Miletree Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spencer, West Virginia.
- Location
- 825 Summit Street, Spencer, West Virginia 25276
- CMS Provider Number
- 515182
- Inspections on file
- 16
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Miletree Center during CMS and state inspections, most recent first.
A dietary aide was observed handling food trays, pushing a cart, and using a telephone without changing gloves or performing hand hygiene before returning to the tray line. This breach in infection control procedures was confirmed by the regional dietary manager and had the potential to impact multiple residents.
A resident was not provided with breakfast or lunch trays on a specific day, as confirmed by both a nurse aide and an LPN. The facility's posted meal times were not adhered to for this resident, and the incident was substantiated by staff during a follow-up investigation.
A resident with worsening incontinence-associated dermatitis (IAD) on the buttocks was not reported to the physician, legal representative, or dietician as required. Documentation showed the wound was deteriorating, but notification sections were left blank and there was no evidence in the medical record that appropriate parties were informed. The DON confirmed the lack of notification.
A resident's quarterly MDS assessment did not accurately reflect the use of an antianxiety medication, Buspar, as required in the medication section. This omission was confirmed by the DON during a review of unnecessary medications.
A resident's pre-admission screening did not reflect their current diagnosis of Major Depressive Disorder, as the PASARR form indicated no major mental illness while other documentation showed the diagnosis. The Administrator confirmed the screening was not updated to match the resident's current condition.
Two residents did not have all of their medical diagnoses included in their care plans, with missing conditions such as paraplegia, acute embolism, panic disorder, chronic hepatitis C, MRSA history, and others. The DON confirmed that the care plans were incomplete after record review.
A resident's care plan was not revised after an antidepressant (Celexa) was discontinued, and the care plan also incorrectly listed a diagnosis of Parkinson's Disease, which the resident did not have. These issues were confirmed by the DON during a record review.
A resident with depression and schizophrenia was prescribed Prozac 40mg daily, but staff did not document required behavior or side effect monitoring for this psychotropic medication. The DON confirmed the absence of such monitoring during the survey.
A resident with a physician order for a puree diet was served crackers by a kitchen aide, which the resident then crumbled into her soup before surveyor intervention. Documentation confirmed that only residents on a Dysphagia Advanced diet may have crackers, not those on a puree diet. The facility did not ensure food was served in the correct consistency as ordered.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents. One resident's POST form was incomplete, lacking a documented choice for medically assisted nutrition, while another resident's hospital transfer forms contained incorrect transfer dates due to a system issue. These deficiencies were confirmed by facility leadership during the survey.
The facility failed to accurately assess three residents, leading to deficiencies in documenting dental status and restraint use. A resident reported dental issues not reflected in their MDS, while two residents had physician's orders for seatbelt restraints that were not documented. The DON confirmed these inaccuracies, indicating lapses in record-keeping and assessment practices.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific health needs. A resident's care plan did not include a diabetes diagnosis, another lacked information on restraint use, and a third had unimplemented fall interventions and meal intake monitoring. Additionally, a resident's dental care needs were not addressed, with the DON admitting to not arranging a dental consult. These issues highlight significant gaps in care planning and implementation.
The facility failed to maintain proper infection control practices, as evidenced by improper storage of a used bath basin and bed pan in a resident's room, and uncovered transport of clean personal items on a linen cart. The DON confirmed these deficiencies, which were attributed to staff oversight.
The facility failed to maintain nutritional standards for two residents, resulting in significant weight loss and inadequate documentation of meal intake. One resident experienced a 10.91% weight loss over four months, with recommendations for snacks and appetite stimulants not implemented. Another resident's meal percentages were inconsistently documented, complicating weight loss monitoring. The DON acknowledged the documentation gap.
The facility failed to document medication refrigerator temperatures on several dates in June and July 2024. A tour revealed missing records for specific PM shifts, contrary to the facility's policy requiring twice-daily checks. The DON confirmed the oversight.
A resident reported significant dental issues, including broken teeth and discomfort, but the facility failed to assist in obtaining dental care. Despite a care plan addressing oral health risks, there was no documentation of dental consultations. The DON acknowledged awareness of the issue but did not document or arrange for care, leading to the deficiency.
A facility failed to maintain an accurate medical record for a resident's transfer to an acute care facility. The transfer form incorrectly stated the transfer date, which was confirmed by the DON during an interview.
