Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caretel Inns Of Tri-cities during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and severe cognitive impairment sustained a full thickness abdominal burn after being fed breakfast in bed and left alone with hot tea within arm's reach. The care plan and Kardex directed staff to assist with eating, use a clothing protector, and provide a covered mug with lid for liquids, but the CNA left the resident unattended while the resident was eating. Staff interviews showed the DON and RN understood the resident required full feeding assistance and supervision with hot liquids, while the CNA reported the resident had been left alone with hot liquids before.
A resident with severe medical conditions was readmitted without a physician order for enteral feeding, resulting in nearly 19 hours without tube feeding or nutrition. Staff did not document timely notification to the physician about the missed feeding, and essential hospice and hospital discharge documents were missing from the record. The resident's condition worsened, leading to rehospitalization.
Nursing staff failed to clarify admission orders, reconcile medications, and provide timely medication administration for two residents after readmission, resulting in missed enteral feeding, administration of oral medications despite NPO status, lack of physician notification, and delayed administration of critical gastrointestinal medication due to unavailability in backup supply. These failures led to delayed care and rehospitalization.
Food was not consistently palatable, attractive, or served at an appetizing temperature. Several residents said they disliked the meals, reported the same foods were served repeatedly, and complained that food was often cold or not replaced with an alternative. During meal observation, tacos were served with excessive grease pooling on the plates and wilted lettuce, and the dining room menu was outdated.
Food service sanitation and hand hygiene deficiencies were observed in the kitchen. An ice machine in a sub kitchen was visibly soiled with black residue, and the Manager of Kitchen V stated Maintenance is supposed to clean it. During lunch prep, [NAME] W removed gloves and put on new gloves without washing hands, which was inconsistent with the facility’s food safety policy and the 2022 Food Code.
Soiled Wheelchairs, Unclean Resident Areas, and Missing Plumbing Backflow Device: Multiple resident wheelchairs were observed with hair, dust, debris, and sticky buildup, and residents reported the chairs were not routinely cleaned. Resident rooms and hallways had scuffed walls, dirty floors, food, paper, and an uncovered trash bin with food and dirty gloves in the hall. A missing atmospheric vacuum breaker on a utility sink left the water system open to the environment, and water spewed from the top of the sink when it was turned on.
Dignified dining and meal assistance failure: Multiple residents with dementia, dysphagia, CP, or other care needs were observed during meals without timely staff assistance, with spilled food on clothing, missing clothing protectors, fluids left out of reach, and delayed meal service. Some residents were not offered food or drinks promptly, one resident ate with fingers and tried to drink from an empty glass, and another had breakfast items missing and no lidded mug despite the meal ticket. Care plans called for feeding help, total assist, covered liquids, and clothing protectors, but these interventions were not consistently followed.
Inconsistent Scheduled Showers and Documentation Issues: Several residents reported that scheduled showers were not being provided unless they asked staff, and shower records showed missed or inconsistent bathing over the prior 30 days. One resident with diabetes, orthostatic hypotension, and syncope had only one documented shower, another with dysphagia, HTN, social phobia, MDD, and DM had only one, and two others also had incomplete or inconsistent shower documentation. The DON acknowledged an issue with showers, and the facility policy required bathing twice weekly with at least one complete shower weekly.
Medication carts were found with crushed pills, loose pills, dust, paper, and sticky residue in multiple drawers, and two partly used insulin pens lacked expiration dates on their labels. Staff could not explain the missing expiration dates, and one nurse left a medication cart unlocked and unattended facing the main lobby before later locking it after being questioned by another nurse and the DON.
Improper Clean Linen and Supply Storage: The cleaning supply room floor was visibly soiled with debris, clean linens were observed stored on the floor in a clean linen closet, and an unused urinal with other trash was found in another clean linen closet. The HSKP M removed the items from the closets during the tour.
Inaccurate Mental Health Diagnosis in Resident Record: The facility failed to ensure a resident had an accurate MH diagnosis in the chart. The resident’s record and MDS continued to list paranoid schizophrenia, while the SW reported the diagnosis was unsubstantiated by the Level II OBRA and psych evals. Staff were unsure why the physician entered the diagnosis, and the resident denied delusions or hallucinations and stated the diagnosis was inaccurate.
Breakfast trays were served without menu items for multiple residents, including missing eggs on egg, sausage, and cheese sandwiches and missing milk for some residents. One resident said they could not eat oatmeal without milk, and a DON observed a tray with no egg on the sandwich. Kitchen staff reported the liquid eggs were still frozen during breakfast prep, no eggs were cooked for residents, and no one was notified; milk was also not placed on some trays because CNAs were expected to get the drinks.
A facility failed to honor food allergies and preferences for two residents. One resident reported being served strawberry jelly despite a strawberry allergy and receiving wheat-containing items such as an English muffin and flour tortilla despite a wheat allergy, while the DON observed the breakfast tray with an English muffin. Another resident with cerebral palsy, hemiplegia, and cognitive communication deficit was served lunch items including spinach and potatoes despite documented dislikes, and the care plan did not include an intervention to follow food preferences.
Two residents experienced injuries related to improper transfer and lack of timely assessment: one developed bruising and sling indentations due to use of an incorrect Hoyer sling size despite care plan instructions, while another, who was non-ambulatory with severe contractures, sustained a leg fracture of unknown origin that was not promptly or accurately assessed or reported by staff, with no clear documentation or explanation for the injury.
Two residents experienced falls with injuries due to the facility's failure to implement and operationalize fall prevention policies, including lack of staff adherence to care plans, inadequate supervision, and absence of meaningful interventions. One resident suffered a hip fracture after being assisted by only one CNA instead of two, while another had multiple falls, resulting in a rib fracture and UTI, with insufficient preventive measures in place.
A resident with multiple chronic conditions, including contractures and immobility, sustained acute fractures of the right tibia and fibula. Despite the new injury and the use of an orthopedic boot, the care plan was not updated to include interventions for the fractures, pain management, or positioning. Staff and family were unable to determine how the injury occurred, and documentation review showed no revisions to address the resident's changed care needs.
A resident with immobility and recent fractures developed two Stage II pressure ulcers on the upper left shoulder due to inadequate repositioning, lack of updated care plan interventions, and insufficient documentation of wound assessment and physician notification. Nursing staff did not consistently follow the facility's pressure injury prevention policy, and wound measurements and records were only completed after surveyor observation.
