SPENCER, WV - Federal health inspectors documented significant care deficiencies at Miletree Center during a July 2024 survey, including failures to adequately manage resident pain, monitor nutritional status, and maintain infection control standards at the 57-bed facility.
Inadequate Pain Management Protocols
Inspectors identified concerning gaps in pain management for a resident experiencing chronic, severe pain. The resident reported pain levels of 8 or above on a 10-point scale consistently, yet medication administration records revealed a pattern of undertreated discomfort that persisted for months.
The facility had three pain medications available for the resident: acetaminophen tablets, naproxen 500mg, and gabapentin 600mg for neuropathy. The acetaminophen and naproxen were ordered "as needed" (PRN) rather than on a scheduled basis. Documentation showed the resident reported pain levels of 4 or 5 on 27 out of 39 days reviewed in June and July 2024. However, acetaminophen was never administered during this period, and naproxen was given or offered on only 8 of those 27 days when pain was documented.
When questioned about the discrepancy, the administrator stated that PRN medications were only given when residents specifically requested them. This approach proved problematic because the resident was documented as incapacitated, potentially limiting their ability to advocate for their own pain relief needs.
The facility's own pain management policy required that PRN pain medications have defined parameters for use, yet no such parameters existed in this resident's medical record despite a diagnosis of chronic pain. A licensed practical nurse acknowledged the gap, stating that medication decisions were sometimes based on the resident's mood rather than objective criteria. The nurse recognized that pain medication orders needed revision to ensure consistent, appropriate administration.
Chronic undertreated pain can lead to numerous complications beyond immediate discomfort. When pain remains poorly controlled, residents may experience decreased mobility, disrupted sleep patterns, reduced appetite, and increased risk of depression. Persistent pain can also interfere with participation in therapy and social activities, accelerating functional decline. Professional pain management standards emphasize the importance of scheduled dosing for chronic pain conditions rather than relying solely on PRN orders, which places the burden on residents to repeatedly request relief.
Critical Nutrition Monitoring Failures
The survey revealed two cases where residents experienced significant weight loss without adequate monitoring or intervention, raising concerns about the facility's nutritional oversight systems.
Resident with 11% Weight Loss
One resident's weight declined from 155.8 pounds in March 2024 to 138.8 pounds by July 2024, representing a 10.91% loss over four months and a 6% loss in a single month. These figures exceed thresholds that typically trigger clinical concern and intervention.
Meal intake documentation showed the resident consumed only 25% of lunch during observation. A June 2024 nutritional assessment by the registered dietician recommended adding between-meal snacks given the resident's suboptimal intake, and suggested considering an appetite stimulant if intake remained poor. However, review of 70 days of meal records from May through July revealed that 29 days had either no intake recorded for some meals or only 25% intake documented.
Despite this concerning pattern, physician notes from June indicated the resident's appetite was marked as "OK" with no documentation addressing the weight loss. The resident had previously refused nutritional supplements due to an ingredient sensitivity, yet no alternative supplementation strategy was documented. When asked why the dietician's recommendation for an appetite stimulant had not been pursued given the persistently poor intake, the administrator acknowledged the documentation did not support adequate nutritional intake.
Resident with Inconsistent Documentation
A second resident with dementia and a care plan noting "significant weight loss with variable intake" had meal percentages that were sporadically documented over a three-month period. On 28 occasions, only one or two meals per day were recorded rather than all three meals. This resident's weight fluctuated dramatically, dropping from 119 pounds in January to 96.2 pounds by July 2024.
The Director of Nursing acknowledged that without complete meal documentation, neither the dietician nor physician could adequately monitor weight trends or make informed care decisions.
