MILETREE CENTER
For profit - Corporation
62 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
58/100
#52 of 122 in WV
Photo by Miletree Center
Photo by Miletree Center
Photo by Miletree Center
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
MileTree Center in Spencer, West Virginia, has a Trust Grade of C, which means it is average-neither the best nor the worst option available. It ranks #52 out of 122 facilities in the state, placing it in the top half, but it is the second and last facility in Roane County, indicating limited local choices. The facility's trend is improving, with a decrease in issues from 15 in 2024 to 10 in 2025. However, staffing is a notable concern, receiving only 1 out of 5 stars, with a turnover rate of 54%, which is concerning for continuity of care. Recent inspection findings included issues with infection control, where a staff member failed to change gloves after using the phone, and inadequate assessments of residents' dental needs, revealing that some residents had untreated dental problems. While the facility has strengths, such as good health inspection scores, these weaknesses in staffing and care planning are important to consider.
- Trust Score
- C
- In West Virginia
- #52/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $3,250 in fines. Higher than 82% of West Virginia facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
58/100
Top 42%
No red flags
15 → 10 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 54%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $3,250
Below median ($33,413)
Minor penalties assessed
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 41 deficiencies on record
Aug 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to notify a resident's legal representative, the resident's attending physician, and the dietician about a worsening Moisture-Associated...
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Based on record review and staff interview, the facility failed to notify a resident's legal representative, the resident's attending physician, and the dietician about a worsening Moisture-Associated Skin Damage (MASD) area on the resident's body. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 56Findings included:a) Resident #67A record review, completed on 08/14/25 at 10:00 AM, revealed that Resident #67 had a documented Moisture-Associated Skin Damage (MASD) area on his intergluteal cleft on his buttocks. A Skin and Wound Evaluation, dated 06/11/25, revealed the following details:MASD Type: Incontinence Associated Dermatitis (IAD)In-house acquiredWound measurements: Area - 39.5 cm2, Length - 9.3 cm, and Width - 6.7 cmDenuded - loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate or friction.Progress - deteriorating Notification boxes for Physician, Resident's Responsible Party, and Dietician were left blankThere was no evidence in the Progress Notes section of the electronic medical record that indicated the physician, resident's responsible party, or the dietician were notified. During an interview, on 06/18/25 at 2:15 PM, the Director of Nursing acknowledged the facility could not produce evidence that the physician, resident's responsible party, or the dietician were notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) including all high...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) including all high risk drug classes for Resident #5. This is true for one (1) of five (5) residents reviewed under unnecessary medications. Resident Identfier: #5. Facility Census: 56. Findings Include:a) Resident #5On 08/14/25 at 9:00 AM, a record review was completed for Resident #5. The review found the MDS quarterly assessment dated [DATE] section N entitled Medications did not indicate the use of an antianxiety medication, Buspar.On 08/14/25 at 10:05 AM, the Director of Nursing (DON) and the Administrator were notified. The DON confirmed the MDS did not include the use of an antianxiety medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and staff interview the facility failed to ensure resident's Pre-admission Screening reflected a c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and staff interview the facility failed to ensure resident's Pre-admission Screening reflected a current diagnosis for Resident #1. Resident identifier: #1. Facility Census 56. Findings included:a) Resident #1Resident #1 was admitted on [DATE]. A review of the Resident #1's documentation revealed the following:-Document titled [NAME] Virginia Department of Health and Human Resources Pre-admission SCREENING dated 04/14/25, Question 40. Major Mental Illness or suspected MI is marked i. None/N/A-Document titled Diagnosis Report included a diagnosis of Major Depressive Disorder, Single Episode, Unspecified on 04/18/25 Interview with Administrator on 08/14/25 at 10:50am who acknowledge that a Pre-admission Screening had not been completed to reflect resident's current diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to develop a care plan including all diagnoses for Resident #5 and #6. This is true for two (2) of five (5) residents reviewed under unn...
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Based on record review and staff interview, the facility failed to develop a care plan including all diagnoses for Resident #5 and #6. This is true for two (2) of five (5) residents reviewed under unnecessary medications. Resident Identifiers: #5 and #6. Facility Census: 56.Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been developed to include all diagnoses. The following diagnoses are as follows: --Non-Alzheimer's disease--Paraplegia--Transient Paralysis --Acute Embolism and Thrombosis, lower extremity--Obstructive and Reflux Uropathy--Retention of UrineOn 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON did confirm all the diagnoses were not included in the care plan.b) Resident #6On 08/13/25 at 11:00 AM, a record review was completed for Resident #6. The review found the care plan had not been developed to include all diagnoses. The diagnoses are as follows:--Panic disorder--Dizziness--Muscle Weakness (generalized)--Inflammatory Liver disease--Chronic Viral Hepatitis C--History of Methicillin-Resistant Staphylococcus Aureus (MRSA)--Disorder of Vestibular Function, unspecified ear--Benign Prostatic Hyperplasia (BPH)--Urinary Retention --Obstructive Sleep Apnea (OSA)--Hypertension (HTN)--Hyperlipidemia (HLD)--Age-related Nuclear Cataract, bilateral--Dry Eye Syndrome--Gastroesophageal Reflux Diseas (GERD)--Constipation On 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON did confirm all the diagnoses were not included in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to revise a care plan when a psychotropic medication was discontinued and an incorrect diagnosis was listed for Resident #5. This was tr...
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Based on record review and staff interview, the facility failed to revise a care plan when a psychotropic medication was discontinued and an incorrect diagnosis was listed for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 56.Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been revised when an antidepressant was discontinued and an incorrect diagnosis was listed. The review found the resident was ordered Celexa 10mg (milligram) by mouth daily for depression from 01/12/24 through 11/16/24. Also, the review found a diagnosis of Parkinson's Disease, which the resident has never been diagnosed with.On 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the Celexa had been discontinued and the resident did not have a diagnosis of Parkinson's Disease. DON notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to follow a physician's order for Resident #4 for side effect monitoring and behavior monitoring of a psychotropic medication. This was ...
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Based on record review and staff interview, the facility failed to follow a physician's order for Resident #4 for side effect monitoring and behavior monitoring of a psychotropic medication. This was true for one (1) of four (4) residents reviewed under the care area of hospitalizations. Resident identifier: #4. Facility Census: 56.Findings Include:a) Resident #4On 08/13/25 at 11:30 AM, a record review was completed for Resident #4. The resident had a diagnosis of depression, unspecified and schizophrenia, unspecified. The resident is receiving Prozac 40mg (milligram) by mouth daily for depression. The resident is not currently receiving any medication for the diagnosis of schizophrenia. However, there is no behavior or side effect monitoring documenation for the antidepressant, Prozac. On 08/13/25 at 11:50 AM, the Director of Nursing (DON) acknowledged there is no behavior or side effect monitoring for the antidepressant Prozac.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on record review, staff interview and observations, the facility failed to ensure a resident was served food in the correct consistency according to the National Dysphagia Diet Levels as ordered...
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Based on record review, staff interview and observations, the facility failed to ensure a resident was served food in the correct consistency according to the National Dysphagia Diet Levels as ordered by the physician. This was a random opportunity for discovery. Resident Identifier: #16. Facility Census: 56.Findings included:a) Resident #16At approximately 12:40 PM on 8/12/25, Resident #16 was given crackers on her plate with a puree diet. This was verified with the Regional Dietary Manager that Kitchen Aide #49 placed the crackers on the plate for Resident #16. Resident #16 crumbled the crackers up with her hands, dropped the crumbled crackers into the soup, and was getting ready to take a bite before surveyor intervention prevented Resident #16 from eating the soup with crackers. The Regional Dietary Manager produced a speech therapy document that read, Dysphagia Advanced (residents) may have crackers with soups. However, Resident #16 had an order for puree which is a different diet description.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on record review the facility failed to provide at least three (3) meals daily, at regular times comparable to normal mealtime in the community in accordance with resident needs, preferences, re...
