Miletree Center: Resident Skipped Two Meals - WV
Resident #63 complained that she received no breakfast or lunch tray on April 20. The facility's own investigation five days later confirmed what happened: Nurse Aide #37 and Licensed Practical Nurse #101 both admitted they failed to provide either meal.
The resident was among 56 people living at the Spencer nursing home when the incident occurred.
Federal inspectors reviewed the facility's internal investigation report, completed April 25. The document showed staff had substantiated the resident's complaint. Two different employees acknowledged their failure to deliver meals during posted meal times of 7:15 AM for breakfast and 12:00 PM for lunch.
The current administrator, interviewed by inspectors on August 19 at 2:33 PM, confirmed that the incident report had been substantiated by staff. The administrator noted the investigation was completed before taking the current position at the facility.
Federal regulations require nursing homes to provide at least three meals daily at regular times comparable to normal community mealtimes. The rules also mandate that facilities serve meals according to residents' needs, preferences, and care plans.
The missed meals represented a clear violation of these standards. Breakfast and lunch account for two-thirds of a resident's daily nutrition, making their absence particularly concerning for elderly patients who may already struggle with maintaining proper nutrition.
The facility posts specific meal times for residents: breakfast at 7:15 AM, lunch at 12:00 PM, and dinner at 5:15 PM. These scheduled times help residents maintain routine and ensure adequate spacing between meals for proper digestion and medication timing.
The investigation revealed a breakdown in basic care delivery. Two licensed staff members working different shifts both failed to complete fundamental duties on the same day for the same resident. The nurse aide would typically be responsible for meal delivery, while the licensed practical nurse would oversee care coordination and ensure residents received proper nutrition.
No documentation indicated the resident refused meals or was unavailable during meal times. The staff acknowledgment suggests the meals were simply overlooked or forgotten during routine care delivery.
The timing of the incident raises additional concerns. April represents a period when many nursing homes face staffing challenges, potentially contributing to missed care. However, the facility's investigation did not explore underlying causes or systemic issues that might have led to the oversight.
Federal inspectors classified the violation as causing minimal harm with few residents affected. This designation indicates the incident was isolated to one person and did not result in serious medical consequences. However, missing two consecutive meals could impact blood sugar levels, medication effectiveness, and overall well-being, particularly for elderly residents with multiple health conditions.
The facility's response to the complaint showed appropriate internal investigation procedures. Staff completed a five-day follow-up investigation and documented their findings. The investigation included interviews with involved personnel who acknowledged their failures.
This transparency in acknowledging mistakes represents proper incident response, though it also highlights the original care failure. The facility substantiated the resident's complaint rather than dismissing or minimizing the concern.
The administrator's acknowledgment during the federal inspection demonstrated awareness of the incident and its investigation. However, the report provides no information about corrective actions taken to prevent similar incidents or additional training provided to staff.
Missing meals affects more than just nutrition. For nursing home residents, meal times often represent primary social interaction and daily structure. Breakfast and lunch provide important opportunities for staff to assess residents' condition, administer medications, and ensure proper hydration.
The incident occurred despite posted meal schedules designed to ensure consistent care delivery. These schedules serve as basic operational tools to coordinate staff responsibilities and resident care throughout each day.
Federal regulations emphasize that nursing homes must provide suitable and nourishing meals at appropriate times. The rules recognize that elderly residents may have specific dietary needs and preferences that require accommodation beyond standard meal service.
The violation demonstrates how basic care can break down even in routine operations. Two separate staff members, working at different times during the same day, both failed to complete essential duties for the same resident.
Resident #63's experience illustrates the vulnerability of nursing home residents who depend entirely on staff for basic needs like nutrition. When multiple staff members fail to provide scheduled meals, residents have few options for addressing immediate hunger or nutritional needs.
The facility's investigation confirmed what the resident already knew: she had been forgotten during two of the day's three meal services, leaving her to rely on dinner as her only substantial nutrition for that day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miletree Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
MILETREE CENTER in SPENCER, WV was cited for violations during a health inspection on August 18, 2025.
Resident #63 complained that she received no breakfast or lunch tray on April 20.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.