care.
Infection Control Deficiencies in Storage and Transport
Penalty
Summary
The facility failed to maintain an appropriate infection control program, as observed in two separate incidents. In room [ROOM NUMBER]A, a used bath basin and bed pan were found improperly stored in the bathtub, along with soiled washcloths on the side of the bathtub and hanging on the window seal. Nurse Aide #58 was informed and removed the items, acknowledging the oversight. The Director of Nursing confirmed the improper storage and disposal, attributing the oversight to a recent hospice visit for the resident's bath. Additionally, a linen cart containing clean personal items was observed being transported uncovered by Laundry Aide #38. The linen cart flaps were not secured, leaving the items exposed. Upon notification, the Laundry Aide admitted forgetting to cover the cart, and the Director of Nursing confirmed the requirement for the cart to be covered during transport.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service in the main dining room and for a specific resident. In the main dining room, dependent residents had their trays placed in front of them simultaneously with other residents without dining limitations, but were not assisted until all trays were served and a staff member was available. This delay in assistance was confirmed by the Director of Nursing, who acknowledged that dependent residents should be assisted immediately when their tray is placed in front of them. Additionally, an observation of a resident during the noon meal revealed that an Occupational Therapist Aide was standing while feeding the resident. The Director of Nursing confirmed that staff should not stand while feeding residents, indicating a failure to adhere to proper feeding protocols.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman of multiple hospital transfers for a resident. The resident was transferred to an acute care facility on three occasions: September 30, 2023, October 1, 2023, and October 9, 2023. Upon review of the notifications to the ombudsman, the Director of Nursing (DON) admitted that there were no records of such notifications. The DON explained that the staff responsible for notifications misunderstood the requirement, believing it applied only to discharges and not to transfers.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices for a resident who was transferred to an acute care facility on three separate occasions. The resident was transferred on 09/30/23, 10/01/23, and 10/09/23. Upon review of the records on 07/10/24, it was found that the facility did not have any documentation of bed hold notices for these transfers. The Director of Nursing confirmed on 07/11/24 that the bed hold notices were not completed.
Failure to Transmit MDS Upon Resident Discharge
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) upon the discharge of a resident. The record review for the resident revealed that the MDS Discharge Return Not Anticipated was completed on March 1, 2024, but was not transmitted within the required timeframe, exceeding 120 days. During an interview, the Clinical Reimbursement Coordinator acknowledged the oversight and expressed uncertainty about the reason for the failure to transmit the MDS.
Deficiency in ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to maintain good personal hygiene for a dependent resident. During an observation, a resident appeared unkempt, with oily hair and facial hair, indicating a lack of proper grooming. A review of the resident's records showed that they did not reject care, yet only two showers were documented in the last 30 days. The Director of Nursing confirmed that the resident did not receive all scheduled showers, highlighting a deficiency in the facility's provision of ADL care.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing activity program that meets the physical, mental, and psychosocial well-being of each resident, as evidenced by the case of a resident who expressed a lack of participation in activities. During an interview, the resident mentioned that they used to attend activities but no longer do so and were unsure of the reasons. A review of the resident's medical records showed that they had participated in only eight out-of-room group activities during their 48-day stay at the facility. The Minimum Data Set (MDS) indicated that attending group activities was very important to the resident. The resident's activity care plan highlighted their preferences for engaging in meaningful daily routines, such as memory games, sensory activities, and group settings. Despite these preferences, the Activity Director acknowledged that the resident no longer attended group activities frequently and was not on a one-to-one visit schedule. The Activity Director admitted to seeing all residents daily, although this was not always documented. No further documentation regarding the resident's participation was provided by the end of the survey.
Failure to Document Restraint Release as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the release of restraints for two residents. For Resident #42, a physician's order dated 05/31/24 required the release of a seatbelt restraint every two hours for repositioning. However, documentation was missing from the Treatment Administration Record (TAR) for specific times on 06/18/24 and 06/30/24. The Director of Nursing confirmed the absence of documentation for these dates and times. Similarly, for Resident #20, the same physician's order was in place, but the TAR lacked documentation for several dates and times in June and July 2024. The Director of Nursing also confirmed the missing documentation for these instances. This indicates a failure to follow the prescribed care plan for both residents, as the required actions were not documented as completed.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident #43, during the Long-Term Care Survey Process. The resident reported experiencing constant pain at a level of 8 or above and expressed dissatisfaction with the current pain management plan, stating that no effective pain medications were provided. The resident's medical records indicated prescriptions for Acetaminophen, Naprosyn, and Gabapentin, but there were no defined parameters for the administration of PRN pain medications. Despite the resident frequently reporting pain levels of 4 or 5, the Medication Administration Record showed that pain medications were not consistently administered or offered. Interviews with facility staff revealed a lack of clarity and consistency in administering PRN pain medications. The administrator acknowledged that the resident did not receive PRN medications unless requested, and there was no documentation to justify the decision not to administer pain relief. An LPN admitted that the decision to give medication was based on the resident's mood rather than a structured assessment of pain levels. The facility's policy required defined parameters for PRN medications, which were not in place, contributing to the deficiency in pain management for the resident.
Inaccurate Transfer Record for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident regarding their transfer to an acute care facility. The record review revealed that the transfer form for the resident indicated an incorrect transfer date. The resident was actually transferred on October 9, 2023, but the form incorrectly stated the transfer date as October 1, 2023. This discrepancy was confirmed by the Director of Nursing during a staff interview, who acknowledged the incorrect date on the transfer form.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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