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Based on record review the facility failed to provide at least three (3) meals daily, at regular times comparable to normal mealtime in the community in accordance with resident needs, preferences, requests and plan of care. Resident identifier: #63. Facility census 56.Findings Included:a)Resident #63A review of the Five-Day Follow-Up investigation completed by the facility on 04/25/25 after resident alleged that she did not receive a breakfast or lunch tray on 04/20/25 revealed the facility substantiated the the report. Nurse Aide (NA) #37 and Licensed Practical Nurse #101 acknowledged that Resident #63 was not given a breakfast tray or lunch tray on 04/20/25.Posted Meal times for residents are as follows: 7:15 AM Breakfast12:00 PM Lunch5:15 PM DinnerInterview with Administrator on 08/19/25 at 2:33 PM who acknowledge that Resident's incident report was substantiated by staff who completed investigation prior to current Administrators current position at this facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #10's Physician's Order for Scope of Treatment (POST) form and two (2) t...
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Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #10's Physician's Order for Scope of Treatment (POST) form and two (2) transfer forms for Resident #5. This is true for two (2) of 22 residents reviewed during the survey process. Resident Identifiers: #10 and #5. Facility Census: 56.Findings Include: a) Resident #10 On 08/11/2025 at 3:04 PM, a record review was completed for Resident #10. The review found the POST form dated 01/31/25 was incomplete. Section D, entitled Medically Assisted Nutrition, did not list a choice regarding feeding through a new or existing surgical tubes, a time-limited trial of the amount of days but no surgically placed tubes, or no artificial means of nutrition desired or discussed but no decision made (provide standard of care). On 08/14/2025 at 10:08 AM, the Administrator and the Director of Nursing (DON) confirmed Section D of the POST form was incomplete. b) Resident #5 On 08/14/25 at 1:15 PM, a record review was completed for Resident #5 regarding hospitalizations. The review found the resident had been transferred to an acute care facility ton two (2) different occasions. The second transfer form listed the transfer date as 11/14/22. However, the correct date was 07/14/25. On 08/14/25 at 2:20 PM, the Administrator did confirm the transfer dates were incorrect due to a system issue.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to maintain an infection control program while serving from the tray line in the resident dining room. This was a random opportunity for d...
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Based on observation and staff interview, the facility failed to maintain an infection control program while serving from the tray line in the resident dining room. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Facility Census: 56. Findings Include:a) Resident Dining RoomOn 08/11/25 12:12 PM, an observation was made of Dietary Aide #46 working the tray line in the resident dining room. The Dietary Aide #46 kept her gloves on and pushed a tray cart from the tray line to the dining room door. The Dietary Aide #46 used the telephone in the dining room with the same gloves on. On 08/11/25 at 12:15 PM, the Dietary Aide #46 returned to the tray line and began putting items on the dining tray while continuing to wear the same gloves. After Surveyor intervention, the Dietary Aide #46 stepped away from the tray line. Dietary Aide #46 completed hand hygiene and returned to the tray line and donned a clean set of gloves.On 08/11/25 at 2:00 PM, Regional Dietary Manager #62 was notified. The Regional Dietary Manager #62 confirmed the dietary aide should have removed her gloves and completed hand hygiene prior to returning to the tray line.
Jul 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
b) Resident #36
On 07/09/24 at 11:40 AM, an observation of Resident #36 was made during the noon meal. Occupational Therapist Aide (OTA) #71 was standing while feeding Resident #36.
On 07/09/24 at 11...
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b) Resident #36
On 07/09/24 at 11:40 AM, an observation of Resident #36 was made during the noon meal. Occupational Therapist Aide (OTA) #71 was standing while feeding Resident #36.
On 07/09/24 at 11:42 AM, the Director of Nursing (DON) was notified and confirmed the staff should not be standing while feeding a resident.
Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service in the main dining room and for Resident #36. This was a random opportunity for discovery. Resident Identifier: #36. Facility census: 57
Findings included:
a) Main Dining Room
During an observation of meal services on 07/09/24 at 12:15 PM, dependent resident's trays being placed in front of them at the same time as table mates without dining limitations. The dependent resident was not assisted until all trays were served in the dining room and there was an available staff member to assist them.
An interview took place at 1:36 PM with the Director of Nursing (Don). The Director of Nursing was present throughout the serving process and verified that all residents at a table should be serve at the same time and dependent residents should be assisted when their tray is placed in front of them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to notify the ombudsman of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed ...
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Based on record review and staff interview, the facility failed to notify the ombudsman of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57.
Findings Include:
a) Resident #10
Findings Include:
On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows:
--09/30/23
--10/01/23
--10/09/23
On 07/11/24 at 9:50 AM, upon request of the notifications to the Ombudsman, the Director of Nursing (DON) stated, we don't have anything .the person doing the notifications didn't know it included transfers .they thought it was only discharges.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide bed hold notices of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents revie...
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Based on record review and staff interview, the facility failed to provide bed hold notices of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57.
Findings Include:
a) Resident #10
On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows:
--09/30/23
--10/01/23
--10/09/23
On 07/11/24 at 9:50 AM, upon request of the bed hold notices , the Director of Nursing (DON) stated, we don't have anything .they weren't done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to transmit a Minimum Data Set (MDS) upon discharge of Resident #22. This was true for one (1) of one (1) residents reviewed under the c...
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Based on record review and staff interview, the facility failed to transmit a Minimum Data Set (MDS) upon discharge of Resident #22. This was true for one (1) of one (1) residents reviewed under the care area of resident assessment. Resident Identifier: #22. Facility Census: 57.
Findings Include:
a) Resident #22
On 07/10/24 11:10 AM, a record review was completed for Resident #22. The review found the MDS Discharge Return Not Anticipated dated on 03/01/24 was completed but not transmitted within greater than 120 days.
On 07/10/24 at 12:10 PM, an interview was held with Clinical Reimbursement Coordinator (CRC) #5. CRC #5 was notified and acknowledged the discharge MDS was completed but was not transmitted. CRC #5 stated, I don't know why it wasn't transmitted .I'll have to look into this.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents. This is true for 0ne (1) of th...
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Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents. This is true for 0ne (1) of three (3) residents reviewed for ADL care. Resident Identifiers: #49. Facility census: 57.
Findings included:
a) Resident #49
During an observation 07/08/24 at about 12:19 PM Resident #49 appeared to be unkept, with oily hair and facial hair.
A continued record review of Resident #49's Significant Change, 04/18/24 Minimum Data Set (MDS), MDS Section E (Behaviors) also indicated Resident #49 does not reject care.
A review of Resident #49's ADL documentation found, only two (2) showers noted in the last 30 days.
On 07/10/24 at 10:03 AM the Director of Nursing verified Resident #49 did not receive all showers as scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview the facility failed to provide an ongoing activity program whi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview the facility failed to provide an ongoing activity program which meets the physical, mental and psychosocial well-being of each resident. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #13. Facility Census 57.
Findings Include:
a) Resident #13
During the initial interview on 07/08/24 at 3:05 PM, Resident #13 stated, I used to attend activities, I just don't anymore. I don't know why. I sometimes don't know what is going on.
A record review on 07/09/24 at 9:30 AM, of Resident #13's medical record revealed, she was admitted to the facility on [DATE].
Further record review of Resident #13's Activity participation record shows during her 48 days at the facility she participated in 8 out of room group activities.
A record review on 07/09/24 at 10:00 AM, of Resident #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24, Section F, section F0500, question E, indicates its very important to Resident #13 to attend group activities.
Further record review of Resident #13's activity care plan read as follows:
Focus:
·While in the facility, resident/patient
states that it is important that s/he has the
opportunity to engage in daily routines that
are meaningful relative to their preferences
such as attending out of room activities that
involve memory games, sensory, bingo,
one on one setting groups etc.