A resident with advanced dementia and palliative care needs sustained a fractured right leg of unknown origin, with evidence suggesting inadequate supervision and inconsistent transfer practices between facility and hospice staff. The injury was discovered after bruising and swelling were noted, and no clear cause was identified, highlighting a failure to prevent accident hazards and ensure proper care coordination.
Two residents who requested alternative menu items were served unappetizing, poorly presented, and cold food, with missing condiments and small portions. Both expressed dissatisfaction and one refused to eat. Ongoing complaints from resident council meetings and staff interviews confirmed persistent issues with food quality, temperature, and service, in violation of facility policies requiring palatable and dignified meal service.
A resident admitted with pneumonia and sepsis did not receive scheduled evening medications on the day of admission due to delays in medication entry and administration, despite some medications being available in the facility's backup supply. The admission process spanned two shifts, and the concern about missed medications was not documented or addressed by facility leadership.
A facility failed to assess and treat a resident's UTI and foot wounds, leading to hospitalization. The resident, with a history of multiple health issues, showed signs of a UTI and had wounds on the feet that were not documented or treated. Upon hospital transfer, the resident was diagnosed with a complicated UTI, acute kidney injury, and osteomyelitis, eventually leading to hospice care and death. Interviews with staff confirmed the lack of documentation and treatment, and issues with laboratory services were noted.
The facility failed to follow catheter care policies and obtain urinalysis testing for three residents. A resident with a history of UTI had no urinalysis results despite a physician's order. Another resident expressed concerns about infrequent catheter emptying, confirmed by documentation and observation. A third resident's catheter was not emptied as per policy. The facility acknowledged issues with documentation and laboratory services.
A resident with severe cognitive impairment and limited mobility developed a facility-acquired Stage III pressure ulcer due to delayed wound assessment, lack of timely treatment, and inadequate documentation. The care plan was not promptly updated with new interventions, and pressure-relieving equipment was found to be in poor condition. Observations during wound care revealed improper dressing technique and the presence of fecal matter in the wound area, highlighting failures in both prevention and treatment of pressure ulcers.
A resident with a history of circulatory surgery and cognitive impairment developed an unstageable coccyx pressure ulcer due to the facility's failure to implement timely interventions. Despite being at risk, necessary measures like an air mattress were not used, leading to infection and hospitalization. The facility's records did not show any refusal by the resident to reposition, which was noted as a factor inhibiting wound healing.
A facility failed to ensure proper PPE use and hand hygiene for a resident requiring enhanced barrier precautions. Staff entered the resident's room without gowns, stored gloves in pockets, and did not perform hand hygiene before donning gloves. The resident had bloody drainage and open sores, and the necessary PPE was not available, leading to potential cross-contamination.
The facility failed to maintain cleanliness and organization of medication carts in three halls, with observations revealing crushed pills, papers, and dried liquids in drawers, and loose pills in another cart. Interviews indicated confusion over cleaning responsibilities, with the DON stating night shift nurses were responsible. Facility policies on medication storage and night shift duties were not adhered to, as there was no documentation of cart maintenance.
The facility failed to maintain cleanliness in its food service area, affecting 50 residents. Equipment such as the coffee machine, blender, and meat slicer were found with encrusted food residue, while the air conditioning unit above the steam table was heavily soiled. The facility's cleaning policies were not adhered to, increasing the risk of cross-contamination.
The facility failed to maintain cleanliness and proper labeling in the residents' refrigerator, with various food items found without labels or dates. The Infection Control Nurse admitted to not inspecting the refrigerator and was unaware of any cleaning policy. Additionally, the facility did not analyze monthly infection control data, with summaries lacking documentation of data analysis. The Infection Control Nurse had only received minimal training, indicating a lack of proper training and oversight.
The facility failed to maintain a clean and safe environment, affecting 50 residents. Observations showed damaged and soiled equipment in common areas, scuffed walls, and paint chips in a resident's room. A family member reported doing laundry due to inadequate facility services. A review revealed 51 rooms needing repairs, indicating maintenance backlogs.
A facility failed to implement a baseline care plan for a resident's oxygen administration, leading to unmet care needs. The resident, admitted with chronic respiratory issues, had unlabeled oxygen tubing and no care plan in the EHR despite a physician's order for oxygen use. An LPN acknowledged the oversight, and the DON was informed of the missing care plan.
A facility failed to label oxygen tubing with the date it was changed for a resident with chronic respiratory conditions, leading to a deficiency in infection control. Observations showed unlabeled tubing despite a physician's order for weekly changes. An LPN confirmed the need for labeling and a care plan, and the DON was informed of the oversight.
A resident admitted with an unstageable pressure injury experienced inadequate care and documentation. The facility failed to consistently stage and measure the wound accurately, with discrepancies noted in the assessments. The facility's policy required weekly documentation, which was not followed, leading to a deficiency. The DON confirmed the inaccuracies and noted a past noncompliance issue related to pressure injuries.
Failure to Supervise Feeding With Hot Liquids
Penalty
Summary
The facility failed to implement care plan interventions and provide appropriate supervision for feeding assistance for a resident with severe cognitive impairment and dysphagia, resulting in an in-house acquired full thickness burn to the left lower quadrant of the abdomen. The resident had diagnoses including muscle weakness, dementia, chronic pain, and dysphagia, and had a BIMS score of 5. The record showed care plan directions to assist with eating, get the resident up in a Broda chair for meals as allowed, use a clothing protector at meals, and provide a covered mug with lid for all liquids due to risk of injury from hot liquids. The incident investigation showed the resident sustained the burn after spilling hot liquids on herself while eating in bed during breakfast. The cup still had the top on it when it was found spilling hot liquid out of it. The resident had a clothing protector in place, but she was left in her room for breakfast with hot tea within arm's reach. The CNA assigned to the resident stated she was unable to get the resident out of bed because the morning was busy, so she fed the resident in the room, left the hot tea nearby, and left to care for another resident. The CNA also stated the resident had been left alone with hot liquids before. Interviews with facility staff showed differing understanding of the feeding intervention. The DON stated that the care plan meant staff had to assist the resident completely with feeding and that the resident should not have been left alone with hot liquids because she was a total assist with feeding. The RN stated she would not leave the resident alone with hot liquids and would want to supervise her in case the cup tipped or she lost her grip. The UM stated she found the resident crying, saw the cup upside down, and removed the resident's clothing to apply cold washcloths to the stomach. The record also documented that the resident later had a hot liquid screen and was changed to total assistance with eating.
