Miletree Center

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an infection control program while serving from the tray line in the resident dining room. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Facility Census: 56. Findings Include:a) Resident Dining RoomOn 08/11/25 12:12 PM, an observation was made of Dietary Aide #46 working the tray line in the resident dining room. The Dietary Aide #46 kept her gloves on and pushed a tray cart from the tray line to the dining room door. The Dietary Aide #46 used the telephone in the dining room with the same gloves on. On 08/11/25 at 12:15 PM, the Dietary Aide #46 returned to the tray line and began putting items on the dining tray while continuing to wear the same gloves. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify a resident's legal representative, the resident's attending physician, and the dietician about a worsening Moisture-Associated Skin Damage (MASD) area on the resident's body. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 56Findings included:a) Resident #67A record review, completed on 08/14/25 at 10:00 AM, revealed that Resident #67 had a documented Moisture-Associated Skin Damage (MASD) area on his intergluteal cleft on his buttocks. A Skin and Wound Evaluation, dated 06/11/25, revealed the following details:MASD Type: Incontinence Associated Dermatitis (IAD)In-house acquiredWound measurements: Area - 39.5 cm2, Length - 9.3 cm, and Width - 6.7 cmDenuded - loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate or friction. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) including all high risk drug classes for Resident #5. This is true for one (1) of five (5) residents reviewed under unnecessary medications. Resident Identfier: #5. Facility Census: 56. Findings Include:a) Resident #5On 08/14/25 at 9:00 AM, a record review was completed for Resident #5. The review found the MDS quarterly assessment dated [DATE] section N entitled Medications did not indicate the use of an antianxiety medication, Buspar. On 08/14/25 at 10:05 AM, the Director of Nursing (DON) and the Administrator were notified. The DON confirmed the MDS did not include the use of an antianxiety medication.

Inspectors wroteBased on documentation review and staff interview the facility failed to ensure resident's Pre-admission Screening reflected a current diagnosis for Resident #1. Resident identifier: #1. Facility Census 56.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a care plan including all diagnoses for Resident #5 and #6. This is true for two (2) of five (5) residents reviewed under unnecessary medications. Resident Identifiers: #5 and #6. Facility Census: 56. Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been developed to include all diagnoses. The following diagnoses are as follows: --Non-Alzheimer's disease--Paraplegia--Transient Paralysis --Acute Embolism and Thrombosis, lower extremity--Obstructive and Reflux Uropathy--Retention of UrineOn 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON did confirm all the diagnoses were not included in the care plan.b) Resident #6On 08/13/25 at 11:00 AM, a record review was completed for Resident #6. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan when a psychotropic medication was discontinued and an incorrect diagnosis was listed for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 56. Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been revised when an antidepressant was discontinued and an incorrect diagnosis was listed. The review found the resident was ordered Celexa 10mg (milligram) by mouth daily for depression from 01/12/24 through 11/16/24. Also, the review found a diagnosis of Parkinson's Disease, which the resident has never been diagnosed with. On 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow a physician's order for Resident #4 for side effect monitoring and behavior monitoring of a psychotropic medication. This was true for one (1) of four (4) residents reviewed under the care area of hospitalizations. Resident identifier: #4. Facility Census: 56. Findings Include:a) Resident #4On 08/13/25 at 11:30 AM, a record review was completed for Resident #4. The resident had a diagnosis of depression, unspecified and schizophrenia, unspecified. The resident is receiving Prozac 40mg (milligram) by mouth daily for depression. The resident is not currently receiving any medication for the diagnosis of schizophrenia. However, there is no behavior or side effect monitoring documenation for the antidepressant, Prozac. [...]

Inspectors wroteBased on record review, staff interview and observations, the facility failed to ensure a resident was served food in the correct consistency according to the National Dysphagia Diet Levels as ordered by the physician. This was a random opportunity for discovery. Resident Identifier: #16. Facility Census: 56.