Goals:
· Resident will plan and choose
to engage in preferred activities
· Resident will pursue
opportunities for involvement in
service related activities within
their home community and/or
the community at large
Interventions:
· Encourage and facilitate residents/patients activity preferences of her interest that
involve small group activities with some verbal cueing for successful participation.
· I prefer to dine in my room or often the dining room.
· It is important for me to have family or a close friend involved in discussions about
my care.
· The following things help me feel better when I am upset is to sometimes be alone
and watch YouTube videos on my tablet.
· I enjoy listening to music and prefer country music.
· I would like pet visits.
· I like to participate in any size group with others. very social and enjoys being
· I enjoy watching/listening to TV.
· I am of the Baptist faith and plan to attend church services at the facility.
· I would benefit from accommodation for hearing loss by placement near
speaker/leader.
· I would benefit from accommodation for cognitive limitations by using decreased
environmental clutter, demonstration, reminders, single step activity.
· I benefit from being informed of facility happenings
During an interview on 07/10/24 at 11:33 AM, The Activity Director (AD) stated, She used to come to group activities, but really doesn't come much anymore. I do not have her on one to one visits but I do see everybody everyday it's not always necessarily documented.' She further stated, I will have to check on her participation.
No further documentation was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
.
Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding the release of restraints. This was true for two (2) of two (2) residents reviewed...
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.
Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding the release of restraints. This was true for two (2) of two (2) residents reviewed under the care area of restraints. Resident Identifiers: #42 and #20. Facility Census: 57.
Findings Include:
a) Resident #42
On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.)
On 07/09/24 at 1:10 PM, a review of the Treatment Administration Record (TAR) was reviewed for June, 2024. The review found the TAR was missing documentation for the following dates:
--06/18/24 2:00 PM
--06/18/24 4:00 PM
--06/30/24 4:00 PM
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed there was no documentation on the TAR for 06/18/24 at 2:00 PM, 4:00 PM and 06/30/24 at 4:00 PM.
b) Resident #20
On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.)
On 07/09/24 at 1:40 PM, a review of the Treatment Administration Record (TAR) was reviewed for June, 2024 and July, 2024. The review found the TAR was missing documentation for the following dates:
--06/18/24 2:00 PM
--06/18/24 4:00 PM
--06/30/24 4:00 PM
--07/03/24 2:00 PM
--07/03/24 4:00 PM
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed there was no documentation on the TAR for 06/18/24 at 2:00 PM and 4:00 PM; 06/30/24 at 4:00 PM and 07/03/24 at 2:00 PM and 4:00 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, staff interview and record review the facility failed to provide pain management consistent with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, staff interview and record review the facility failed to provide pain management consistent with professional standards of practice. This failed practice was found true for (1) one of (3) three residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier #43. Facility Census 57.
Findings Include:
a) Resident #43
During an initial interview on 07/08/24 at 2:09 PM, Resident #43 stated, My pain is an 8 or above all the time. I want a different doctor but no more are available. They won't give me pain meds to help. Resident states his pain is an 8 or above all the time.
A record review on 07/09/24 at 11:37 AM, of Resident #43 orders revealed the following pain medications ordered for Resident #43.
Ordered on 04/24/24 :
Acetaminophen Tablet 325 milligrams (MG)
Give 2 tablets by mouth every 6 hours as needed for General Discomfort Notify physician/midlevel provider if discomfort persists. Do not exceed 3g/day
Ordered on 05/29/24:
Naprosyn Oral Tablet 500 MG (Naproxen)
Give 500 mg by mouth every 12 hours as needed for pain
Ordered on 04/26/24:
Gabapentin Oral Tablet 600 MG
Give one tablet by mouth three times a day for Neuropathy pain.
Further record review showed a Pain assessment dated [DATE] which reads, Resident #9's pain is frequently at a (6) six.
During a record review on 07/09/24 at 1:00 PM, of Resident #43's Medication Administration Record (MAR) for the months of June and July of 2024 revealed Resident #43 reported pain at (4) four or (5) five 27 of 39 days. He had no Acetaminophen administered and had Naprosyn administered or offered (8) eight of the 27 days pain of (4) four or (5) five was reported.
During an interview on 07/09/24 at 2:10 PM, The Administrator stated, I guess he didn't ask for it so if he didn't ask for it he would not have got it because it's a PRN medication. He is also a known drug user.
A record review on 07/09/24 at 2:20 PM, showed Resident #43 was incapacitated
Further record review revealed Resident #43 has a diagnosis of pain and no parameters are set for PRN pain medications.
A review of the facilities policy on 07/09/24 at 3:00 PM titled {Pain Management} under Practice Standards number 6 reads PRN pain medications will have defined parameters for use.
During an interview on 07/09/24 at 2:48 PM, Licensed Practical Nurse (LPN) #24 stated, Sometimes I think a (5) five pain level is a baseline for him. We did get him Gabapentin for his pain and it seemed to help so the doctor increased it. When the surveyor asked how do you know when he needs the PRN pain medication? LPN #24 stated, For me it's all about his mood if he gets the medicine. Then further stated, Yes I guess we need to call the doctor and get it changed on a schedule or something so we know when to give it.
During an interview on 07/09/24 at 2:55PM, the administrator confirmed there was no documentation to support the pain level of (5) five and why PRN pain medication was not given.
No further documentation was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to maintain an accurate and complete record regarding a transfer for Resident #10. This was true for one (1) of one (1) residents review...
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Based on record review and staff interview, the facility failed to maintain an accurate and complete record regarding a transfer for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57.
Findings Include:
a) Resident #10
On 07/11/24 at 1:00 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility on 10/09/23. The transfer form indicated the resident was transferred on 10/01/23.
On 07/11/24 at 1:30 PM, the Director of Nursing (DON) confirmed the date was incorrect on the transfer form. The DON stated, there was a corporate call discussing this issue .it does have the incorrect date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, staff interview and record review the facility failed to complete an accurate assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, staff interview and record review the facility failed to complete an accurate assessment to reflect resident's dental status, and for the use of restraints for two (2) other residents. This failed practice was found true for (3) three of 15 residents reviewed for assessment accuracy during the Long-Term Care Survey Process. Resident identifiers #47, #42, and #20. Facility Census 57.
Findings Include:
a) Resident #47
During an initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars.
During the initial observation on 07/08/24 at 4:55PM, it was revealed Resident #47 had teeth which were in poor condition with many broken off at the gum line.
A record review on 07/09/24 at 3:34 PM, of Resident #47's Minimum Data Set (MDS) annual assessment with an assessment reference date (ARD) of 12/22/23, Section L, question B, indicated Resident #47 has no natural teeth or tooth fragments. Question D indicated Resident #47 has no obvious or likely cavity or broken natural teeth.
During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consultation.
At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there are no notes or dental consults in her chart. I will get that taken care of immediately.
b) Resident #42
On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints.
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints.
c) Resident #20
On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints.
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints.
b) Resident #42
On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints.
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints.
c) Resident #20
On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints.
On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #10 regarding a diagnosis of diabetes mellitus, Resident #20 for th...
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Based on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #10 regarding a diagnosis of diabetes mellitus, Resident #20 for the use of restraints, Resident #52 for fall interventions and meal intake and Resident #47 regarding dental care. This was true for five (5) of 15 residents reviewed during the survey process. Resident Identifiers: #10, #20, #52 and #47. Facility Census: 57.
Findings Include:
a) Resident #10
On 07/09/24 at 11:15 AM, a record review was completed for Resident #10. The review found the care plan was not developed regarding the diagnosis of diabetes mellitus.
On 07/09/24 at 11:50 AM, the Director of Nursing (DON) confirmed the care plan did not include the diagnosis of diabetes mellitus.
b) Resident #20
On 07/09/24 at 1:30PM, a record review was completed for Resident #20. The review found the care plan was not developed regarding the use of restraints.