A resident reported constant severe pain, but the facility failed to provide adequate pain management. Despite having prescriptions for pain medications, the resident's pain was not consistently addressed, and there were no defined parameters for PRN medication use. Staff interviews revealed that medication administration was based on subjective assessments rather than structured guidelines.
A facility failed to provide adequate ADL care for a resident, who was observed to be unkempt with oily hair and facial hair. Despite not rejecting care, the resident received only two showers in the last 30 days. The DON confirmed the resident did not receive all scheduled showers, indicating a deficiency in maintaining personal hygiene.
A resident expressed a lack of participation in activities, despite their care plan indicating the importance of group activities. The resident participated in only eight activities during a 48-day stay. The Activity Director acknowledged the resident's infrequent attendance and lack of one-to-one visits, with no further documentation provided.
The facility failed to follow physician's orders for two residents regarding the release of seatbelt restraints every two hours for repositioning. Documentation was missing from the Treatment Administration Record for specific dates and times, as confirmed by the DON. This indicates a failure to adhere to the prescribed care plan.
The facility failed to ensure dignified meal service by delaying assistance to dependent residents and allowing staff to stand while feeding a resident. The DON confirmed these practices were inappropriate.
A facility failed to notify the ombudsman of a resident's multiple hospital transfers. The resident was transferred to an acute care facility three times, but the DON revealed that the staff responsible for notifications mistakenly thought the requirement only applied to discharges, not transfers.
A facility failed to provide bed hold notices for a resident transferred to an acute care facility on three occasions. The resident was transferred on specific dates, and upon review, it was found that no bed hold notices were documented. The DON confirmed that these notices were not completed.
A facility failed to transmit a Minimum Data Set (MDS) upon the discharge of a resident. The MDS Discharge Return Not Anticipated was completed but not transmitted within the required timeframe, exceeding 120 days. The Clinical Reimbursement Coordinator acknowledged the oversight and was unsure why the MDS was not transmitted.
Failure to Maintain Infection Control During Food Service
Penalty
Summary
A deficiency was identified when a dietary aide failed to follow proper infection control procedures while serving food from the tray line in the resident dining room. The aide was observed wearing the same gloves while pushing a tray cart, using the telephone, and then returning to handle food items on the tray line without changing gloves or performing hand hygiene. This lapse in infection control was confirmed by the regional dietary manager, who acknowledged that gloves should have been removed and hand hygiene performed before resuming food service tasks. The incident was observed during a random opportunity and had the potential to affect more than an isolated number of residents, given the facility's census of 56 at the time.
Failure to Provide Scheduled Meals to Resident
Penalty
Summary
The facility failed to provide at least three meals daily at regular times in accordance with resident needs, preferences, requests, and plan of care. Specifically, one resident did not receive a breakfast or lunch tray on a specified date, as confirmed by a facility-conducted Five-Day Follow-Up investigation. Both a nurse aide and an LPN acknowledged that the resident was not given a breakfast or lunch tray on that day. The posted meal times for residents were 7:15 AM for breakfast, 12:00 PM for lunch, and 5:15 PM for dinner. The administrator confirmed that the incident was substantiated by staff during the investigation.
Failure to Notify Physician, Responsible Party, and Dietician of Worsening MASD
Penalty
Summary
The facility failed to notify a resident's legal representative, attending physician, and dietician regarding a worsening Moisture-Associated Skin Damage (MASD) area, specifically Incontinence Associated Dermatitis (IAD), located on the resident's intergluteal cleft. Documentation from a Skin and Wound Evaluation indicated the wound was in-house acquired, measured 39.5 cm2, and was deteriorating, with denuded skin due to exposure to bodily fluids. Notification sections for the physician, responsible party, and dietician were left blank, and there was no evidence in the electronic medical record or progress notes that these parties were informed. The Director of Nursing confirmed that the facility could not provide documentation of the required notifications.
Inaccurate MDS Assessment for Medication Use
Penalty
Summary
A review of records for one resident revealed that the facility failed to provide an accurate Minimum Data Set (MDS) assessment. Specifically, the quarterly MDS assessment did not indicate the use of an antianxiety medication, Buspar, in the section related to medications. This omission was confirmed by the Director of Nursing (DON) during an interview after being notified of the discrepancy. The deficiency was identified during a review of five residents under unnecessary medications, with the facility census at 56 residents at the time.