Failure to Reconcile Enteral Feeding Orders Resulting in Missed Nutrition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic hypoxic respiratory failure, severe protein-calorie malnutrition, septic shock, diabetes type 2, and a gastrostomy, was readmitted to the facility. Upon readmission, there was no physician order for enteral feeding/nutrition, and an NPO (nothing by mouth) order was in place. The resident did not receive tube feeding or nutrition for approximately 19 hours following readmission, as documented in the electronic medical record (EMR) and confirmed by staff interviews and record reviews. Progress notes indicated that staff were aware the resident had not received their prescribed Glucerna tube feeding since returning from the hospital, and the feeding was not initiated until the following morning after staff made calls to confirm orders. There was no documentation clarifying who was contacted for the order, nor was there evidence that the physician was notified of the missed tube feeding. Additionally, the resident's condition deteriorated, with lethargy, decreased oxygen saturation, and a high glucose level, leading to rehospitalization. Further review revealed that hospice documentation and hospital discharge medication lists were missing from the EMR at the time of readmission, and the hospice nurse may have inadvertently taken these documents. The facility's admission policy requires written physician orders for immediate care, including dietary instructions, but these were not present. The lack of clear orders and documentation resulted in a failure to provide essential tube feeding/nutrition to the resident for an extended period.
Failure to Clarify Admission Orders and Timely Medication Administration
Penalty
Summary
Nursing staff failed to clarify admission orders, reconcile medications, provide timely medication administration, and coordinate with hospice and the physician for two residents following their readmission. For one resident with multiple complex diagnoses, including chronic hypoxic respiratory failure, severe malnutrition, and diabetes, there was no documentation of hospice admission paperwork or clarification of orders upon readmission. The resident was ordered NPO, but oral medications were still administered and documented, and there was no order or administration of enteral feeding for nearly 19 hours. The medical record lacked evidence of physician notification regarding the missed tube feeding, and the Director of Nursing (DON) was unaware of the lapse until it was pointed out during the survey. Additionally, the hospice nurse reportedly took the hospital discharge paperwork, and there was no documentation of communication with the physician or hospice to clarify orders or obtain missing information. For the same resident, progress notes indicated that the resident did not receive prescribed tube feeding upon return from the hospital, and the feed was only started the following morning after staff made calls to confirm orders. There was no documentation specifying who was contacted, what orders were clarified, or if the physician was notified about the missed feeding. The resident later became lethargic, experienced a significant drop in oxygen saturation, and had a critically high blood glucose level, leading to rehospitalization. The facility's admission policy required written physician orders for immediate care, including dietary instructions and medications, but these were not present or clarified at the time of admission. A second resident, readmitted with gastrointestinal diagnoses including esophageal ulcer and bleeding, did not receive scheduled gastrointestinal medication (Nexium) as ordered via PEG tube. The medication was not available in the facility's backup supply, resulting in missed doses until the evening after admission. The DON confirmed the importance of the medication given the resident's condition but stated that the medication was not administered until it was delivered the next day. The facility's backup medication list did not include Nexium, contributing to the delay in administration.
Food Served Unappetizing and Not Consistently Per Resident Preference
Penalty
Summary
The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature for multiple residents, including residents who were alert and able to be interviewed. Several residents stated they disliked the food, reported that the same foods were served repeatedly, and said the food was often cold or not replaced with an alternative when they did not want what was served. One resident reported requesting a cheeseburger that was overcooked and hard to chew, while another said he hated the food and was upset that staff did not provide anything else if he did not like the meal. During the noon meal observation, the majority of residents were served tacos with rice, and several tacos were observed with grease dripping from them and dark amber grease pooling on the plates; the lettuce on some tacos was wilted. The posted food menu in the dining room was dated July 2025. Resident council notes documented repeated concerns about the food, including bad taste, cold food, missing items, and questions about portion sizes and diabetic options. The Dietary Manager stated that some residents did not get eggs because a cook did not report that eggs were available, and that the meat on the tacos had been greasy and needed to be drained.
Food Service Sanitation and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety. During a kitchen tour with the Manager of Kitchen V, the inside of the ice machine in the sub kitchen on [NAME] hallway was observed to be visibly soiled with black residue. When asked about the cleaning schedule for the ice machine, the Manager of the Kitchen V stated that Maintenance is supposed to clean it and then told staff not to use the ice in that machine. During lunch observation, [NAME] W was observed removing gloves and then putting on new gloves without washing hands while preparing lunch. The facility policy for Food & Nutrition Services/Sanitation and Food Safety states that employees will thoroughly wash their hands and exposed areas of their arms with soap and water between removing gloves or aprons and before putting on new gloves or aprons. The report also cites the 2022 Food Code requiring food employees to clean their hands immediately before food preparation and before donning gloves for tasks involving food.
Soiled Wheelchairs, Unclean Resident Areas, and Missing Plumbing Backflow Device
Penalty
Summary
The facility failed to maintain clean wheelchairs for five residents. During initial screening on 8/5/2025, wheelchairs were observed with strands of hair, dried or sticky substances, dust, debris, and other buildup. Resident #6’s wheelchair had dust, debris, and sand-like particles on both footrests and in the crevices of the chair, and the resident stated he did not believe the chair had been cleaned since admission. Resident #38’s wheelchair had a red tacky substance on the wheels and unknown built-up material in the crevices and around the brakes. Resident #15 stated her wheelchair had not been cleaned in 1.5 years and said staff were supposed to clean it when she was showered; her chair had unknown debris particles in some areas. Resident #41 stated in Resident Council that her wheelchair was not routinely cleaned by facility staff, and Resident #44’s wheelchair was observed with particles, hair, and dust. The DON stated aides were responsible for cleaning resident chairs, and no documentation was found in the residents’ charts related to wheelchair cleaning. The facility also failed to ensure a clean and comfortable environment in resident rooms and hallways. Observation of the 100 hall revealed numerous black scuff marks on walls and resident doors, food and paper on the floor in Room 103, scuffed walls and chipped paint on wall molding, and another room with paper on the floor, scuffed walls, dirty bathroom floor, food under and beside the bed, a sticky substance on the bedside table, a urinal partly under the bed, torn wallpaper, and a dirty bathroom floor. Observation of the 400 hall revealed a large gray trash bin with food and dirty medical gloves inside sitting in the hallway in front of the office with no lid. Housekeeping staff stated they cleaned resident rooms after public areas and that there were only two housekeepers for all resident rooms, while the Housekeeping Supervisor stated there were complaints about wallpaper, wall marks, dirty carpets, and that the carpets were stained and nasty. The facility also failed to maintain plumbing in good repair. On 8/5/2025, an atmospheric vacuum breaker was observed missing from the top of the utility sink in Bay 1, leaving the water system open to the environment. When the sink was turned on, water spewed out from the top where the vacuum breaker was supposed to be. The Maintenance Director stated the vacuum breaker had been ordered and said that when things are broken, they fix them when they notice it. The report also noted that the Infection Control RN did daily morning sweeps and looked into resident rooms, but did not document observations of infection control rounds on hallways or resident rooms.