On 07/09/24 at 2:00 PM, the DON confirmed the care plan did not include the use of restraints.
c1) Resident #52
On 07/12/24 at 12:00 PM, a record review was completed for Resident #52. The review found the care plan was not implemented regarding a fall intervention. A fall intervention listed on the care plan stated, fall mat to left side of bed to prevent injury. (Typed as written.)
On 07/12/24 at 12:15 PM, an observation of the resident resting in bed was made. The fall mat to the left side of the bed was not in place.
On 07/12/24 at 12:19 PM, Nurse Aide (NA) #41 confirmed the fall mat was not in place at the left side of the bed.
On 07/12/24 at 12:22 PM, the DON was notified and confirmed the fall mat should be in place.
c2) Resident #52
On 07/12/23 at 12:00 PM, a record review was completed for Resident #52. The review found the care plan was not implemented regarding nutrition. An intervention listed on the care plan stated, monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. (Typed as written.)
On 07/10/24 at 2:15 PM, an interview was held with the DON. The DON was notified the meal intakes were not being monitored as care planned. The DON stated, I don't know why the meal percentages were not documented .the dietician and physician cannot monitor weight loss if all meals are not documented.
d) Resident #47
During an initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars.
During the initial observation on 07/08/24 at 4:55PM, it was revealed Resident #47 has teeth which are in poor condition with many broken off at the gum line.
A record review on 07/09/24 at 3:34 PM revealed, Resident #47 had the following care plan created on 01/14/23 related to dental care:
Focus:
Resident is at risk for oral health or dental
care problems as evidenced by being
edentulous.
Goal:
· The resident will maintain
intact oral mucous membranes
as evidence by the absence of
discomfort, gum
inflammation/infection, oral
lesions x 90 days.
Interventions:
· Assess for oral lesions, inflammation and bleeding and signs and symptoms of pain
during care and report to MD as indicated
· Encourage resident to brush teeth and gums twice daily and as needed
· Provide oral hygiene/mouth care twice per day and prn
·Use a mouth rinse as appropriate
During an interview on 07/09/24 at 3:36 PM, Resident #47 stated, I was chewing on the left side because I have a cavity on the right side. Now the left side is starting to hurt.
During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed, Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consult.
At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there is no notes or dental consults in her chart. I will get that taken care of immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to maintain acceptable parameters of nutrition whi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to maintain acceptable parameters of nutrition which are consistent with professional standards of practice. This failed practice was found true for two (2) of (2) two residents looked at for nutrition during the Long-Term Care Survey Process. Resident identifiers #9, and #52. Facility Census 57.
Findings Include:
a) Resident #9
An initial observation on 07/08/24 at 1:00 PM, of Resident #9 eating lunch revealed, she had only eaten about 25% of her lunch and her tray was away from her.
A record review on 07/09/24 at 2:20 PM, of Resident #9's weights read as follows:
7/5/2024 16:23
138.8 pounds (Lbs)
6/4/2024 10:18
140.4 Lbs
6/3/2024 17:02
140.4 Lbs
6/3/2024 10:58
144.4 Lbs
5/4/2024 10:57
148.8 Lbs
4/2/2024 10:20
139.0 Lbs
4/1/2024 15:52
139.0 Lbs
3/1/2024 15:15
155.8 Lbs
These weights show a 10.91 percent weight loss in (4) four months and a (6) six percent weight loss in one month.
Further record review revealed a Nutritional Assessment completed on 06/05/24 by the Registered Dietician (RD) which read under summary: 1. Recommend adding snacks in-between meals given her suboptimal daily avg. PO intake. 2. If her daily average PO intake remains suboptimal, if medically appropriate, consider then incorporate an appetite stimulant at the MD/NP'S discretion in the scenario.
Record review on 07/10/24 at 9:30 AM, of Resident #9's meal intake from 05/01/24 to present revealed out of the 70 days which were reviewed, 29 of those days had no intake recorded for some meals and only 25% meal intake recorded for some meals.
Further record review of Resident #9's physician visit on 06/09/24, found the physician marked her appetite as OK. No further notes from the physician are found in the medical record regarding Resident #9's weight loss.
During an interview on 07/10/24 at 10:06 AM, the administrator stated, (Resident #9 name) has refused supplement in the past due to it having [NAME] Gum in it, saying that it had [NAME] in it. When the surveyor asked the administrator, Why the appetite stimulant had not been started per the RD's recommendation if the residents' intake remained suboptimal? The administrator responded by saying, I see what you are saying, the documentation does not show that she is eating.
No further documentation was provided by the end of the survey.
b) Resident #52
On 07/10/24 at 1:45 pm, a record review was completed for Resident #52. The review found a care plan intervention under the focus area of nutritional risk related to the diagnosis of dementia which may impact nutritional status. Also, under the focus area was noted significant weight loss with variable intake.
On 07/10/24 at 1:50 PM, the meal percentages for May, 2024 through July, 2024 were reviewed.
Reviewed meal percentages for May through July, 2024. The review found the meal percentages were not documented throughout the months reviewed. The following list show the documentation of how many meals meals were documented daily throughout the month reviewed:
--05/01/24 one meal only
--05/03/24 one meal only
--05/06/24 one meal only
--05/12/24 one meal only
--05/16/24 two meals only
--05/23/24 one meal only
--05/28/24 two meals only
--05/30/24 one meal only
--06/03/24 two meals only
--06/06/24 one meal only
--06/07/24 one meal only
--06/13/24 one meal only
--06/17/24 two meals only
--06/29/24 one meal only
--07/03/24 one meal only
--07/05/24 one meal only
The review found 28 meals had no documentation of percentages of meal intakes. The resident's weights were also reviewed. The following list show the documented weights by dates:
--12/21/23 116.2 pounds
--12/28/23 118.1 pounds
--01/01/24 119.0 pounds
--02/07/24 112.5 pounds
--03/01/24 98.4 pounds
--03/28/24 118.5 pounds
--04/03/24 114.0 pounds
--05/09/24 99.00 pounds
--06/03/24 99.00 pounds
--07/04/24 96.2 pounds
On 07/10/24 at 2:15 PM, an interview was held with the Director of Nursing (DON). The DON stated, I don't know why the meal percentages were not documented .the dietician and physician cannot monitor weight loss if all meals are not documented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery. Facility Census: 57.
...
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Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery. Facility Census: 57.
Findings Include:
a) Medication Refrigerator
On 07/10/24 at 9:25 AM, a tour of the medication room was completed. The tour found one (1) medication refrigerator temperatures were not being documented in June, 2024 and July, 2024.
The following dates indicate no documentation had been completed:
--07/08/24 PM
--06/26/24 PM
--06/27/24 PM
--06/28/24 PM
b) Facility Policy
A review of the facility policy entitled, Medication and Vaccine Refrigerator/Freezer Temperatures with a revision date of 07/01/24 was reviewed on 07/10/24 at 9:35 AM. The review found under the heading, Policy, which stated, Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will checked twice a day for proper temperatures.
On 07/10/24 at 9:45 AM, the Director of Nursing (DON) confirmed the refrigerator temperatures were not documented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
.
Based on resident interview, record review and staff interview the facility failed to assist residents in obtaining routine and emergency dental care. This failed practice was found true for (1) one...
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Based on resident interview, record review and staff interview the facility failed to assist residents in obtaining routine and emergency dental care. This failed practice was found true for (1) one of (1) one residents looked at for dental treatment during the Long-Term Care Survey Process. Resident identifier #47. Facility Census 57.
Findings Include:
a) Resident #47
During the initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars.
During the initial observation on 07/08/24 at 4:55 PM, it was revealed Resident #47 has teeth which are in poor condition with many broken off at the gum line.
A record review on 07/09/24 at 3:34 PM revealed, Resident #47 had the following care plan created on 01/14/23 related to dental care:
Focus:
Resident is at risk for oral health or dental
care problems as evidenced by being
edentulous.