Inspectors wroteBased on record review the facility failed to provide at least three (3) meals daily, at regular times comparable to normal mealtime in the community in accordance with resident needs, preferences, requests and plan of care. Resident identifier: #63. Facility census 56. Findings Included:a)Resident #63A review of the Five-Day Follow-Up investigation completed by the facility on 04/25/25 after resident alleged that she did not receive a breakfast or lunch tray on 04/20/25 revealed the facility substantiated the the report. Nurse Aide (NA) #37 and Licensed Practical Nurse #101 acknowledged that Resident #63 was not given a breakfast tray or lunch tray on 04/20/25. Posted Meal times for residents are as follows: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #10's Physician's Order for Scope of Treatment (POST) form and two (2) transfer forms for Resident #5. This is true for two (2) of 22 residents reviewed during the survey process. Resident Identifiers: #10 and #5. Facility Census: 56. Findings Include: a) Resident #10 On 08/11/2025 at 3:04 PM, a record review was completed for Resident #10. The review found the POST form dated 01/31/25 was incomplete. Section D, entitled Medically Assisted Nutrition, did not list a choice regarding feeding through a new or existing surgical tubes, a time-limited trial of the amount of days but no surgically placed tubes, or no artificial means of nutrition desired or discussed but no decision made (provide standard of care). [...]

Inspectors wroteb) 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.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints. c) 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. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #10 regarding a diagnosis of diabetes mellitus, Resident #20 for the use of restraints, Resident #52 for fall interventions and meal intake and Resident #47 regarding dental care. This was true for five (5) of 15 residents reviewed during the survey process. Resident Identifiers: #10, #20, #52 and #47. Facility Census: 57. Findings Include: a) Resident #10 On 07/09/24 at 11:15 AM, a record review was completed for Resident #10. The review found the care plan was not developed regarding the diagnosis of diabetes mellitus. On 07/09/24 at 11:50 AM, the Director of Nursing (DON) confirmed the care plan did not include the diagnosis of diabetes mellitus. b) Resident #20 On 07/09/24 at 1:30PM, a record review was completed for Resident #20. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to maintain acceptable parameters 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to assist residents in 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. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an appropriate infection control 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; [...]

Inspectors wroteBased on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service in the main dining room and for Resident #36. This was a random opportunity for discovery. Resident Identifier: #36. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to notify the ombudsman of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 Findings Include: On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the notifications to the Ombudsman, the Director of Nursing (DON) stated, we don't have anything .the person doing the notifications didn't know it included transfers .they thought it was only discharges.

Inspectors wroteBased on record review and staff interview, the facility failed to provide bed hold notices of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the bed hold notices , the Director of Nursing (DON) stated, we don't have anything .they weren't done.

Inspectors wroteBased on record review and staff interview, the facility failed to transmit a Minimum Data Set (MDS) upon discharge of Resident #22. This was true for one (1) of one (1) residents reviewed under the care area of resident assessment. Resident Identifier: #22. Facility Census: 57. Findings Include: a) Resident #22 On 07/10/24 11:10 AM, a record review was completed for Resident #22. The review found the MDS Discharge Return Not Anticipated dated on 03/01/24 was completed but not transmitted within greater than 120 days. On 07/10/24 at 12:10 PM, an interview was held with Clinical Reimbursement Coordinator (CRC) #5. CRC #5 was notified and acknowledged the discharge MDS was completed but was not transmitted. CRC #5 stated, I don't know why it wasn't transmitted .I'll have to look into this.

Inspectors wroteBased on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents. This is true for 0ne (1) of three (3) residents reviewed for ADL care. Resident Identifiers: #49. Facility census: 57.

Inspectors wroteBased on resident interview, record review, and staff interview the facility failed to provide an ongoing activity program which meets the physical, mental and psychosocial well-being of each resident. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #13. Facility Census 57. Findings Include: a) Resident #13 During the initial interview on 07/08/24 at 3:05 PM, Resident #13 stated, I used to attend activities, I just don't anymore. I don't know why. I sometimes don't know what is going on. A record review on 07/09/24 at 9:30 AM, of Resident #13's medical record revealed, she was admitted to the facility on [DATE]. Further record review of Resident #13's Activity participation record shows during her 48 days at the facility she participated in 8 out of room group activities. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to follow physician's orders 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: [...]