Dignified Dining and Meal Assistance Failure
Penalty
Summary
The facility failed to ensure a dignified dining experience and failed to follow care planned interventions for multiple residents during meals. During observation in the small dining room, Resident #33 was seen with soup spilled down the shirt, pants, and table, without a clothing protector and with no staff in the area. The resident later used the tablecloth as a napkin and to wipe the nose. Resident #38 was sitting alone asking for more pop. Residents #27, #28, #29, and #44 were seated in wheelchairs and were not initially offered food items, and Resident #44 had a second glass of lemonade placed out of reach. Further observations showed delayed meal service and lack of assistance. Residents #27, #28, and #29 still had not received meals when fluids were placed in front of them, and no sips were offered. Resident #27 was later identified by CNA X as needing assistance with eating. Resident #28 and Resident #29 were eventually assisted after a delay. Resident #44 continued eating with fingers, was not offered additional fluids, and remained at the table using a napkin to cover spilled liquid while a full cup of lemonade stayed out of reach. On the following day, Resident #44 was again observed attempting to drink from an empty glass, placing a butter packet into the glass, and eating with fingers without staff assistance. Record review showed that the affected residents had care plans requiring assistance or specific dining supports. Resident #27 required assistance with feeding; Resident #28 required total assist with all meals; Resident #29 needed assistance with eating; Resident #33 required limited assistance, covered liquids in a covered mug, weighted silverware, and a clothing protector at every meal; Resident #38 was to have covered lids on all liquids and be offered a clothing protector; and Resident #44 had a care plan for staff assistance at meals to provide encouragement. Resident #22 was also observed with breakfast items that did not match the meal ticket, including missing milk and no lidded mug for liquids, while lying flat in bed with the meal untouched. The facility policy stated residents shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Inconsistent Scheduled Showers and Documentation Issues
Penalty
Summary
The facility failed to consistently provide scheduled showers to residents who were unable to complete bathing independently. Resident #15 reported that her shower days were Monday and Thursday, but she did not receive a shower on her scheduled day and stated that if she does not ask, many aides do not mention it. A review of the last 30 days showed only one shower documented for Resident #15, with one additional shower noted in a progress note that was not included in the 30-day lookback. Resident #15 was admitted with diagnoses including diabetes, hypokalemia, syncope and collapse, and orthostatic hypotension, and her Kardex indicated she preferred showers twice weekly on Monday and Thursday night shift. Resident #35, Resident #37, and Resident #41 also reported that showers were not being provided as scheduled and that they often had to ask staff for them. Resident #35’s record showed only one shower in the last 30 days despite a Kardex indicating bathing on Wednesday and Saturday nights; her diagnoses included dysphagia, hypertension, social phobia, major depressive disorder, and diabetes. Resident #37’s shower record showed showers on 7/9/25, 7/16/25, 7/29/25, 7/30/25, and 8/6/25, with skipped weeks, and her diagnoses included COPD, major depressive disorder, hemiplegia, hypertension, polyneuropathy, and diabetes. Resident #41 stated she was supposed to receive showers on Wednesdays and Saturdays but did not regularly receive them, and her 30-day lookback showed only three showers with additional progress note documentation not reflected in the lookback; her diagnoses included atrial fibrillation, anemia, bipolar disorder, and hyperlipidemia. The DON acknowledged there was an issue with showers, and the facility policy stated all residents would be offered bathing twice weekly and a complete shower at least weekly.
Medication carts left unclean and unsecured
Penalty
Summary
The facility failed to ensure medication carts were maintained clean and sanitized and that drugs and biologicals were stored in accordance with accepted professional principles. During observation of the 300 Hall medication cart, partly used insulin pens for two residents had no expiration date written on the sticker, and the nurse could not explain when the insulin expired or why the expiration date was missing. The bottom drawer of that cart also contained a large area of sticky substance, crushed medication, dust, small pieces of paper, and two whole pills. Observation of the 200 Hall medication cart found a loose tan pill, crushed medications, small pieces of paper, dust, and a sticky substance in the drawers. Observation of the 400 Hall medication cart found two cream-colored round pills in the bottom of a drawer. Staff interviews indicated the nurses on night shift clean the medication carts, while the Administrator stated the night shift cleans them. In a separate observation, a nurse left a medication cart unlocked and unattended facing outward toward the main lobby while entering the locked medication room, and both another nurse and the DON stated medication carts are not supposed to be left unattended while unlocked.
Improper Clean Linen and Supply Storage
Penalty
Summary
The facility failed to maintain general cleanliness of clean linen and sanitary supply storage. During an environmental tour with the Housekeeping Manager and Director of Maintenance, the cleaning supply room floor was visibly soiled with debris. When asked about the cleaning schedule, the Housekeeping Manager stated they were coming in and sweeping the floor on a regular basis. Later, clean linens were observed stored on the floor of the clean linen room on the 300 hall, and the Housekeeping Manager picked up the linens and removed them from the clean linen closet. In the clean linen closet on the 100 hall, an unused urinal was observed on the floor along with other trash, and the Housekeeping Manager removed the urinal and trash from the closet, commenting, "I'm not even sure how that got in here."
Inaccurate Mental Health Diagnosis in Resident Record
Penalty
Summary
The facility failed to ensure Resident #6 had an accurate mental health diagnosis in the medical record. During interview, the Social Worker stated the resident was not prescribed any medications for paranoid schizophrenia and later reported that investigation showed the diagnosis was incorrect, unsubstantiated by the Level II OBRA completed in May 2025 and by the contracted psychiatric group that evaluated him. She also stated she was unsure where the physician obtained the information used to make the diagnosis and that the inaccurate diagnosis should have been removed from the record timely. Record review showed the resident was admitted with diagnoses including paranoid schizophrenia, anxiety, insomnia, diabetes, and hypertension, and the MDS assessments continued to list paranoid schizophrenia in February, May, and August 2025. Physician notes from May 2024 repeatedly documented a history of paranoid schizophrenia, while the Level II OBRA dated 6/2/2025 listed major depressive disorder, generalized anxiety disorder, and unspecified personality disorder instead. The facility’s change-in-condition form and psychiatric evaluation also reflected other mental health diagnoses, and staff reported uncertainty about why the resident had been given the paranoid schizophrenia diagnosis. The resident stated he did not know how he got the diagnosis, believed it was inaccurate, and denied delusions or hallucinations.