Goal:
The resident will maintain
intact oral mucous membranes
as evidence by the absence of
discomfort, gum
inflammation/infection, oral
lesions x 90 days.
Interventions:
Assess for oral lesions, inflammation and bleeding and signs and symptoms of pain
during care and report to MD as indicated
Encourage resident to brush teeth and gums twice daily and as needed
Provide oral hygiene/mouth care twice per day and prn
Use a mouth rinse as appropriate
During an interview on 07/09/24 at 3:36 PM, Resident #47 stated, I was chewing on the left side because I have a cavity on the right side. Now the left side is starting to hurt.
During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consultation.
At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there are no notes or dental consults in her chart. I will get taken care of immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage of a bath basin, bed pan, disposal of soiled linen and transportation of personal belongings. These were random opportunities for discovery. Facility Census: 57.
a) room [ROOM NUMBER]A
On 07/08/24 at 1:28 PM, an observation was made in room [ROOM NUMBER]A. The observation found a used bath basin and bed pan sitting in the bathtub; a soiled washcloth was on the side of the bathtub as well as a soiled washcloth was hanging on the window seal. Nurse Aide (NA) #58 was notified and removed the bath basin, bed pan, and soiled washcloths from the room. NA #58 stated, let me take care of this.
On 07/08/24 at approximately 1:45 PM, the Director of Nursing (DON) was notified and confirmed the bath basin and the bed pan were not stored correctly; and, the soiled linens were not disposed of in the correct manner. The DON stated, Hospice was just in there giving the resident a bath .the items should have been stored and disposed of in the correct manner.
b) Linen Cart
On 07/09/24 at 2:06 PM, an observation of Laundry Aide (LA) #38 pushing a linen cart of clean personal items was completed. The observation found the clean personal items were not covered. The linen cart flaps were laying across the top of the cart.
On 07/09/24 at 2:08 PM, LA #38 was interviewed regarding the linen cart not being covered. Laundry Aide #38 stated, I forgot to cover it.
On 07/09/24 at 2:10 PM, the DON was notified and confirmed the linen cart should have been covered during transport.
Mar 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was kept on Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was kept on Resident #30's medical chart. This was true for one (1) of 22 sample residents. Resident identifier: #30. Facility census: 61.
Findings included:
a) Resident #30
An electronic medical record review, completed on 03/06/23 at 3:14 PM, indicated that Resident #30 was admitted to the facility on [DATE]. It also identified the following details:
-A Physician Determination of Capacity was on file and indicated Resident #30 had capacity to make her own medical decisions.
-A WV Physician Orders for Scope of Treatment (POST) form was on file and indicated Resident #30 had reported there was a family member who had been appointed as Resident #30's Medical Power of Attorney (MPOA) in the event the resident lost capacity and could no longer make her own medical decisions. The professional who assisted in completing the form was identified as the facility's Social Worker.
-There was no copy of the Medical Power of Attorney scanned into the electronic record.
During an interview, on 03/07/23 at 10:06 AM, Medical Records Worker #22 confirmed a copy of Resident #30's MPOA was not part of the actual chart at the nurse's station and that it was not scanned in as part of the electronic medical record. The medical records worker added Resident #30 had been a resident at the facility, then transferred to a different facility for a period of time, and then returned to this facility in June 2022. Including the MPOA paperwork in resident's electronic medical records and/or chart when she had returned had been an oversight.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #41's History of Trauma / Post-Traumatic Stress Disorder (PTSD)
A medical record review, completed on 03/08/23 at ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #41's History of Trauma / Post-Traumatic Stress Disorder (PTSD)
A medical record review, completed on 03/08/23 at 8:45 AM, revealed the following:
-Resident #41 was admitted to the facility on [DATE].
-A Social Services Assessment, dated 11/23/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A second Social Services Assessment, dated 12/12/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A third Social Services Assessment, dated 01/31/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-The Medicare 5-Day MDS, dated [DATE], failed to identify PTSD / History of trauma.
-The Quarterly MDS, dated [DATE], also failed to identify PTSD / History of trauma.
During an interview on 03/08/23 at 1:53 PM, the MDS Nurse #47 reported she had no knowledge of Resident #41's history of trauma / PTSD and confirmed that it was not captured on the MDS. The MDS Nurse #47 stated it is the Social Worker's role to identify a past history of trauma, That section of the MDS is the Social Worker's responsibility and to also care plan it. Under normal circumstances, the Social Worker would speak to the MDS Nurse and together they would contact the attending physician to query about a medical diagnosis of PTSD.
Based on record review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment. This is true for two (2) of 21 sample residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #41 and #59. Facility census: 61.
Findings included:
a) Resident #59
A discharge medical record review of Resident #59's revealed a progress note on 1/14/23 at 9:56 AM that stated that the Resident left Against Medical Advice (AMA) with her responsible party.
According to the Annual Minimum Data Set (MDS) Discharge assessment for Resident #59, with an Assessment Reference Date (ARD) 01/14/23, Section A (Identification information) was not accurately assessed for discharge return not anticipated, unplanned to an acute hospital.
During an interview on 03/08/23 at 9:58 AM the Clinical Reimbursement Coordinator (CRC) Nurse confirmed Resident #59's Discharge MDS was incorrect. She stated that Resident #59 was discharged to home.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
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Based on resident interview, record review, and staff interview, the facility failed to ensure a resident with decision-making capacity was informed of the initial plan for delivery of care and serv...
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Based on resident interview, record review, and staff interview, the facility failed to ensure a resident with decision-making capacity was informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This was true for one (1) of one (1) residents reviewed for care plans. Resident identifier: #41. Facility census: 61.
Findings included:
a) Resident #41
During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings or receiving a copy of the initial baseline care plan.
A record review, completed on 03/07/23 at 7:45 PM, revealed:
-Resident #41 had decision-making capacity.
-Licensed Practical Nurse (LPN) #95, on 12/12/2022 at 9:37 AM, documented Resident #41 was out of the facility at the hospital
-Social Worker #6 documented in the Post admission Patient/Family Conference Note, dated 12/12/22 at 9:46 AM, The following were in attendance: Patient, Social Services, and CRC [Clinical Research Coordinator]. Expectations: Patient's stay is expected to be Short Term. Patient/family and IDT agree upon projected length of stay. Advance Directives not yet in place. The role of each IDT member was discussed. Discussed rehospitalization and the clinical capabilities of Center if the patient's condition changes, and the benefits of staying at the Center for treatment.
Additional Information Discussed: Prior living situation, Prior level of function, Current level of function, Recent losses/traumatic events, Behavior symptoms/successful approaches, Initiation dates/reasons for Psychotherapeutic Medications, if prescribed, Routine preferences, There are no known transportation needs post transition. Patient's Post-Skilled Nursing Facility disposition will be home. Status is projected to not be homebound. Home Health Services are being recommended. Additional Comments: This baseline, Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post admission Patient/Family Conference and given to the resident and/or resident representative, and updated as indicated. Resident plans to discharge home once her health is stable
-Registered Nurse (RN) #96, on 12/12/2022 at 5:27 PM, documented, Resident arrived back in facility from [hospital] via ambulance stretcher assist of three (3) from stretcher to bed.
-There was no other documentation related to and subsequent care plan meetings.
During an interview on 03/08/23 at 11:34 AM, Social Worker #6 reported the documentation stating Resident #41 attended the Post admission Patient/Family Conference and received a copy of her baseline care plan would have been in error since resident was out to the hospital on that day. Social Worker #6 offered the note may have auto-populated with erroneous details when the type of note was selected. Social Worker #6 went on to state that it would not have been possible to give Resident #41 a copy of her baseline care plan since she had not been in the building.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to develop and/or implement a person-centered comprehensive care pla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to develop and/or implement a person-centered comprehensive care plan for one (1) of 22 sample residents reviewed during the long term care survey process. A history of trauma/Post-Traumatic Stress Disorder (PTSD) was not addressed for Resident #41. Resident identifier: #41. Facility census: 61.
