Inspection Reports for Milestone Senior Living LLC

Follow-up to the annual survey to verify correction of previously identified deficiencies.

The deficiencies identified in the prior annual survey were corrected as of the follow-up visit.

Follow-up to Complaint #39860 to verify correction of previously identified deficiencies.

The deficiency related to safety and supervision was corrected as of the follow-up inspection on 10/06/2025.

Follow-up to Complaint #39860; the deficiency was corrected.

Investigation of Complaint #39860 conducted from 08/19/25 to 08/20/25 regarding resident rights and facility practices.

The complaint was substantiated with a deficiency cited for failure to ensure residents were permitted to retain and use personal possessions. Specifically, Resident #15 had their phone and tablet confiscated without documentation after calling 911.

The complaint was substantiated. Resident #15 reported confiscation of personal items after calling 911. Administrator confirmed confiscation due to Resident #15 calling police when they felt they were not getting enough to eat.

Annual survey conducted from 06/09/2025 to 06/11/2025 to assess compliance with licensing and regulatory requirements for Milestone Senior Living, LLC.

The facility was found deficient in multiple areas including medication administration with missing signed physician orders, inadequate housekeeping and maintenance, improper infection control practices related to catheter bags, unlocked storage of hazardous materials, incomplete RN visit logs, and exceeding licensed resident capacity.

Annual environmental inspection conducted to assess maintenance, housekeeping, and safety conditions of the facility.

The licensee failed to maintain a safe, sanitary, and accident-free living environment, including locked exit doors requiring keys, unlocked electrical panels with missing breakers, and housekeeping deficiencies such as carpet damage and missing bathroom fixtures.

Annual environmental inspection conducted to assess compliance with health and safety regulations.

Twenty-five deficiencies were cited during the annual environmental inspection. A re-visit on August 20, 2025, confirmed that all deficiencies were corrected.

The visit was conducted as an annual survey of the facility to assess compliance with regulatory standards.

The annual survey conducted from June 3 to June 5, 2024, found no deficiencies cited at the facility.

Investigation of Complaint #32138 regarding the facility.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #32138 was investigated and found to be unsubstantiated with no deficiencies cited.

Annual survey conducted to assess compliance with state regulations including resident care plans, medication administration, housekeeping, maintenance, and health assessments.

The facility failed to ensure resident care plans reflected current needs, medications were administered and documented properly, housekeeping and maintenance were adequate, and annual health assessments were completed timely. Deficiencies were noted in care plan content for diabetic residents, medication administration documentation, housekeeping conditions, and incomplete resident assessments.

The inspection was conducted as an annual environmental survey of the facility.

The inspection found no deficiencies cited during the annual environmental survey.

This was a 1st follow-up/revisit to the initial survey to verify correction of previously cited deficiencies.

Deficiencies from the initial survey were corrected and cleared. No new deficiencies were identified during this follow-up visit.

Annual survey conducted to assess compliance with health, safety, medication administration, record keeping, and facility maintenance regulations.

The facility was found deficient in multiple areas including failure to report major incidents timely, inadequate medication orders and documentation, missing physician assessments, incomplete resident records, and inadequate housekeeping and maintenance.

The inspection was conducted to evaluate the facility's compliance with health, safety, housekeeping, laundry, maintenance, and physical environment regulations during a routine environmental survey.

The facility was found to have deficiencies related to improper storage of soiled laundry, missing or damaged physical facility components such as floor transitions, missing light fixture covers, and inadequate housekeeping and maintenance. The facility acknowledged these deficiencies and provided plans of correction including installation of proper laundry containers, monthly maintenance checks, and repair or replacement of damaged fixtures and flooring.

Follow-up to annual survey to verify correction of previous deficiencies.

The inspection was conducted as a follow-up to the annual survey with a census of 14 residents. No specific deficiencies or findings are detailed in this report excerpt.

Follow-up survey was conducted on 08/31/21 to review the correction of tags 0440, 0450, and 0497.