Breakfast Menu Items Not Provided
Penalty
Summary
The facility failed to provide food items per the scheduled menu for residents who received facility-prepared meals, including missing eggs on breakfast sandwiches and missing milk for several residents. On 8/06/2025, Resident #63 was observed resting in bed with an untouched breakfast tray on the overbed table; the tray did not include the egg listed on the meal ticket for an egg, sausage, and cheese sandwich, and no 2% milk was provided. Resident #22 was observed in bed flat with breakfast on the overbed table and complained they could not eat the oatmeal because they needed milk; their tray also lacked the egg listed on the meal ticket and did not have brown sugar, although sugar had been written on the ticket. Additional residents had similar missing items from breakfast trays. Resident #64 did not receive an egg on the breakfast sandwich or any milk, Resident #65 complained they did not get an egg on the sandwich, milk, or oatmeal, and Resident #66 complained they did not get an egg on the breakfast sandwich. During observation of Resident #66’s tray with the DON present, there was no egg on the sandwich. In the kitchen, the Dietary Manager was unaware whether eggs had run out, and staff reported the liquid eggs were still frozen during breakfast preparation. Staff stated no eggs were cooked for any residents and no one was notified. The Dietary Manager also stated milk was not placed on some trays because meal tickets were called out and CNAs were expected to get the drinks.
Failure to Honor Food Allergies and Preferences
Penalty
Summary
The facility failed to honor food allergies and food preferences for two residents reviewed for allergies and preferences. Resident #66 stated they were served strawberry jelly almost every morning even though they reported an allergy to strawberries, and strawberry jelly packets were observed on their over-bed table. The resident also complained they were given a taco with a flour shell and later an English muffin, stating they had a wheat allergy and had not been offered gluten-free food items. During an observation with the DON, Resident #66’s breakfast tray contained an English muffin, and the DON was alerted that the resident had also received a flour tortilla the prior day. Resident #38, who had diagnoses including cerebral palsy, hemiplegia affecting the left side, and cognitive communication deficit, required assistance with all ADLs and had impaired cognition. At lunch, the resident was observed with cream of broccoli soup and then served ham, scalloped potatoes, and spinach. The resident stated they did not like spinach and later said they wanted a hotdog instead. The meal ticket listed dislikes of broccoli, spinach, and potatoes, and the care plan identified nutrition risk due to small appetite but did not include an intervention to follow food preferences.
Failure to Prevent Injury and Properly Assess Changes in Condition During Resident Transfers
Penalty
Summary
A deficiency occurred when staff failed to prevent bruising and sling indentations during a mechanical transfer for a resident who was immobile, totally dependent on staff for all ADLs, and receiving hospice care. The resident had multiple diagnoses, including malnutrition, dementia, and a history of fractures. Despite a care plan specifying the use of a small sling for transfers, staff used an incorrect sling size, resulting in red indentation marks on both thighs and a new bruise above the right knee. The resident was observed to be in pain during the transfer, and the sling indentations matched the pattern of the sling used. Documentation confirmed that a small sling was available but not used as directed in the care plan. Another deficiency was identified when a resident with severe cognitive impairment, non-ambulatory status, and bilateral lower extremity contractures sustained a fracture of the right tibia and fibula of unknown origin. The resident was found with right ankle swelling, bruising, and pain, but staff were unable to determine or report how the injury occurred. The resident was unable to move or turn herself, and family members reported that she was bedridden and required a Hoyer lift for transfers. The incident was not promptly or accurately reported by the LPN on duty, who attributed the injury to pressure from the mattress and failed to document a physical assessment or notify appropriate personnel in a timely manner. Interviews and record reviews revealed that the facility lacked a clear nursing assessment policy for documenting changes in resident condition. The LPN did not obtain an order for a boot applied to the resident's foot and did not report the full extent of the injury to the next nurse. The injury was only escalated after a CNA showed a photo of the bruising to the RN, DON, and NHA, leading to further assessment and hospital transfer. The facility was unable to provide an explanation for the injury, and there was no documentation of skin monitoring or assessment at the time the injury was first noted.
Failure to Implement Fall Prevention Policies and Ensure Adequate Supervision
Penalty
Summary
The facility failed to implement and operationalize fall prevention policies and procedures for two residents, resulting in a lack of planned and meaningful interventions to prevent falls. One resident, who was cognitively intact and required total assistance for bed mobility and transfers, experienced a fall while receiving a bed bath from a single CNA, despite the care plan specifying the need for two staff members. The CNA did not review the resident's care plan prior to providing care and relied on previous training from another CNA. The resident rolled out of bed, which was positioned at waist height without a fall mat in place, and suffered a broken hip requiring emergency surgery. The incident was not immediately reported to the DON as involving a care plan violation, and the DON was unaware of the fracture until the resident returned from the hospital. Another resident, admitted with multiple medical diagnoses including dementia and a history of falls, experienced five falls within a short period. During one incident, the resident was found on the floor next to the bed and subsequently returned to bed without staff assistance. The resident stated he had jumped on the floor to get a drink. After being sent to the hospital, the resident was found to have a rib fracture and a urinary tract infection. The only intervention documented after the incident was to keep drinks within reach, but there was no evidence of a comprehensive fall prevention strategy or meaningful interventions to address the repeated falls. In both cases, the facility did not ensure that staff followed care plans or implemented adequate supervision and interventions to prevent accidents. Staff failed to review care plans before providing care, and there was a lack of assessment for assistive devices or environmental modifications. These failures resulted in residents experiencing falls with injuries, unnecessary pain, and a decline in overall health status.
Failure to Update Care Plan After Resident Sustained Acute Fractures
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for a resident following a significant change in condition. The resident, an elderly female with multiple complex medical diagnoses including muscle weakness, dysphagia, malnutrition, diabetes, mood disorder, Alzheimer's disease, and contractures of the lower extremities, sustained acute fractures of the right tibia and fibula. Despite the presence of an orthopedic boot and the resident being bedridden and non-weight bearing, there were no updates or new interventions added to her care plan to address the new fractures, the use of the orthopedic boot, or specific positioning and pain management needs related to the injury. Observation and interviews revealed that the resident and her family were unaware of how the injury occurred, and facility staff could not provide information regarding the onset of the injury or swelling. The hospital record confirmed the acute fractures and noted the resident's chronic contractures and immobility. Review of the care plan documentation showed no revisions or additions to address the resident's new care needs following the injury, and the chronic pain care plan did not include interventions for the acute fracture, positioning, or follow-up care.