Findings included:
a) Resident #41
During an interview, on 03/06/23 at 11:26 AM , Resident #41 reported she had a history of trauma in early life affecting privacy concerns and would like to have counseling.
A record review, completed on 03/07/23 at 7:45 PM, revealed:
-Resident #41 was admitted to the facility on [DATE].
-A Social Services Assessment, dated 11/23/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A second Social Services Assessment, dated 12/12/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A third Social Services Assessment, dated 01/31/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], failed to identify PTSD / History of trauma.
-The Quarterly MDS, dated [DATE], also failed to identify PTSD / History of trauma.
-Resident #41's care plan failed to address Resident #41's history of PTSD.
On 03/08/23 at 9:35 AM, Social Worker #6 reported having knowledge of Resident #41 reporting a history of previous trauma / PTSD. She recalled resident having nightmares when she was first admitted to the facility and seems to have improved. Social Worker #6 acknowledged the facility had failed to implement a comprehensive, person-centered care plan with measurable goals and objectives related to trauma-informed care for Resident #41.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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c) Resident #41
During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings.
A record review, completed on 03/07/23 at 7:45 PM, reve...
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c) Resident #41
During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings.
A record review, completed on 03/07/23 at 7:45 PM, revealed:
-Resident #41 had decision-making capacity.
-LPN #95, on 12/12/2022 at 9:37 AM, documented Resident #41 was out of the facility at the hospital
-Social Worker #6 documented in the Post admission Patient/Family Conference Note, dated 12/12/22 at 9:46 AM, The following were in attendance: Patient, Social Services, and CRC [Clinical Research Coordinator]. Expectations: Patient's stay is expected to be Short Term. Patient/family and IDT agree upon projected length of stay. Advance Directives not yet in place. The role of each IDT member was discussed. Discussed rehospitalization and the clinical capabilities of Center if the patient's condition changes, and the benefits of staying at the Center for treatment.
Additional Information Discussed: Prior living situation, Prior level of function, Current level of function, Recent losses/traumatic events, Behavior symptoms/successful approaches, Initiation dates/reasons for Psychotherapeutic Medications, if prescribed, Routine preferences, There are no known transportation needs post transition. Patient's Post-Skilled Nursing Facility disposition will be home. Status is projected to not be homebound. Home Health Services are being recommended. Additional Comments: This baseline, Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post admission Patient/Family Conference and given to the resident and/or resident representative, and updated as indicated. Resident plans to discharge home once her health is stable.
-RN #96, on 12/12/2022 at 5:27 PM, documented, Resident arrived back in facility from [hospital] via ambulance stretcher assist of three (3) from stretcher to bed.
-There was no other documentation related to and subsequent care plan meetings.
During an interview on 03/08/23 at 11:34 AM, Social Worker #6 reported the documentation stating Resident #41 attended the Post admission Patient/Family Conference and received a copy of her baseline care plan would have been in error since resident was out to the hospital on that day. Social Worker #6 offered the note may have auto-populated with erroneous details when the type of note was selected. Social Worker #6 went on to state that no member of Resident #41's family had attended the meeting either.
When asked what evidence the facility has that residents with decision-making capacity are invited to care plans, Social Worker #6 replied, If they have capacity, I just tell them about their meetings. I do not document the invitation to prove it happens each time or what their responses may be about attending. Social Worker #6 agreed the care plan goals did not show evidence of Resident #41's input.
b) Resident #20
Review of Resident #20's medical record on 03/07/23 found the following care plan:
Focus:
--Resident is at risk for complications of restraint use Restraint type a lap buddy.
Goal:
--Resident will not experience any adverse effect of restraint use for 90 days such as skin breakdown, increased agitation, or anxiety.
Intervention:
-- Assess for adverse effects of restrain use such as incontinence, skin breakdown, decrease functional ability and confusion and consult with physician.
-- Utilize and release restraint per physician order.
Continued review revealed, no active Physician order for a physical restraint. Resident #56's order for a physical restraint (lap buddy) was discontinued 02/24/22.
On 03/07/23 at 3:02 PM during an interview the Director of Nursing (DON) verified the physical restraint (lap buddy) was discontinued on 02/24/23. She stated that she would resolve the restraint care plan on this date.
Based on medical record review and staff interview, the facility failed to invite a resident and/or family member to attend the care plan meeting. In addition, care plans were not updated to reflect a change in vision or the discontinuation of a restraint. This is true for three (3) of 22 care plans reviewed. Resident identifiers: #41, #20, and #28. Facility census: 61.
Findings include:
a) Resident (R) #28
Review of the medical record on 03/08/23, found R#28 was referred to an Optometrist when she reported visual changes to her physician. The Optometrist evaluation dated 01/31/23, identifies floaters and black spots in both of R#28's eyes. The assessment states vitreous detachment right eye. The plan is for prescription glasses, monitor the retina and vitreous, report any changes, and follow up in six (6) months.
On 03/08/23 at 10:00 AM the Director of Nursing (DON) confirmed R#28's visual changes and her recent visit to the Optometrist. The DON agreed the care plan was not updated to reflect R#28's change in vision and recommendation to monitor for changes.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on policy review, record review and staff interview, the facility failed to provide care and services in a timely fashio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on policy review, record review and staff interview, the facility failed to provide care and services in a timely fashion in accordance with acceptable standards of practice. The facility failed to obtain a resident's weight upon admission. This was true for one (1) of 22 sample residents during the annual recertification survey. Resident identifier: #261. Facility census: 61.
Review of the facility's Weights and Heights Policy, with a review date of 06/15/22, instructed, Patients are weighed upon admission and/or re-admission .
Findings included:
a) Resident #261
On 03/06/23 at 2:29 PM, an electronic health record review revealed:
-Resident #261 was admitted to the facility on [DATE].
-Resident #261's first weight was documented on 03/04/23.
-A physician order, dated 03/06/24 at 1:08 PM, Weigh every day shift every Wed [Wednesday] for four (4) Weeks AND every day shift on the 1st and ending on the 5th every month.
During an interview, on 03/08/23 at 8:59 AM, Licensed Practical Nurse (LPN) #58 confirmed Resident #261 was admitted to the facility on [DATE] and was not weighed until 03/04/23. LPN #58 stated it was best case practice to weigh residents upon admission. She explained that frequently the Certified Nursing Assistant (CNA) on duty would be asked to obtain the resident's weight if possible. If not, the nurse doing the admission would obtain it. It would be placed into the electronic medical record under weights and is not documented anywhere else. There is no weight log kept at the nurses station. LPN #58 confirmed Resident #261's initial weight upon admission was not obtained and documented in the electronic medical record. It appears that Resident's weight was first recorded as part of the weights that are taken the 1st thru 5th of the month for every resident in the building.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care ...
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Based on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #41, #161. Facility census: 61.
Findings included:
a) Resident #41
On 03/08/23 at 11:00 AM observation of Licensed Practical Nurse (LPN) #83 opened the sterile tracheostomy (trach) care kit and proceeded to put on sterile gloves. After pouring hydrogen peroxide into two (2) of the sections in the trach care kit. LPN #83 removed the soiled trach dressing and proceeded to take sterile swabs, dipped into the peroxide solution and clean around the trach stoma. After removing the sterile gloves, performed hand washing and put on unsterile gloves, removed the inner cannula and placed into one of the sections containing hydrogen peroxide. After rotating the inner cannula in the peroxide solution, tapped the inner cannula on a sterile 4x4 pad in an attempt to remove the peroxide. When LPN #83 was asked if there was sterile saline/water to rinse the inner cannula she replied Oh yes. I am just nervous. After rinsing the inner cannula with sterile water, replaced the inner cannula in the trach tube.
LPN #83 had a face shield that was on the top of her head and not pulled down to cover her face during the entire procedure.