Unintended weight loss in long-term care residents is associated with increased morbidity and mortality. Weight loss exceeding 5% in one month or 10% over six months is considered clinically significant and requires prompt evaluation and intervention. Inadequate nutrition compromises immune function, increases infection risk, impairs wound healing, and accelerates muscle wasting. For residents with dementia, additional strategies may be needed including modified food textures, assistance with eating, and environmental modifications to reduce distractions during meals. Complete and accurate meal intake documentation serves as an essential monitoring tool that enables early identification of declining nutritional status before severe weight loss occurs.
Physical Restraint Documentation Gaps
The facility failed to consistently document the release of physical restraints as ordered by physicians for two residents who used seatbelt restraints while in wheelchairs. Both had physician orders requiring restraint release every two hours for repositioning—a safety measure intended to prevent complications from prolonged immobilization.
Review of treatment administration records revealed multiple instances where documentation was missing for scheduled 2:00 PM and 4:00 PM releases throughout June and early July 2024. The Director of Nursing confirmed the documentation gaps but could not verify whether the releases actually occurred despite missing documentation.
Physical restraints, even those used for positioning support, carry risks including skin breakdown, circulation impairment, decreased muscle tone, and psychological distress. Regular release and repositioning are essential safety measures that allow for circulation restoration, skin assessment, range-of-motion movement, and toileting needs. When documentation is incomplete, surveyors cannot verify that these critical safety measures occurred, and facility staff lack a reliable system to ensure consistent implementation of physician orders.
Delayed Dental Care Access
A resident with multiple broken teeth and dental pain reported difficulty accessing needed dental services. During the survey, the resident stated that "teeth bother me a lot, some of them are broken off at the gums" and expressed concern about inability to afford dental care. Observation confirmed teeth in poor condition with several broken at the gum line.
The resident's care plan, created in January 2023, focused on oral hygiene for someone without teeth (edentulous), despite the resident clearly having natural teeth present. The resident reported pain on both sides of the mouth, with a cavity causing discomfort on one side and recent pain development on the other.
The Director of Nursing stated she had been working on scheduling a dental consultation but could find no documentation of the referral request or any notes about the resident's dental concerns in the medical record, despite the resident reporting the problems "a while back."
Untreated dental disease causes more than localized pain. Oral infections can lead to systemic health problems, particularly concerning for older adults with compromised immune systems. Broken teeth and dental pain interfere with adequate nutrition, as residents may avoid foods that require chewing or favor one side of the mouth, potentially leading to nutritional deficiencies. Poor oral health has been linked to increased risk of pneumonia, cardiovascular disease, and diabetic complications. Professional standards emphasize that nursing facilities must assist residents in obtaining both routine and emergency dental services.
Additional Issues Identified
Activities Program Deficiencies: One resident's care plan emphasized the importance of participating in group activities involving memory games, sensory activities, and bingo. However, the Activities Director acknowledged the resident "doesn't come much anymore" and did not have the resident scheduled for one-on-one visits despite the care plan indicating strong preference for social engagement.
Medication Storage: Temperature monitoring logs for the medication refrigerator were incomplete, with multiple dates showing no documentation in June and July 2024. The facility's policy required temperature checks twice daily to ensure medications and vaccines remained within acceptable storage ranges.
Infection Control Lapses: Inspectors observed a used bath basin and bedpan stored improperly in a bathtub alongside soiled washcloths. In a separate instance, clean personal laundry items were transported through the facility on an uncovered cart, creating potential for contamination. Staff members acknowledged these items should have been handled differently according to infection control protocols.
Medical Record Accuracy: A hospital transfer form contained an incorrect transfer date, with the documented date not matching the actual date the resident was transferred to acute care. The Director of Nursing confirmed the discrepancy, noting it had been discussed on a corporate call.
The Centers for Medicare & Medicaid Services conducted this standard health inspection on July 11, 2024. These deficiencies were classified as having potential for minimal harm or actual harm to residents. Federal regulations require nursing facilities to meet specific standards of care to participate in Medicare and Medicaid programs, and facilities must submit plans of correction addressing identified deficiencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miletree Center from 2024-07-11 including all violations, facility responses, and corrective action plans.
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