Failure to Prevent and Document Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of two Stage II pressure ulcers on the upper left shoulder of a resident who was at high risk due to immobility and recent right leg fractures. Observations showed the resident was frequently positioned in a reclining Broda chair, leaning to one side for extended periods without repositioning, and with contractures limiting mobility. The care plan for skin integrity had not been updated with new interventions following the development of the pressure ulcers, and preventive measures such as regular repositioning and pressure relief were not adequately implemented. Record reviews revealed that wound care for the left shoulder began after the ulcers were discovered, but there was a lack of documentation regarding wound measurements, photographs, and timely physician progress notes. The wounds were first noted as blisters, and there was no evidence of comprehensive assessment or communication with the physician about the new pressure injuries or the resident's recent fractures. The facility's own policy required regular assessment, use of pressure redistribution devices, and individualized repositioning, but these were not consistently followed. Interviews with nursing staff and the DON confirmed that wound measurements and documentation were only completed after the surveyor's observation, and there was no prior photographic or measurement record of the wounds. The lack of timely assessment, documentation, and implementation of preventive interventions contributed to the development and progression of the pressure ulcers, as well as the resident's pain and discomfort.
Failure to Prevent Injury of Unknown Origin Resulting in Fractured Leg
Penalty
Summary
A deficiency occurred when a resident with significant medical vulnerabilities, including dementia, Alzheimer's, protein malnutrition, and palliative care needs, sustained a fractured tibia and fibula of the right leg while residing in the facility. The resident was nonverbal, frail, and dependent on staff for all care, including transfers with a mechanical lift requiring two staff members per facility protocol. However, hospice staff, who also provided care, reportedly used only one staff member for transfers. The resident was often positioned in a Broda chair, with observations noting her leaning to one side and her right heel positioned in the leg extension crack of the chair. Documentation from certified nursing assistants indicated no concerns with the resident's positioning or skin condition in the days leading up to the discovery of the injury. On the day the injury was identified, a hospice staff member noticed bruising on the resident's right ankle, which had not been present previously. Subsequent assessment revealed swelling and yellow/greenish bruising, and an X-ray confirmed fractures of the tibia and fibula. The cause of the injury could not be determined, but it was suggested by facility management and the resident's family that improper securing of the resident's legs during movement in the Broda chair or accidental bumping of the foot/ankle during transfers or transport may have contributed. Interviews with facility and hospice staff highlighted inconsistencies in care coordination and communication. Hospice aides did not consistently communicate with facility staff regarding the care provided, and there were differences in transfer practices between hospice and facility staff. The facility's investigation did not identify a specific cause for the injury, and the injury was classified as of unknown origin. The facility's abuse prevention policy prohibits neglect, but the lack of adequate supervision and coordination between facility and hospice staff led to the resident sustaining a significant injury.
Failure to Provide Palatable and Properly Presented Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, visually appealing, and at a preferred temperature, as observed during a noon meal. Two residents, both alert and dependent on staff for activities of daily living, requested hamburgers from the Always Available Menu instead of the main meal option. The hamburgers provided had smashed buns, very small meat patties, and were missing requested condiments such as onions and gravy. One resident was unable to add ketchup due to the condition of the food, and both residents expressed dissatisfaction, with one stating the food was cold and not tolerable, ultimately refusing to eat the meal. Further review of confidential Resident Council meeting notes over several months revealed ongoing complaints regarding the quality, temperature, and portion size of food, as well as not receiving ordered items. An interview with the Director of Activities confirmed awareness of continuous food complaints, describing the food as unappetizing and likening it to gas station food. Facility policies reviewed indicated requirements for food to be attractively presented, palatable, and for residents to be treated with dignity and respect, which were not met in these instances.
Failure to Timely Administer Admission Medications and Complete Admission Procedures
Penalty
Summary
The facility failed to timely and accurately complete the admission process and administer medications as ordered for a newly admitted resident. Upon review, it was found that the resident, who was admitted with diagnoses including pneumonia, sepsis, and a need for assistance with personal care, did not receive her scheduled evening medications on the day of admission. The resident's hospital discharge medication list included several medications due that evening, but the Medication Administration Record (MAR) showed that these medications were not scheduled to begin until the following day. Although one of the required medications, Eliquis, was available in the facility's backup supply, it was not administered. The resident arrived at the facility in the evening, after the cutoff for the nightly medication delivery, and the medications were not entered into the system until after midnight, spanning two nursing shifts. The process required one nurse to input all medications and a second nurse to review for accuracy and notify the physician, but this was not completed in a timely manner. Additionally, the facility administrator was unaware of a concern form submitted by the resident regarding the missed medications, and no documentation of this concern was found in the facility's records. The administrator explained that some records may have been lost when the previous DON left the facility.
Failure to Assess and Treat UTI and Foot Wounds
Penalty
Summary
The facility failed to properly assess, identify, and treat wounds on the feet and a urinary tract infection (UTI) for Resident #2, who was one of three residents reviewed for a change in condition. Upon re-admission, Resident #2 had multiple diagnoses, including difficulty walking, diabetes, and a history of UTI. Despite a progress note indicating blood-tinged urine and an order for urinalysis and culture, there were no results documented in the medical record. The resident's condition worsened, with dark orange urine and loose stools, leading to a physician's order for IV hydration and antibiotics. However, the family insisted on hospital transfer due to the resident's declining health. At the hospital, Resident #2 was diagnosed with a complicated UTI, acute kidney injury, and osteomyelitis of the right great toe. The hospital records revealed a foul-smelling discharge from the toe, which was not documented or treated at the facility. The resident's condition included dehydration and renal failure, and the family opted for hospice care after a discussion about potential amputation of the toe. The resident eventually passed away, with the death certificate citing acute osteomyelitis as the main cause of death. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, confirmed the lack of documentation and treatment for the resident's foot wounds and UTI. The facility's policy on preventing catheter-associated UTIs was not effectively implemented, as evidenced by the resident's condition upon hospital transfer. The facility also reported issues with their laboratory services, which may have contributed to the lack of timely diagnosis and treatment.
Plan Of Correction
1. Resident #2 no longer resides in the facility. 2. Like residents are identified as any resident with a change in condition. A sweep was conducted on 3/24/2025 to ensure all residents with catheters and any wound had care plan reviews. Like resident medical records were reviewed between 3/22/25 to 3/25/2024 to ensure appropriate interventions were in place for the prevention of skin breakdown and changes in condition were identified timely and reported to the MD appropriately and timely. All future residents admitted with potential risk factors will be identified upon admission and appropriate interventions implemented in the plan of care timely. 3. The Policy on reporting changes in condition has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate interventions implemented in their plan of care timely. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission with any change in condition between 3/13/25 and 3/21/2025. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.