Failure to Update PASARR with Current Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Pre-admission Screening and Resident Review (PASARR) accurately reflected the resident's current mental health diagnosis. Documentation review showed that the pre-admission screening form indicated no major mental illness or suspected mental illness, while a separate diagnosis report listed Major Depressive Disorder, Single Episode, Unspecified. Staff interview with the Administrator confirmed that the pre-admission screening had not been updated to reflect the resident's current diagnosis at the time of admission. This deficiency was identified for one resident out of a facility census of 56, based on both documentation review and staff interview.
Care Plans Incomplete for Residents with Multiple Diagnoses
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included all current diagnoses for two residents. For one resident, the care plan did not address diagnoses such as non-Alzheimer's disease, paraplegia, transient paralysis, acute embolism and thrombosis of the lower extremity, obstructive and reflux uropathy, and retention of urine. For another resident, the care plan omitted multiple diagnoses, including panic disorder, dizziness, generalized muscle weakness, inflammatory liver disease, chronic viral hepatitis C, a history of MRSA, vestibular disorder, benign prostatic hyperplasia, urinary retention, obstructive sleep apnea, hypertension, hyperlipidemia, bilateral age-related nuclear cataract, dry eye syndrome, GERD, and constipation. These omissions were confirmed by the DON following record reviews.
Care Plan Not Updated After Medication Change and Incorrect Diagnosis Listed
Penalty
Summary
The facility failed to revise a resident's care plan after the discontinuation of a psychotropic medication and also listed an incorrect diagnosis in the care plan. Specifically, the care plan for a resident was not updated when Celexa, an antidepressant prescribed for depression, was discontinued. Additionally, the care plan incorrectly documented a diagnosis of Parkinson's Disease, despite the resident never having been diagnosed with this condition. These deficiencies were identified during a record review and confirmed by the Director of Nursing.
Failure to Monitor Side Effects and Behaviors for Antidepressant Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident who had diagnoses of depression and schizophrenia. The resident was prescribed Prozac 40mg daily for depression, but there was no documentation of behavior or side effect monitoring for this antidepressant as required. This deficiency was identified during a record review, and the DON confirmed that such monitoring was not being conducted or documented for the resident receiving Prozac. This lapse was noted for one out of four residents reviewed in the care area of hospitalizations, with the facility census at 56 at the time of the survey.
Resident on Puree Diet Served Incorrect Food Consistency
Penalty
Summary
A resident with a physician order for a puree diet was served crackers on her plate during a meal service. The incident occurred when a kitchen aide placed crackers on the resident's plate, which was verified by the Regional Dietary Manager. The resident then crumbled the crackers and added them to her soup, preparing to eat the mixture before a surveyor intervened. Documentation from speech therapy indicated that only residents on a Dysphagia Advanced diet may have crackers with soups, but this resident was on a puree diet, which does not permit crackers. The facility failed to ensure that food was prepared and served in the correct consistency as ordered by the physician.
Incomplete Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident, the Physician's Order for Scope of Treatment (POST) form dated 01/31/25 was found to be incomplete, specifically missing a documented choice in Section D regarding medically assisted nutrition options. This omission was confirmed by both the Administrator and the DON. For another resident, a review of transfer documentation revealed that the date on the second hospital transfer form was incorrect, listing an earlier year instead of the actual transfer date. The Administrator confirmed that the incorrect dates were due to a system issue. These findings were based on record reviews and staff interviews conducted during the survey process, affecting two of the 22 residents reviewed.
