Milcrest Nursing Center

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure a resident or resident representative had timely access to their medical records upon request. This affected one (Resident #49) out of one resident reviewed for a records request. The facility census was 48.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a fall with major injury. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 48.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure fall interventions were updated in the medical record and care plan after a fall. This affected one (Resident #41) of three residents reviewed for falls. The facility census was 48.

Inspectors wroteBased on record review, staff and resident interview and policy review, the facility failed to ensure showers were completed as scheduled. This affected one (Resident #20) out of three residents reviewed for Activities of Daily Living (ADL) care. The facility census was 48. Findings Included:Review of the medical record revealed Resident #20 admitted to the facility on [DATE]. Diagnoses included muscle weakness, anxiety disorder, benign neoplasm of the rectum, type two diabetes, hypokalemia, depression, hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status score of 15 and normal cognitive function. Further review confirmed the resident required substantial/max assistance with tub/shower transfers. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure the accuracy of the medical record. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 48.

Inspectors wroteBased on observations, interviews, medical record review, and policy review, the facility failed to ensure a resident received appropriate incontinence care. This affected one (Resident #43) of three residents reviewed for incontinence care. The facility census was 44. Review of the medical record for Resident #43 revealed an admission date of 02/07/25. Diagnoses included transient ischemic attack, cerebral infarction, vascular dementia, and chronic respiratory failure with hypoxia. Review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively impaired. Resident #43 required assistance with bed mobility. Review of the Care Plan dated 04/10/26 revealed Resident #43 was frequently incontinent. Interventions included care as needed, resident with be clean, dry, and odor free, and bed in the low position. Observation on 05/14/26 at 7:45 A.M. [...]

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure residents received their showers as scheduled. This deficient practice affected two (Resident #16 and Resident #37) of three residents reviewed for shower assistance. The facility census was 49. Findings Include: 1. Review of the medical record for Resident #16 revealed an admission date of 10/28/24 and diagnoses of muscle weakness, anxiety, dysarthria and anarthria, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), tobacco use, and dementia. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required partial to moderate assistance with showering and bathing. [...]

Inspectors wroteBase on observation, interview, and record review the facility failed to ensure linen and personal clothing was not soiled for one, (Resident #16). This affected one (Resident #16) of three residents reviewed for Activities of Daily Living (ADL). The facility census was 49. Findings Include:Review of Resident #16's medical record revealed an admission date of 04/25/25, diagnoses included acquired absence of right left below the knee, chronic venous hypertension with ulcer and inflammation of the left lower extremity, cellulitis, obesity, edema, anemia, hypothyroidism, bilateral blindness, hypertension, peripheral vascular disease, gastro-esophageal reflux, acquired absence of right and left fingers, muscle weakness, Type II Diabetes, and osteomyelitis. [...]

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure safe storage of food in the kitchen. This had potential to affect all facility residents as they all ate food from the kitchen. The facility census was 44.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to ensure a resident's bathroom door opened and closed properly. This affected one (#08) resident out of sixteen residents reviewed for environment. The facility census was 44.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a resident had a care plan for elopement and the use of a Wanderguard. This affected one (#25) out of one residents reviewed for elopement. The facility census was 44.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly and included participation of the interdisciplinary team and the resident/responsible party. This affected two (#1 and #13) residents reviewed for care conferences. The facility census was 44.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to maintain hospice documentation for one (#11) of one resident reviewed for Hospice. The facility identified three residents receiving hospice care (#11, #14 and #37). The facility census was 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pressure reducing interventions as recommended to aide in the healing of a pressure ulcer for one (#08) out of four residents reviewed for pressure ulcers. The facility census was 44.

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure nail care was provided for one (#30) of three residents reviewed for activities of daily living. The facility census was 44.

Inspectors wroteBased on review of the medical record and staff interviews, the facility failed to implement interventions in a timely manner after a significant weight loss. This affected one (#29) of four residents reviewed for nutrition. The facility census was 44.