Inspectors wroteBased on resident interview, staff interview and record review the facility failed to provide pain management 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 : [...]

Inspectors wroteBased 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 hospitalizations. 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.

Inspectors wroteBased on observation and staff interview, the facility failed to honor resident privacy when leaving an elopement binder containing resident pictures and elopement risk identification forms in the front lobby accessible to any passerby. This was a random opportunity for discovery and was true for 18 residents. Resident identifiers: #26, #51, #6, #54, #2, #53, #37, #39, #49, #34, #45, #46, #43, #111, #211, #40, #24, and #13. Faciity census: 61.

Inspectors wroteBased on review of facility grievances, facility reportables, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state agencies as required. This had the potential to cause more than minimal harm. This was a random opportunity for discovery. Resident identifiers: #8, #32, #44, and #56. Facility census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure monthly pharmacy medication reviews were completed by the consulting pharmacist and reviewed by the physician. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #38, #30, and #4. Facility census: 61.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifier: #41. Facility census: 61.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was kept on Resident #30's medical chart. This was true for one (1) of 22 sample residents. Resident identifier: #30. Facility census: 61.

Inspectors wroteBased on record review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment. This is true for two (2) of 21 sample residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #41 and #59. Facility census: 61.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a resident with decision-making capacity was informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This was true for one (1) of one (1) residents reviewed for care plans. Resident identifier: #41. Facility census: 61.

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement a person-centered comprehensive care plan for one (1) of 22 sample residents reviewed during the long term care survey process. A history of trauma/Post-Traumatic Stress Disorder (PTSD) was not addressed for Resident #41. Resident identifier: #41. Facility census: 61.

Inspectors wrotec) Resident #41 During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings. A record review, completed on 03/07/23 at 7:45 PM, revealed: -Resident #41 had decision-making capacity. -LPN #95, on 12/12/2022 at 9:37 AM, documented Resident #41 was out of the facility at the hospital -Social Worker #6 documented in the Post admission Patient/Family Conference Note, dated 12/12/22 at 9:46 AM, The following were in attendance: Patient, Social Services, and CRC [Clinical Research Coordinator]. Expectations: Patient's stay is expected to be Short Term. Patient/family and IDT agree upon projected length of stay. Advance Directives not yet in place. The role of each IDT member was discussed. [...]

Inspectors wroteBased on policy review, record review and staff interview, the facility failed to provide care and services in a timely fashion in accordance with acceptable standards of practice. The facility failed to obtain a resident's weight upon admission. This was true for one (1) of 22 sample residents during the annual recertification survey. Resident identifier: #261. Facility census: 61. Review of the facility's Weights and Heights Policy, with a review date of 06/15/22, instructed, Patients are weighed upon admission and/or re-admission .

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #41, #161. Facility census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #41. Facility census: 61.

Inspectors wroteBased on record review, staff interview, the facility failed to have an accurate diagnosis for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for Unnecessary medications. Resident identifier: #12. Facility census: 61.

Inspectors wroteBased on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 61.

Inspectors wroteBased on observation and staff interview, the facility failed to complete labeling and dates on refrigerator items in accordance with professional standards for food service safety related to storage. This has the ability to affect a limited number of Residents that get their nutrition from the kitchen. Facility Census: 61. Findings Included: a) Kitchen During the initial kitchen tour on 03/06/23 at 11:00 AM., an observation found: --Walk-in refrigerator -a container with 3 cabbage heads, and a large container of wilted loose-leaf lettuce was not labeled or dated. During an interview on 03/06/23 at 11:12 AM., the Account Manager, confirmed the items were not labeled. She removed the lettuce at this time and labeled the container of cabbage. .

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. A Physician Order for Scope of Treatment Form (POST Form) was not filled out and the hard medical chart did not contain the updated POST form. This practice affected one (1) of (22), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #21. Facility census: # 61.