Inaccurate Assessments for Dental Status and Restraint Use
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in the documentation of dental status and the use of restraints. Resident #47 reported significant dental issues, including broken teeth, which were not accurately reflected in their Minimum Data Set (MDS) assessment. The MDS inaccurately indicated that the resident had no natural teeth or tooth fragments and no obvious dental issues, despite the resident's visible dental problems and their own report of discomfort. The Director of Nursing (DON) acknowledged the oversight and the absence of any notes or dental consultations in the resident's chart. Additionally, the facility failed to document the use of restraints for Residents #42 and #20 in their MDS assessments. Both residents had physician's orders for seatbelt restraints while in wheelchairs due to their inability to maintain an upright sitting position independently. However, the MDS for both residents did not reflect the use of these restraints. The DON confirmed that the MDS for both residents was incorrect and should have indicated the use of restraints, highlighting a lapse in accurate record-keeping and assessment practices.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific health needs. Resident #10's care plan did not include a diagnosis of diabetes mellitus, which was confirmed by the Director of Nursing (DON). Similarly, Resident #20's care plan lacked information regarding the use of restraints, which was also acknowledged by the DON. These omissions indicate a lack of thoroughness in the care planning process for these residents. Additionally, Resident #52's care plan was not properly implemented concerning fall interventions and meal intake monitoring. A fall mat, which was supposed to be placed on the left side of the bed, was missing, and meal intakes were not documented as required, hindering the dietician and physician's ability to monitor weight loss. Resident #47's dental care needs were not adequately addressed, as the resident reported significant dental issues, and the DON admitted to not having documented or arranged for a dental consult. These failures highlight significant gaps in the facility's care planning and implementation processes.
Infection Control Deficiencies in Storage and Transport
Penalty
Summary
The facility failed to maintain an appropriate infection control program, as observed in two separate incidents. In room [ROOM NUMBER]A, a used bath basin and bed pan were found improperly stored in the bathtub, along with soiled washcloths on the side of the bathtub and hanging on the window seal. Nurse Aide #58 was informed and removed the items, acknowledging the oversight. The Director of Nursing confirmed the improper storage and disposal, attributing the oversight to a recent hospice visit for the resident's bath. Additionally, a linen cart containing clean personal items was observed being transported uncovered by Laundry Aide #38. The linen cart flaps were not secured, leaving the items exposed. Upon notification, the Laundry Aide admitted forgetting to cover the cart, and the Director of Nursing confirmed the requirement for the cart to be covered during transport.
Failure to Maintain Nutritional Standards for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, as observed during the Long-Term Care Survey Process. Resident #9 experienced a significant weight loss of 10.91% over four months and 6% in one month. Despite a recommendation from the Registered Dietician to add snacks and consider an appetite stimulant, the facility did not implement these measures. The resident's meal intake records showed numerous days with no intake recorded or only 25% intake, and the physician's notes did not address the weight loss. The administrator acknowledged the lack of documentation regarding the resident's eating habits. Resident #52 also faced issues with nutritional management, as evidenced by significant weight fluctuations and inconsistent meal intake documentation. The care plan noted nutritional risk due to dementia, but meal percentages were frequently undocumented, making it difficult for the dietician and physician to monitor the resident's weight loss. The Director of Nursing admitted to not knowing why meal percentages were not documented, highlighting a gap in the facility's monitoring and documentation processes.
Failure to Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to record temperatures for the medication refrigerator, which was identified during a tour of the medication room. On July 10, 2024, at 9:25 AM, it was observed that the medication refrigerator temperatures were not documented for several dates in June and July 2024, specifically on June 26, 27, 28, and July 8, 2024, during the PM shifts. The facility's policy, revised on July 1, 2024, requires that refrigerators and freezers used to store medications and vaccines operate within an acceptable temperature range and be checked twice daily. The Director of Nursing confirmed the lack of documentation for the refrigerator temperatures.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility failed to assist residents in obtaining routine and emergency dental care, as evidenced by the case of a resident who reported significant dental issues. During an interview, the resident expressed that their teeth were in poor condition, with some broken off at the gums, and they were experiencing discomfort. The resident mentioned financial constraints as a barrier to accessing dental care, stating they could not afford it. An observation confirmed the resident's poor dental condition, and a review of their care plan revealed a focus on oral health risks due to being edentulous, with goals and interventions aimed at maintaining oral health. Despite the care plan, there was no documentation of dental consultations or notes addressing the resident's dental issues. The DON acknowledged the resident's dental condition and admitted to being aware of the problem but failed to document or arrange for a dental consultation. This lack of action and documentation contributed to the deficiency, as the resident continued to experience dental pain and discomfort without receiving the necessary dental care.