In an interview with the Director of Nursing (DON) on 03/08/23 at 2:33 PM, the DON agreed that LPN #83 did not follow the policy and procedure for completing trach care and that a face shield was required when doing trach care.
b) Resident (R) #161
On 03/06/23 at 11:22 AM, one (1) of two (2) filters on R #161's oxygen concentrator was found covered with a thread like substance. Registered Nurse (RN) #66 confirmed this observation and immediately change the filter.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident who was a trauma survivor received trauma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #41. Facility census: 61.
Findings included:
a) Resident #41
A medical record review, completed on 03/08/23 at 8:45 AM, revealed the following:
-Resident #41 was admitted to the facility on [DATE].
-A Social Services Assessment, dated 11/23/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A second Social Services Assessment, dated 12/12/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past.
-A third Social Services Assessment, dated 01/31/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month if she had felt very upset when something reminded her of a stressful experience from the past
On 03/08/23 at 9:35 AM, Social Worker #6 reported having knowledge of Resident #41 reporting a history of previous trauma/PTSD. She recalled resident having nightmares when she was first admitted to the facility and seems to have improved. Social Worker #6 acknowledged the facility had failed to implement a comprehensive, person-centered care plan with measurable goals and objectives related to trauma-informed care for Resident #41. Additionally, Social Worker #6 acknowledged the facility failed to identify triggers which may cause re-traumatization.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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Based on record review, staff interview, the facility failed to have an accurate diagnosis for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for Unnecessary med...
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Based on record review, staff interview, the facility failed to have an accurate diagnosis for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for Unnecessary medications. Resident identifier: #12. Facility census: 61.
Findings included:
a) Resident #12
A medical record review for Resident #12 found, Physician orders:
--Celexa Oral Tablet 20 MG (Citalopram Hydrobromide)
Give 1 tablet by mouth one time a day for depression, with an order date 12/23/2022.
--Seroquel Oral Tablet 100 MG (Quetiapine Fumarate)
Give 100 mg by mouth two times a day for mood and behaviors. Order date 12/23/2022.
--Seroquel Oral Tablet 200 MG (Quetiapine Fumarate)
Give 200 mg by mouth at bedtime for mood and behaviors. Order date12/23/2022
--Buspirone HCl Tablet 15 MG
Give 2 tablet by mouth two times a day for anxiety Give two tablets (30mg),
Order date 12/23/22.
Continued medical record review of Resident #12's active diagnosis list did not find diagnoses for Depression or Anxiety.
On 03/08/23 at 1:25 PM during an Interview the Administrator verified Resident #12 did not have depression and anxiety active diagnoses in his medical chart. Also, she confirmand there was not an accurate diagnosis on the Seroquel orders.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
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Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the k...
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Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 61.
Findings included:
a) Kitchen
On 03/08/22 at 2:00 PM a review of training certificate for food handlers found:
Dietary [NAME] #38 - No documentation of Food Handlers Training prior to 03/06/23.
During an Interview with the District Manager on 03/08/23 at 2:20 PM, verified the staff in question did not have Food Handlers Training until this date.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to complete labeling and dates on refrigerator items in accordance with professional standards for food service safety related to storag...
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Based on observation and staff interview, the facility failed to complete labeling and dates on refrigerator items in accordance with professional standards for food service safety related to storage. This has the ability to affect a limited number of Residents that get their nutrition from the kitchen. Facility Census: 61.
Findings Included:
a) Kitchen
During the initial kitchen tour on 03/06/23 at 11:00 AM., an observation found:
--Walk-in refrigerator -a container with 3 cabbage heads, and a large container of wilted loose-leaf lettuce was not labeled or dated.
During an interview on 03/06/23 at 11:12 AM., the Account Manager, confirmed the items were not labeled. She removed the lettuce at this time and labeled the container of cabbage.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. A Physician Order for Scope of Treatment Form (POST Form) was not filled out...
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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. A Physician Order for Scope of Treatment Form (POST Form) was not filled out and the hard medical chart did not contain the updated POST form. This practice affected one (1) of (22), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #21. Facility census: # 61.
Findings included:
a) Resident #21
A electronic medical record review on 03/07/23 at 9:14 AM revealed, Resident #21's Post form Section D did not contain the required physician's full name , date signed, phone number or License number.
A review of Resident #21's active hard chart did not contain the active/revised POST form.
During an interview on 03/07/23 at 10:49 AM, the Social Worker verified the wrong POST form was on Resident #21's hard chart and the revised Post did not contain all required information in section D.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to honor resident privacy when leaving an elopement binder containing resident pictures and elopement risk identification forms in the f...
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Based on observation and staff interview, the facility failed to honor resident privacy when leaving an elopement binder containing resident pictures and elopement risk identification forms in the front lobby accessible to any passerby. This was a random opportunity for discovery and was true for 18 residents. Resident identifiers: #26, #51, #6, #54, #2, #53, #37, #39, #49, #34, #45, #46, #43, #111, #211, #40, #24, and #13. Faciity census: 61.
Findings included:
a) Elopement Binder
Observation, on 03/06/23 at 10:38 AM, found the facility's elopement binder in the front lobby accessible to any passerby. The elopement binder contained resident pictures and an elopement risk identification form completed for each resident who had been deemed an elopement risk. The resident picture and the elopement risk identification form were to be provided to law enforcement and search party at the time of any resident elopement. The elopement risk identification forms included resident information like date of birth , distinguishing characteristics like colostomy bag, last known address in the community.
Pictures and an elopement risk identification form were on file for the following residents:
-Resident #26
-Resident #51
-Resident #6
-Resident #54
-Resident #2
-Resident #53
-Resident #37
-Resident #39
-Resident #49
-Resident #34
-Resident #45
-Resident #46
-Resident #43
-Resident #111
-Resident #211
-Resident #40
-Resident #24
Resident #13
During an interview on 03/06/23 at 10:50 AM, the Administrator agreed it was a privacy issue for the elopement binder to be in the lobby. It's not supposed to be here. It is usually kept in the front office.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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Based on review of facility grievances, facility reportables, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state ag...
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Based on review of facility grievances, facility reportables, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state agencies as required. This had the potential to cause more than minimal harm. This was a random opportunity for discovery. Resident identifiers: #8, #32, #44, and #56. Facility census: 61.
Findings included:
a) Resident #8
On 03/07/23 at 2:04 PM, a review of the facility grievance log from September 2022 through March 2023 found the following resident complaint:
-On 10/13/22, Resident #8's family member asked how often resident should be being showered. She was told at least twice a week and bed baths in between those times. Resident #8's family member reported, Well, that isn't happening. The family member also reported Resident #8's teeth are not getting cleaned.
During an interview on 03/08/23 at 10:10 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
Additional review found on 01/18/23, Resident #8's family member reported resident was not getting her shower on her shower days, the nurse was not notified by the aide that resident was feeling sick and feeling like she might puke, and that her teeth are not put in when her daughter arrives at 12:30 PM.
During an interview on 03/08/23 at 10:13 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
b) Resident #32
On 03/07/23 at 2:08 PM, a review of the facility grievance log from September 2022 through March 2023 found the following resident complaint:
-On 12/05/22, Resident #32 reported his call light was not being answered timely and it was supposedly related to the aides trying to find help for care.
During an interview on 03/08/23 at 10:11 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
Additional review found on 10/13/22, Resident #32's family member stated resident had not had a shower since the 27th of January.
During an interview on 03/08/23 at 10:14 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
c) Resident #44
On 03/07/23 at 2:14 PM, a review of the facility grievance log from September 2022 through March 2023 found the following resident complaint:
-On 01/07/23, Resident #44 reported he had told two (2) women (on midnight shift) that he had a BM [bowel movement] and no one changed him until way later in the night. It was noted in the nursing note that Resident does not typically make complaints.
During an interview on 03/08/23 at 10:12 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
d) Resident #56 - 02/17/23 Grievance/Concern
On 03/07/23 at 2:28 PM, a review of the facility grievance log from September 2022 through March 2023 found the following resident complaint:
-On 02/17/23, Resident #56's family member reported resident was not changed in a timely manner and there was no sheet on resident's bed.
