Miletree Center

F-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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 to engage in preferred activities

Level of Harm - Minimal harm or Resident will pursue potential for actual harm opportunities for involvement in Residents Affected - Few 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 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 Level of Harm - Minimal harm or everybody everyday it's not always necessarily documented.' She further stated, I will have to check on her potential for actual harm participation.

Residents Affected - Few No further documentation was provided by the end of the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 45173 potential for actual harm Based on observation, record review and staff interview, the facility failed to follow physician's orders Residents Affected - Few 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 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. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45173 potential for actual harm Based on observation, record review and staff interview the facility failed to maintain acceptable parameters Residents Affected - Some 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 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 Level of Harm - Minimal harm or loss. potential for actual harm

During an interview on 07/10/24 at 10:06 AM, the administrator stated, (Resident #9 name) has refused Residents Affected - Some 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 --06/17/24 two meals only

Level of Harm - Minimal harm or --06/29/24 one meal only potential for actual harm --07/03/24 one meal only Residents Affected - Some --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.

49465

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49465 potential for actual harm Based on resident interview, staff interview and record review the facility failed to provide pain management Residents Affected - Few 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 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. Level of Harm - Minimal harm or potential for actual harm A record review on 07/09/24 at 2:20 PM, showed Resident #43 was incapacitated

Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 45173 Residents Affected - Some 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 49465 potential for actual harm Based on resident interview, record review and staff interview the facility failed to assist residents in Residents Affected - Some 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 during care and report to MD as indicated

Level of Harm - Minimal harm or Encourage resident to brush teeth and gums twice daily and as needed potential for actual harm Provide oral hygiene/mouth care twice per day and prn Residents Affected - Some 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 45173

Residents Affected - Few 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 hospitalization s. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 515182 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515182 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miletree Center 825 Summit Street Spencer, WV 25276

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45173 potential for actual harm Based on observation and staff interview, the facility failed to maintain an appropriate infection control Residents Affected - Some 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 515182