Inaccurate Transfer Record for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident regarding their transfer to an acute care facility. The record review revealed that the transfer form for the resident indicated an incorrect transfer date. The resident was actually transferred on October 9, 2023, but the form incorrectly stated the transfer date as October 1, 2023. This discrepancy was confirmed by the Director of Nursing during a staff interview, who acknowledged the incorrect date on the transfer form.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident #43, during the Long-Term Care Survey Process. The resident reported experiencing constant pain at a level of 8 or above and expressed dissatisfaction with the current pain management plan, stating that no effective pain medications were provided. The resident's medical records indicated prescriptions for Acetaminophen, Naprosyn, and Gabapentin, but there were no defined parameters for the administration of PRN pain medications. Despite the resident frequently reporting pain levels of 4 or 5, the Medication Administration Record showed that pain medications were not consistently administered or offered. Interviews with facility staff revealed a lack of clarity and consistency in administering PRN pain medications. The administrator acknowledged that the resident did not receive PRN medications unless requested, and there was no documentation to justify the decision not to administer pain relief. An LPN admitted that the decision to give medication was based on the resident's mood rather than a structured assessment of pain levels. The facility's policy required defined parameters for PRN medications, which were not in place, contributing to the deficiency in pain management for the resident.
Deficiency in ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to maintain good personal hygiene for a dependent resident. During an observation, a resident appeared unkempt, with oily hair and facial hair, indicating a lack of proper grooming. A review of the resident's records showed that they did not reject care, yet only two showers were documented in the last 30 days. The Director of Nursing confirmed that the resident did not receive all scheduled showers, highlighting a deficiency in the facility's provision of ADL care.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing activity program that meets the physical, mental, and psychosocial well-being of each resident, as evidenced by the case of a resident who expressed a lack of participation in activities. During an interview, the resident mentioned that they used to attend activities but no longer do so and were unsure of the reasons. A review of the resident's medical records showed that they had participated in only eight out-of-room group activities during their 48-day stay at the facility. The Minimum Data Set (MDS) indicated that attending group activities was very important to the resident. The resident's activity care plan highlighted their preferences for engaging in meaningful daily routines, such as memory games, sensory activities, and group settings. Despite these preferences, the Activity Director acknowledged that the resident no longer attended group activities frequently and was not on a one-to-one visit schedule. The Activity Director admitted to seeing all residents daily, although this was not always documented. No further documentation regarding the resident's participation was provided by the end of the survey.
Failure to Document Restraint Release as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the release of restraints for two residents. For Resident #42, a physician's order dated 05/31/24 required the release of a seatbelt restraint every two hours for repositioning. However, documentation was missing from the Treatment Administration Record (TAR) for specific times on 06/18/24 and 06/30/24. The Director of Nursing confirmed the absence of documentation for these dates and times. Similarly, for Resident #20, the same physician's order was in place, but the TAR lacked documentation for several dates and times in June and July 2024. The Director of Nursing also confirmed the missing documentation for these instances. This indicates a failure to follow the prescribed care plan for both residents, as the required actions were not documented as completed.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service in the main dining room and for a specific resident. In the main dining room, dependent residents had their trays placed in front of them simultaneously with other residents without dining limitations, but were not assisted until all trays were served and a staff member was available. This delay in assistance was confirmed by the Director of Nursing, who acknowledged that dependent residents should be assisted immediately when their tray is placed in front of them. Additionally, an observation of a resident during the noon meal revealed that an Occupational Therapist Aide was standing while feeding the resident. The Director of Nursing confirmed that staff should not stand while feeding residents, indicating a failure to adhere to proper feeding protocols.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman of multiple hospital transfers for a resident. The resident was transferred to an acute care facility on three occasions: September 30, 2023, October 1, 2023, and October 9, 2023. Upon review of the notifications to the ombudsman, the Director of Nursing (DON) admitted that there were no records of such notifications. The DON explained that the staff responsible for notifications misunderstood the requirement, believing it applied only to discharges and not to transfers.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices for a resident who was transferred to an acute care facility on three separate occasions. The resident was transferred on 09/30/23, 10/01/23, and 10/09/23. Upon review of the records on 07/10/24, it was found that the facility did not have any documentation of bed hold notices for these transfers. The Director of Nursing confirmed on 07/11/24 that the bed hold notices were not completed.
Failure to Transmit MDS Upon Resident Discharge
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) upon the discharge of a resident. The record review for the resident revealed that the MDS Discharge Return Not Anticipated was completed on March 1, 2024, but was not transmitted within the required timeframe, exceeding 120 days. During an interview, the Clinical Reimbursement Coordinator acknowledged the oversight and expressed uncertainty about the reason for the failure to transmit the MDS.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
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