The facility had deficiencies related to tags 0440, 0450, and 0497 identified during the environmental survey on August 2, 2021, which were being reviewed during this follow-up survey.

Annual survey conducted to assess compliance with health, safety, personnel, medication administration, infection control, resident care, employee training, and other regulatory requirements at Milestone Senior Living, LLC.

The facility was found deficient in multiple areas including failure to maintain proper personnel health records (TB screening), inadequate housekeeping and maintenance, missing legal authority documents for residents, incomplete medication administration supervision, inadequate visitor COVID-19 screening, failure to document resident death notifications properly, incomplete employee orientation and training records, and failure to document resident weights upon admission.

The inspection was conducted to assess compliance with health, safety, housekeeping, maintenance, and emergency preparedness regulations at the facility.

The facility was found deficient in maintaining locked storage for hazardous supplies, providing adequate housekeeping and maintenance to ensure a safe and sanitary environment, and having a complete disaster and emergency preparedness plan including procedures for missing residents, floods, and severe weather. Corrective actions and plans of correction were documented for each deficiency.

The inspection was conducted as an Infection Control Survey to assess compliance with infection control standards.

No deficiencies were cited during the Infection Control Survey conducted on January 25, 2021.

The inspection was conducted to assess compliance with health and safety regulations and included a behavioral health survey conducted February 9-11, 2004, with follow-up evidence accepted in lieu of an onsite revisit.

The facility was found to have deficiencies related to safety and supervision, specifically lack of awake-night staff on weekends and unsecured outside doors in adolescent bedrooms and common areas. The deficiency was later corrected as credible evidence was accepted.

Follow-up visit to verify correction of previously cited deficiencies.

The citation has been corrected, and credible evidence was accepted in place of an onsite revisit.

The visit was a follow-up survey to review deficiencies identified at the Annual Survey and to verify correction of previous deficiencies related to dietary services and weight monitoring.

The facility failed to notify physicians of unplanned weight loss or gain of five pounds or more for two residents. Documentation of physician notification was unavailable. The facility implemented a plan of correction involving staff training and improved weight monitoring and notification procedures.

The inspection was conducted as a complaint survey related to failure to notify the registered nurse of a resident's nursing care needs following a fall and re-admission after surgery.

The licensee failed to ensure the registered nurse was notified when a resident with nursing care needs was re-admitted after a fall and surgery. Documentation and interviews revealed the LPN did not notify the RN of the resident's declining condition, and no RN assessment was completed. Additionally, housekeeping and maintenance deficiencies were noted in the facility environment.

Complaint ID WV00024631 was substantiated. The complaint involved failure to notify the RN of a resident's nursing care needs after a fall and re-admission. The resident sustained a fractured hip, underwent surgery, and exhibited declining condition without RN notification or assessment.

Annual survey conducted to assess compliance with state regulations for Milestone Senior Living, LLC.

The facility was found deficient in multiple areas including medication administration practices, infection control especially related to COVID-19, housekeeping and maintenance, staff training and certification, record keeping, dietary services, and policies and procedures. Specific issues included improper medication handling, lack of COVID-19 policies and training, expired medications stored, inadequate housekeeping, missing documentation of resident dentists, lack of CPR/First Aid certification for some staff, and failure to notify physicians of significant weight changes in residents.

The inspection was conducted as a complaint investigation based on complaint number 24058.

The complaint was unsubstantiated following the investigation conducted from July 20 to July 23, 2020.

Complaint #24058 was investigated from 07/20/20 to 07/23/20 and found to be unsubstantiated.

The inspection was conducted as a routine environmental survey to assess compliance with physical facility standards, housekeeping, maintenance, and emergency preparedness requirements.

The facility was found deficient in maintaining a safe and sanitary environment, including lack of accessible call systems in resident rooms, inadequate housekeeping and maintenance such as rusty registers and dirty kitchen areas, and failure to document annual emergency preparedness plan rehearsals.

The document is a plan of correction related to a previous citation at E423, indicating follow-up on compliance.

Credible evidence review revealed that the citation at E423 was corrected as of the date of the report.