Deficient Catheter Care and Urinalysis Testing
Penalty
Summary
The facility failed to adhere to its policies and procedures for catheter care and urinalysis testing for three residents. Resident #2 was readmitted with multiple diagnoses, including urinary retention and a history of urinary tract infection (UTI). Despite a physician's order for urinalysis and culture due to blood-tinged and cloudy urine, there were no urinalysis results in the medical record. The facility did not implement a task for documenting catheter care, and the Administrator confirmed that catheter care documentation was not performed. Resident #4, who had a Foley catheter and was dependent on assistance for mobility and toileting, expressed concerns about staff not emptying her catheter bag frequently enough. Documentation showed the catheter was emptied only once a day on several occasions, and not at all on one day, despite the facility's policy to empty the drainage bag every shift. An observation confirmed the resident's catheter bag was partially filled with urine and sediment. Resident #5, also with a Foley catheter, had documentation indicating the catheter was emptied only once a day on certain days and not at all on others. The facility's policy required emptying the catheter bag every shift, but this was not consistently documented or performed. The Administrator acknowledged issues with laboratory services and a lack of follow-up on urinalysis testing, contributing to the deficiency in care for these residents.
Plan Of Correction
1. Resident #2 no longer resides in the facility. Resident #4 is a long-term resident of the facility; the care plan was reviewed and was deemed appropriate. 2. Like residents were identified as those with Foley catheters and are at risk for developing urinary tract infections. Like residents' medical records were reviewed between 3/22/25 through 3/25/25 to ensure their plan of care includes interventions for the prevention of a urinary tract infection. 3. The policy regarding indwelling catheter care and maintenance was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate processes for initiating timely interventions upon admission and with any change of condition between 3/13/25 and 3/21/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for catheter maintenance are initiated timely upon admission. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.
Failure to Prevent and Timely Treat Facility-Acquired Stage III Pressure Ulcer
Penalty
Summary
A facility failed to operationalize its policies and procedures for skin and wound assessments and treatments, resulting in the development and worsening of a facility-acquired Stage III pressure ulcer for a resident. The resident, who had significant cognitive impairment, limited mobility, incontinence, and other comorbidities such as diabetes and Alzheimer's disease, was dependent on staff for most activities of daily living. Despite these risk factors, documentation showed that the resident did not have a pressure ulcer at the time of a recent assessment, but a new Stage III ulcer was identified later without timely assessment or intervention. There was a lack of timely wound assessment and treatment following the initial identification of the pressure ulcer. The wound was first identified on one date, but the first documented assessment by the wound care nurse occurred two days later. There was no documentation of wound care or dressing changes until several days after the wound was identified. Additionally, the physician and the resident's representative were not notified until several days after the wound was discovered. The care plan was not promptly updated with new interventions specific to the newly developed wound, and existing interventions lacked measurable details, such as specific repositioning intervals or air mattress settings. Observations revealed that the resident's pressure-relieving equipment, such as the wheelchair cushion, was in poor condition and had not been replaced in a timely manner. During a dressing change, improper technique was observed, including adhesive from the dressing being placed over the open wound bed and the presence of fecal matter in the wound area. Staff interviews confirmed gaps in documentation, assessment, and communication regarding the wound, as well as delays in updating care plans and implementing appropriate interventions.
Plan Of Correction
1. Resident #4 resides in the facility. It was identified that the resident's wound was in fact a Kennedy Ulcer, and the resident has been placed on hospice for additional support. 2. Like residents are identified as those with a Braden scale of 16 or less. A sweep was completed on 3/17/25 of all current residents to assess their current Braden scale. Like resident's medical records were reviewed between 3/17 through 3/20/25 to ensure their plan of care includes appropriate interventions for prevention of skin breakdown. All future residents admitted with a Braden score of 16 or lower will have appropriate interventions implemented in their plan of care timely. 3. The Policy on Skin Management has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission and with any change of condition between 3/13 and 3/20/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of Compliance 3/27/2025
Failure to Prevent Pressure Ulcer Leads to Infection and Hospitalization
Penalty
Summary
The facility failed to implement timely and appropriate interventions to prevent a pressure ulcer for a resident, resulting in an unstageable coccyx pressure injury, infection, and subsequent hospitalization. The resident was admitted with a history of circulatory system surgery, moderate cognitive impairment, and required assistance with personal care. Despite being identified as at risk for pressure ulcers upon admission, the facility did not implement all necessary preventative measures, such as an air mattress, which could have mitigated the risk of pressure ulcer development. The resident's condition deteriorated rapidly, with the pressure ulcer being identified as facility-acquired shortly after admission. The wound assessment revealed significant tissue damage and infection, with heavy growth of Proteus Penneri and Escherichia Coli. The resident exhibited symptoms of infection, including clammy skin, chills, and confusion, leading to hospitalization. The facility's records did not indicate any refusal by the resident to reposition, which was noted as a factor inhibiting wound healing. The facility's Skin Management Program required appropriate preventative measures for residents at risk, as indicated by a Braden Scale score of 18 or less. However, the interventions documented in the care plan were not fully implemented, contributing to the development and worsening of the pressure ulcer. The administrator acknowledged the oversight in not utilizing an air mattress upon admission, despite the resident's history of weight loss and recent heart surgery, which increased their vulnerability to skin integrity issues.
Inadequate PPE Use and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene during care for a resident requiring enhanced barrier precautions. Observations revealed that two CNAs and a nurse entered the resident's room without wearing gowns, and gloves were improperly stored in uniform pockets. The CNAs and nurse did not perform hand hygiene before donning gloves, and the CNAs handled the resident, who had bloody drainage and open sores, without wearing gowns, leading to potential cross-contamination. The resident's electronic medical record indicated a physician order for enhanced barrier precautions due to a knee incision. Despite this, the necessary PPE was not available in or outside the resident's room, and the staff did not adhere to infection control protocols. The administrator acknowledged the absence of PPE carts and the need for more carts due to issues with confused residents moving them. The report highlights the lack of adherence to infection prevention protocols, resulting in potential cross-contamination and inadequate infection control measures.