During an interview on 03/08/23 at 10:15 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure monthly pharmacy medication reviews were completed by the consulting pharmacist and reviewed by the physician. This was true...
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Based on record review and staff interview, the facility failed to ensure monthly pharmacy medication reviews were completed by the consulting pharmacist and reviewed by the physician. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #38, #30, and #4. Facility census: 61.
Findings included:
a) Resident #38
A record review, completed on 03/08/23 at 3:02 PM, found the following progress notes from the consulting pharmacist:
-Drug Regimen Review Documentation, dated 10/20/2022 at 6:07 PM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted.
-Drug Regimen Review Documentation, dated 12/16/2022 at 10:17 AM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted.
-Drug Regimen Review Documentation, dated 02/20/2023 at 10:29 AM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted.
The pharmacist reports for the months of October 2022, December 2022, and February 2023 were not scanned into the electronic medical record or a part of Resident #38's chart at the nurses station.
During an interview, on 03/08/22 at 4:00 PM, the Administrator reported neither she nor the Director of Nursing (DON) could locate the pharmacist recommendation for the above-mentioned months. The Administrator reported the facility had not received the normal email from the pharmacist for each of those months which would have the recommendations attached. The Administrator also acknowledged the physician did not review the pharmacist recommendations for the months of October 2022, December 2022, and February 2023 because they had not been received and were not part of the medical record.
b) Resident #30
A record review, completed on 03/08/23 at 3:21 PM, found the following progress notes from the consulting pharmacist:
-Drug Regimen Review Documentation, dated 10/20/2022 at 06:36 PM, revealed A medication regimen review was performed- see report for comments / recommendation(s) noted.
-Drug Regimen Review Documentation, dated 12/16/2022 at 10:40 AM, revealed A medication regimen review was performed- see report for comments / recommendation(s) noted.
The pharmacist reports for the months of October 2022 and December 2022 were not scanned into the electronic medical record or a part of Resident #30's chart at the nurses station.
During an interview, on 03/08/22 at 4:02 PM, the Administrator reported neither she nor the Director of Nursing (DON) could locate the pharmacist recommendation for the above-mentioned months. The Administrator reported the facility had not received the normal email from the pharmacist for each of those months which would have the recommendations attached. The Administrator also acknowledged the physician did not review the pharmacist recommendations for the months of October 2022 and December 2022 because they had not been received and were not part of the medical record.
c) Resident #4
A record review, completed on 03/08/23 at 3:43 PM, found the following progress notes from the consulting pharmacist:
-Drug Regimen Review Documentation, dated 02/20/23 at 5:16 PM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted.
The pharmacist report for the month of February 2023 was not scanned into the electronic medical record or a part of Resident #4's chart at the nurses station.
During an interview, on 03/08/22 at 4:02 PM, the Administrator reported neither she nor the Director of Nursing (DON) could locate the pharmacist recommendation for the above-mentioned month. The Administrator reported the facility had not received the normal email from the pharmacist for each of those months which would have the recommendations attached. The Administrator also acknowledged the physician did not review the pharmacist recommendations for the month of February 2023 because it had not been received and was not part of the medical record.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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e) A-Wing Observation
On 03/07/23 at 12:20 PM, an observation was made of the lunch time meal service on the A-Wing of the facility was made for the first cart food delivery. There was no opportuni...
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e) A-Wing Observation
On 03/07/23 at 12:20 PM, an observation was made of the lunch time meal service on the A-Wing of the facility was made for the first cart food delivery. There was no opportunity given to Residents #4, #23, #37, #7 and #47 for hand hygiene before the lunchtime meal was served.
During an interview on 03/07/23 at 12: 43 PM, Nurse Aide (NA) #78 and NA #73 confirmed they had not offered a hand hygiene option to the above-mentioned residents before the meal was served.
b) Kitchen
An observation on 03/07/23 at 11:41 AM revealed Dietary Aide #94 washing her hands she did not wash her hands for 20 sec and turned the faucet off with her wet hands prior to drying. With surveyor intervention, she rewashed her hands and turned the faucet off with a wet paper towel prior to her hands being dry.
During an interview with Dietary aid #94 on 03/07/23 at 11:41 AM, she confirmed she did not turn the faucet off with a paper towel.
During an interview on 03/07/23 at 11:42 AM the District Manager verified Dietary Aide #94 did not wash her hands correctly and turned the faucet off with her wet hands.
c) Dining
On 03/06/23 at 12:04 PM an observation of dining room meal pass revealed, no resident hand hygiene prior to the noon meal.
On 03/07/23 at 12 :10 PM a second Observation of the dining room meal pass found no hand hygiene provided prior to the meal.
03/07/23 at 12:16 PM an observation of Resident #57 touching his catheter tubing prior to his being tray provided.
During an interview on 03/07/23 at 12:28 PM with Residents #31, #18, and #57, they verified no one offers them to clean their hands prior to meals.
On 03/07/23 at 12:34 PM the Activities Director stated that she was unsure if the residents had hand hygiene prior to the staff passing trays.
d) In room dining
Observations during lunch service on 03/06/23 at 12:37 PM, found residents dining in their rooms were not given the opportunity to clean their hands prior to eating. Resident (R) #161 acknowledged her lunch tray lacked any device or wipe to clean her hands before eating. R#77 reported the meal trays never contain a towelette or wipe for her to utilize before eating and she wheels herself to the sink if she wants to clean her hands. Nursing Assistant Student #77 verified the meal trays lacked wipes to clean the residents hands before eating, during this observation.
Based on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifier: #41. Facility census: 61.
Findings included:
a) Resident #41
On 03/08/23 at 11:00 AM observation of Licensed Practical Nurse (LPN) #83 opened the sterile tracheostomy (trach) care kit and proceeded to put on sterile gloves. After pouring hydrogen peroxide into two (2) of the sections in the trach care kit, LPN #83 removed the soiled trach dressing and proceeded to take sterile swabs, dipped into the peroxide solution and clean around the trach stoma. After removing the sterile gloves, performed hand washing and put on unsterile gloves, removed the inner cannula and placed into one of the sections containing hydrogen peroxide. After rotating the inner cannula in the peroxide solution, tapped the inner cannula on a sterile 4x4 pad in an attempt to remove the peroxide. When LPN #83 was asked if there was sterile saline/water to rinse the inner cannula she replied Oh yes. I am just nervous. After rinsing the inner cannula with sterile water, replaced the inner cannula in the trach tube.
LPN #83 had a face shield that was on the top of her head and not pulled down to cover her face during the entire procedure.
In an interview with the Director of Nursing (DON) on 03/08/23 at 2:33 PM, the DON agreed that LPN #83 did not follow the policy and procedure for completing trach care and that a face shield was required when doing trach care.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • $3,250 in fines. Lower than most West Virginia facilities. Relatively clean record.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (58/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 58/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Miletree Center's CMS Rating?
CMS assigns MILETREE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Miletree Center Staffed?
CMS rates MILETREE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Miletree Center?
State health inspectors documented 41 deficiencies at MILETREE CENTER during 2023 to 2025. These included: 41 with potential for harm.
Who Owns and Operates Miletree Center?
MILETREE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 62 certified beds and approximately 57 residents (about 92% occupancy), it is a smaller facility located in SPENCER, West Virginia.
How Does Miletree Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MILETREE CENTER's overall rating (3 stars) is above the state average of 2.7, staff turnover (54%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Miletree Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Miletree Center Safe?
Based on CMS inspection data, MILETREE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Miletree Center Stick Around?
MILETREE CENTER has a staff turnover rate of 54%, which is 8 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Miletree Center Ever Fined?
MILETREE CENTER has been fined $3,250 across 1 penalty action. This is below the West Virginia average of $33,111. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Miletree Center on Any Federal Watch List?
MILETREE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.