Annual licensure survey conducted to assess compliance with regulatory requirements including provision of social and recreational activities and maintenance of a safe environment.

The facility failed to provide a monthly calendar listing the duration of all social and recreational activities for residents, with repeated deficiencies noted in August and September 2019. Additionally, housekeeping and maintenance issues were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.

Routine inspection conducted to assess compliance with regulations regarding activities, resident death procedures, housekeeping, laundry, record accuracy, and medication administration at Milestone Senior Living.

The facility failed to provide accurate activity calendars with durations, did not document release of resident belongings after death, had inadequate housekeeping and maintenance issues, failed to secure toxic materials properly, had incomplete Physician Orders for Scope of Treatment (POST) forms, and omitted a medication order from the medication administration record for one resident.

The visit was conducted as an annual licensure survey focusing on environmental conditions at the facility.

No environmental deficiencies were cited during the inspection.

The inspection was conducted as a complaint investigation related to medication administration and record-keeping practices at Milestone Senior Living, LLC.

The investigation found that the facility failed to ensure written physician orders for medications, failed to keep accurate medication administration records including dosage amounts, and did not maintain proper narcotic count sheets. Deficiencies were identified in medication management and documentation.

Complaint ID WV00022031. The complaint investigation focused on medication administration and record-keeping deficiencies for residents #7 and #C1.

The inspection was conducted as a complaint investigation from October 1-4, 2018, regarding concerns about the protection of physical and mental well-being of residents, medication administration, and housekeeping and maintenance issues.

The facility failed to protect the physical and mental well-being of residents, including inadequate medication administration, lack of physician orders for treatments and wound care, poor communication with Hospice, and inadequate housekeeping and maintenance. Multiple deficiencies were noted in medication management, resident care, and environmental safety.

Complaint ID WV00021187 involved allegations that the licensee, administrator, and nursing staff failed to protect residents' well-being, ignored residents' discomfort, refused medication administration, and had poor communication with Hospice. Staff reported fears of retaliation and described restrictive medication administration practices.

The inspection was conducted as a complaint investigation from October 1 to 4, 2018, related to Complaint ID WV00021187.

The complaint investigation identified deficiencies which were subsequently corrected as verified by a follow-up survey on November 28, 2018.

Complaint ID WV00021187 was investigated during the visit from October 1 to 4, 2018. A follow-up survey on November 28, 2018, confirmed that deficiencies were corrected.

The inspection was conducted as a complaint investigation based on Complaint ID WV00020877 during August 14-15, 2018.

No deficiencies were cited during the complaint investigation.

Complaint ID WV00020877 was investigated and found to have no deficiencies cited.

The inspection was conducted as a complaint investigation for Complaint #WV00020832.

The complaint investigation found the complaint to be unsubstantiated after the inspection.

Complaint #WV00020832 was investigated and found to be unsubstantiated.

The visit was conducted as an annual licensure survey and environmental inspection of the facility.

The inspection found no deficiencies during the annual environmental survey conducted on July 3, 2018.

The inspection was conducted as an annual licensure survey to assess compliance with state regulations for Milestone Senior Living, LLC.

The survey identified multiple deficiencies including failure to provide timely employee orientation and training, incomplete personnel records, improper use of physical restraints and bed rails, inadequate preparation of resident transfer summaries, medication administration errors, and failure of registered nurses to conduct and document weekly resident progress notes. Additionally, housekeeping and maintenance issues were observed in the facility environment.

The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.

The annual licensure survey identified deficiencies which were subsequently corrected by the follow-up survey conducted on September 7, 2018.

The inspection was conducted as a complaint investigation based on Complaint ID WV00020386.

No deficiencies were cited during the complaint investigation conducted on June 4-5, 2018.

Complaint ID WV00020386 was investigated with no deficiencies cited.

The visit was a follow-up inspection conducted on September 7, 2017, to verify correction of previously cited deficiencies from the annual licensure survey conducted July 3-5, 2017.