Medication Cart Cleanliness and Organization Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and organization of medication carts across three different halls, as observed during a survey. Specifically, the medication cart on the 300 Hall was found to have crushed pills, papers, and dried liquids in multiple drawers. Additionally, loose pills were discovered in the cart for Hall 100, visible between the metal lock box and the cart. Interviews with nursing staff revealed a lack of clarity regarding responsibility for cleaning the carts, with one nurse indicating it was the second shift's responsibility, while another, an agency nurse, was unaware of who was responsible. The Director of Nursing stated that night shift nurses were tasked with cleaning the carts. The facility's policies on medication storage and night shift duties were reviewed, revealing that the medication storage conditions were supposed to be monitored regularly, and the night shift was responsible for cleaning and stocking the medication carts. However, there was no documentation or observation of how the medication carts were maintained, indicating a lapse in adherence to these policies. This lack of proper maintenance and organization of medication carts could lead to issues such as medication not being taken, lost or uncounted medications, and potential contamination.
Failure to Maintain Cleanliness in Food Service Area
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in its food service area, affecting 50 residents. During an inspection, several pieces of equipment were found with accumulated and encrusted food residue, including a coffee machine, blender, microwave oven, meat slicer, and stand mixer. The Vulcan ovens and deep fat fryer were also observed with significant soil and grease deposits. Additionally, the air conditioning unit in the sub-kitchen was heavily soiled with dust and dirt, located directly above the steam table, which could contribute to cross-contamination and bacterial harborage. The facility's policies and procedures for cleaning and sanitizing equipment were reviewed, revealing a lack of adherence to the established cleaning schedules and procedures. The cleaning schedule was supposed to include both routine and deep cleaning tasks, but the observed conditions indicated these were not being followed. The meat slicer, in particular, had a detailed cleaning procedure that was not implemented, as evidenced by the soiled condition of the equipment. This lack of effective cleaning and maintenance increased the likelihood of cross-contamination and compromised air quality in the food service area.
Inadequate Infection Control and Refrigerator Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the residents' refrigerator, as observed during a survey. Various food items were found without labels or dates, including yogurt, salad dressing, spaghetti with meatballs, egg sandwiches, hard salami, cheese ziti, fruits, shrimp, fish, chicken, salad, bologna, miracle whip, and ice cream. The Infection Control Nurse, RN C, acknowledged that all items should be labeled with the guest's name, date, and room number, and discarded after three days. However, RN C admitted to never inspecting the refrigerator and was unaware of any facility policy regarding its cleaning. The Director of Nursing also confirmed the need for the refrigerator to be cleaned. Additionally, the facility failed to analyze monthly infection control data, which was evident from the review of the facility's Infection Control Program and monthly summaries for April, May, and June 2024. The summaries only included the total number of infections and residents on antibiotics, with no documentation of data analysis. Nurse C stated that she had only received two days of training and had not been trained on data analysis, indicating a lack of proper training and oversight in infection control practices.
Deficiencies in Facility Cleanliness and Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining a clean and safe environment, affecting 50 residents. Observations revealed that the microwave oven in the Family Dining Room was etched and scored, and the hand sink basin was chipped, exposing the cast iron sub-surface. In the Occupational Therapy/Physical Therapy area, the refrigerator and freezer were heavily soiled with food residue, and the microwave oven was similarly damaged. The Staff Break Room contained worn-out furniture with protruding inner padding and soiled appliances. The facility's housekeeping and maintenance policies were reviewed, but they lacked specific dates, indicating a possible lapse in adherence to cleaning and maintenance protocols. Further observations in a resident's room revealed heavily scuffed walls and a large amount of paint chips on the bathroom floor, which had been mopped over without being removed. The Director of Housekeeping/Maintenance acknowledged the issue but attributed it to staffing challenges. Additionally, a room inspection found soiled clothing in an open bag emitting a strong urine odor, and the carpet was stained. A family member expressed concerns about the cleanliness and stated they had been doing the resident's laundry due to inadequate facility services. A review of the facility's repair list showed 51 rooms requiring attention, highlighting significant maintenance backlogs.
Failure to Implement Baseline Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement a baseline care plan for a resident's oxygen administration, resulting in unmet care needs. The resident, who is of advanced age, was admitted with chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, and emphysema. Observations on two consecutive days revealed that the oxygen tubing used by the resident was not labeled with the date of the last change. A physician's order for oxygen administration via nasal cannula at a flow rate of 2 liters per minute was present, but there was no corresponding care plan in the electronic health record for oxygen use and equipment management. An LPN confirmed the absence of labeling and a care plan, acknowledging the need for both and indicating an intention to address these issues. The Director of Nursing was informed of the missing care plan for the resident's oxygen use.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
The facility failed to properly label the oxygen tubing with the date it was last changed for a resident, leading to a deficiency in infection control practices. Resident #261, who is [AGE] years old, was admitted with chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, and emphysema. Observations on two consecutive days revealed that the oxygen tubing on the resident's concentrator was not labeled with the date of the last change, despite a physician's order to change the tubing weekly every Sunday on the night shift. A review of the medication administration record indicated that the tubing was reportedly changed on 07/14/24, but there was no label to confirm this. The facility's policy on oxygen administration, created in July 2022, requires that the oxygen delivery device be changed weekly and dated to assist with tracking. An interview with an LPN confirmed that the tubing should have been labeled and that a care plan should be in place for the resident's oxygen use. The Director of Nursing was informed of the issue, highlighting a lapse in adherence to the facility's infection control policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident admitted with a pressure injury. The resident was admitted with sepsis due to an unstageable pressure injury on the sacrum. Initial assessments and documentation of the wound were inconsistent, with discrepancies in staging and measurements. The admission assessment inaccurately recorded the wound size, and subsequent assessments varied in staging from unstageable to Stage 3, despite the presence of significant slough. The facility's policy required weekly assessments and documentation, which were not consistently followed, as evidenced by missing assessments after a certain date. The Director of Nursing (DON) confirmed the inaccuracies in the initial measurements and acknowledged the inconsistency in staging the pressure injury. The DON also noted that the facility had a past noncompliance issue related to pressure injuries but did not include this resident in the corrective actions because the focus was on injuries developed within the facility. The facility's Skin Management Program policy required weekly documentation of wound characteristics, which was not adhered to in this case, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage House Nursing And Rehabilitation | 3.8 mi | ★★★★★ | 1 | 0 |
| Bay Shores Senior Care And Rehab Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Hampton Nursing And Rehabilitation | 5.1 mi | ★★★★★ | 0 | 0 |
| Great Lakes Rehabilitation Center | 5.1 mi | ★★★★★ | 24 | 0 |
| Hoyt Nursing & Rehab Centre | 7.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.