Inspectors wroteBased on review of the medical record, pharmacy recommendations, interviews, and policy review, the facility failed to timely implement pharmacy recommendations for one (#29) of five residents reviewed for medications. The facility census was 44.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a resident received dental care after breaking a tooth. This affected one (#05) resident out of two residents reviewed for dental care. The facility census was 44.

Inspectors wroteBased on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed during medication administration. This affected one (#197) of four residents reviewed for medication administration. The facility census was 44.

Inspectors wroteBased on review of Resident Council minutes, resident interview, and staff interview, the facility failed provide ongoing communication to residents about their rights. This had potential to affect all residents. The facility census was 44.

Inspectors wroteBased on review of the facility's Self-Reported Incident (SRI) and investigation, review of the facility's video surveillance, closed medical record review, review of the hospital records, staff interviews, and review of the facility policy, the facility failed to ensure a resident was free from neglect when the Director of Nursing (DON) and License Practical Nurse (LPN) #21 failed to adequately assess, monitor, and timely notify the physician of the resident's condition in accordance with professional standards of practice. [...]

Inspectors wroteBased on closed medical record review, review of the facility's video surveillance, staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the Emergency Medical Services (EMS) run report, review of the facility policy, and review of the American Heart Association (AHA) guidelines, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact EMS timely for one resident (#15), who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. In addition, once initiated, the facility failed to provide adequate CPR techniques for Resident #15. [...]

Inspectors wroteBased on medical record review, staff interviews, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report allegations of neglect to the State Survey Agency and Local Law Enforcement. This affected one (Resident #15) of three residents reviewed for abuse and neglect. The facility census was 47 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure an advanced directive was signed by the physician on the hard chart. This affected one resident (#34) out of 18 residents reviewed for advanced directives. The facility census was 45.

Inspectors wroteBased on observation, and resident and staff interviews, the facility failed to maintain a clean and sanitary environment. This affected two residents (#38 and #20) out of five residents reviewed for environment. The census was 45.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to update a care plan for one resident (#15) out of four residents reviewed for care planning. The facility census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure fall interventions were utilized as identified in the plan of care. This affected one (#13) of four resident reviewed for falls. The census was 45.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure an indwelling urinary catheter was stabilized. This affected one resident (#4) out of of two residents reviewed for urinary catheter. The census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to assess a resident upon return from dialysis. This affected one resident (#38) out of one resident reviewed for dialysis. The census was 45.

Inspectors wroteBased on observation, staff and resident interview and policy review the facility failed to ensure food was served at appropriate temperatures. This had the potential to affect all 37 residents. The census was 37.

Inspectors wroteBased on facility policy review and staff interview the facility failed to monitor and test for Legionella in the facility. This had the potential to affect all 37 residents.

Inspectors wroteBased on medical record review, observations, resident and staff interviews and review of the activity calendar the facility failed to ensure an ongoing activity program was provided for the residents, failed to ensure there were activities provided in the evenings and also failed to ensure participation for activities were documented. This affected four (#13, #15, #32, and #35) of four residents reviewed during the annual survey for activities. The census was 37.

Inspectors wroteBased on record review and staff interview the facility failed to notify resident's representatives of transfer to the hospital. This affected one (#36) resident of two reviewed for hospitalizations. The facility also failed to notify the Long- Term Care Ombudsman of transfers to the hospital. This affected two (#6 and #36) of two residents reviewed for hospitalizations. The facility census was 37.

Inspectors wroteBased on record review, resident and staff interview, and review of facility policy the facility failed to have quarterly care conferences for residents and failed to have the proper staff attend the care conferences. This affected three Residents (#7, #13, and #35) of 16 reviewed during the investigative phase of the survey. The facility census was 37.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to follow recommendations for restorative therapy. This affected one (#35) of one resident for restorative therapy. The facility identified seven residents who currently receive restorative care. The census was 37 residents.

Inspectors wroteBased on medical record review, staff and resident interview, the facility failed to ensure physicians orders were followed to hold blood pressure medication for a resident prior to receiving dialysis. This affected one (#35) of one resident reviewed for dialysis. The facility identified two residents who attending dialysis off grounds. The census was 37.