The facility was found to have repeat deficiencies related to failure of the registered nurse and administrator to develop and document service plans addressing nursing and medical needs for residents with gastrostomy tubes and Foley catheters. The plan of correction was partially implemented but deficiencies remained.

The inspection was conducted as a complaint investigation based on Complaint ID WV00018579 during August 9-10, 2017.

No deficiencies were found during the complaint investigation.

Complaint ID WV00018579 was investigated and found to have no deficiencies.

The inspection was conducted as an annual licensure survey to assess compliance with health, safety, and emergency preparedness regulations at Milestone Senior Living.

The facility was found deficient in disaster and emergency preparedness, including lack of an emergency alternate shelter agreement, emergency transportation policy, and failure to maintain hot water temperatures within required limits. Additionally, housekeeping and maintenance issues were noted, such as damaged carpets, missing bathroom fixtures, and inadequate physical environment monitoring.

The inspection was conducted as an annual licensure survey to assess compliance with health care standards and regulatory requirements at Milestone Senior Living, LLC.

The inspection identified multiple deficiencies including failure to complete required tuberculosis screenings for residents, improper medication storage with unlabeled bottles, lack of documented service plans for residents with medical needs, failure to notify physicians of significant weight changes, and inadequate housekeeping and maintenance issues within the facility.

Complaint investigation conducted April 24-27, 2017, triggered by complaints and concerns regarding resident care, medication administration, incident reporting, abuse allegations, and facility maintenance.

The facility was found deficient in multiple areas including failure to comply with medication administration policies, inadequate incident reporting, improper use of restraints, failure to report and investigate suspected abuse, inadequate response to resident complaints, lack of physician orders for medications and treatments, and poor housekeeping and maintenance. The RN failed to maintain proper visit records. Several residents were restrained improperly and there were unreported major incidents involving residents.

Complaint investigation for complaint number WV00017803 with eight deficiencies cited. Census at time of investigation was 13 residents.

The inspection was conducted as a complaint investigation regarding the administration of gastric tube feedings and other regulatory compliance issues at the facility.

The facility failed to protect the physical and mental well-being of residents by allowing unlicensed personnel to administer g-tube feedings, failed to ensure resident privacy during medical treatments, and failed to secure medications properly. Multiple deficiencies were identified related to medication administration, resident privacy, and housekeeping/maintenance.

Complaint Number: WV00016948. The investigation was triggered by concerns about improper administration of g-tube feedings and medication storage. The complaint was substantiated with three deficiencies cited.

The inspection was conducted as a complaint investigation based on complaint number WV00016948.

Three deficiencies were identified during the complaint investigation conducted from December 5-7, 2016. A follow-up survey on January 4, 2017, found no deficiencies and confirmed correction of previous issues.

Complaint investigation related to complaint number WV00016948 with three deficiencies found; substantiation status not explicitly stated.

The visit was a follow-up survey conducted to verify correction of deficiencies identified during the initial licensure survey conducted October 10-12, 2016.

The follow-up survey found no deficiencies; all previously cited deficiencies were corrected.

Annual licensure survey and environmental survey conducted to assess compliance with regulatory requirements.

No deficiencies were cited during this annual licensure and environmental survey.

Initial licensure survey conducted from October 10-12, 2016 to assess compliance with licensing requirements for Milestone Senior Living, LLC.

The survey identified one deficiency related to employee orientation and training, specifically the failure to provide training prior to scheduling employees to work unsupervised and maintain a written record of training for two new employees.

The visit was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.

The center failed to provide a safe environment as adolescent girls' bedrooms had outside doors without alarms or locking mechanisms, and staff were not awake on weekend nights to monitor consumers. A plan of correction was proposed to provide awake-night supervision on weekends by July 1, 2004.

The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.

The center failed to provide a safe environment as evidenced by unsecured outside doors in adolescent girls' bedrooms and the TV room, and lack of awake staff supervision on weekend nights. A plan of correction was proposed to employ staff or arrange alternate sleeping arrangements to provide awake-night supervision during weekend shifts by July 1, 2004.