Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Covenant Skilled Nursing And Rehabilitation At Wel during CMS and state inspections, most recent first.
Kitchen sanitation and food labeling deficiencies: Surveyors observed trash bins placed next to active food prep areas, dirty pots and pans stored for use, food residue on mixers, microwaves, the salad bar, the pop machine, and other food-contact surfaces, plus grease buildup, broken floor tiles, and hood vent damage. Two opened ice cream containers had no use-by dates, and the dietary manager acknowledged they should have been dated when opened. The sanitizer bucket tested at zero quat, and additional concerns included a bee over the prep area, an ice machine with residue, and no ice machine cleaning logs.
The facility failed to maintain clean resident rooms and appropriate temperature control, contrary to its own environmental cleaning policy. Multiple residents reported that their rooms were not being cleaned daily or at all since admission, and surveyors observed dirty floors, dust, food crumbs, tissue and paper debris, and dried BM in toilets and bathroom corners in several rooms, including those of residents with intact cognition. In one room, cold air was blowing from the heater during cold weather, and staff had placed bath blankets over the heater vents to block the cold air while the resident complained of feeling cold. Maintenance staff reported that second-shift staff were changing heater/AC settings, and the Director of Maintenance confirmed the heat-to-AC system changes and that he had to lock the heaters. The Infection Control RN stated he was new and had not yet performed or documented environmental rounds.
A facility failed to offer and deliver daily snacks in accordance with its snack policy, which stated that between-meal snacks were to be offered daily unless contraindicated and that snack consumption should be documented. In a confidential resident group meeting, 6 of 6 attendees voiced anger and frustration that they were not told they could have snacks, were not being offered daily snacks, and were not receiving any snacks; the report also noted residents documented to receive evening snacks were not offered or delivered snacks.
The facility failed to keep care plans current and resident-specific for three residents, leading to missing or delayed interventions for skin and catheter management. One resident with fractures and a new pressure ulcer on the right inner ankle had physician orders for specific wound care, but the skin care plan was not updated to include interventions for the newly acquired ulcer. Another resident admitted with an indwelling Foley catheter was repeatedly observed with the drainage bag and spout on the floor and no privacy bag in place, while the catheter care plan was not added until days after admission, despite facility policy requiring proper positioning and privacy of drainage bags. A third resident with fragile skin, existing wounds, and a history of pressure-induced deep tissue damage was observed multiple times with painful heels resting on the bed or footboard and reporting a sore tailbone, yet the care plan contained only general skin care measures and lacked interventions such as an air mattress, positioning devices, or a turning schedule.
Surveyors identified multiple infection control failures, including a resident’s CPAP mask repeatedly left on a nightstand next to a dirty urinal instead of being cleaned and stored in a plastic bag per facility policy, and family—not staff—performing mask cleaning. During several medication passes, an RN and LPNs prepared and administered medications, including eye drops and nasal sprays, without performing required hand hygiene between residents or between tasks, and one RN left an unlocked med and treatment cart unattended while a controlled drug shift-change log lacked a required nurse signature. Meal trays were delivered to residents in their rooms without offering hand hygiene, and a resident with a Foley catheter had the drainage bag resting on the floor, all of which the surveyors cited as increasing the risk of cross contamination, respiratory infection, and contamination during meals and medication administration with risk of resident illnesses and hospitalization.
Failure to provide daily ADL care and maintain dignity for a resident receiving hospice services. The resident was unable to participate in ADLs, had chronic pain, and was observed with an odor and a soiled shirt with dried food while family reported staff said they were waiting for the Hospice aide to clean him up. An LPN stated the resident should have been cleaned up, while a CNA said residents are cleaned daily.
Incomplete Psychotropic Medication Consents: Two residents were not fully informed, per consent, of the dosage and frequency of their psychotropic/antidepressant meds. One resident’s Mirtazapine consent lacked the dose and administration frequency, and another resident’s single consent for hydroxyzine, trazodone, lurasidone, and duloxetine also omitted dose/frequency details and did not identify antidepressant side effects.
A resident with dementia, severe cognitive impairment, and multiple chronic conditions left AMA after becoming upset and refusing care. The resident said he had used the call light many times and waited hours for a toothbrush, while family said they would not pick him up. The record showed no APS or welfare check referral, no discharge summary, no home care referral, and no documentation of when, how, or with whom the resident left.
Failure to prevent pressure-related skin injury was identified for a resident with fragile skin and existing open areas. The resident was observed with both heels resting on the bed footboard, later flat on the mattress without heel offloading or positioning devices, and then with red, painful areas on both heels. The care plan addressed skin care and moisture control but did not include an air mattress, turning schedule, or heel pressure-relief measures.
Two residents signed binding arbitration agreements that did not clearly identify a venue convenient to both parties. An RN stated she obtained signatures and reviewed the form with residents, but the agreements themselves did not list any venue, despite the facility policy requiring a convenient venue selection.
Two residents who required assistance with ADLs did not receive scheduled showers as documented, with one resident going 15 days between showers and another receiving only two showers during her stay. Documentation inconsistencies and unclear use of 'NA' were noted, and residents reported not receiving showers as scheduled.
The facility failed to monitor and manage psychotropic medications for four residents, resulting in improper indications and duplicate therapy without rationale. A resident was prescribed Duloxetine for anxiety instead of depression, another received dual therapy for depression without justification, a third was given Quetiapine for Alzheimer's without the diagnosis, and a fourth had incorrect documentation for Duloxetine. The social worker admitted to not monitoring medication indications, leading to these deficiencies.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including unclean equipment, undated open foods, and improper storage practices. Observations revealed dried food on equipment, build-up in machines, and undated bread, despite the kitchen duty list indicating all tasks were completed.
The facility failed to ensure a resident wore a prescribed cervical collar while sitting up, did not perform wound care per physician orders for another resident, and inaccurately documented a readmitted resident's IV in the admission assessment. These deficiencies highlight lapses in adherence to treatment plans and documentation protocols.
The facility failed to ensure medication carts were clean and sanitized, as observed on [NAME] Hall. Dried liquid medications, crushed substances, and debris were found in medication drawers. An LPN was unsure who was responsible for cleaning, and the DON acknowledged the lack of a specific cleaning policy for the inside of medication carts. This resulted in potential cross-contamination for 34 residents receiving medications.
The facility failed to prevent and manage pressure ulcers for two residents, leading to worsening conditions and the development of new ulcers. One resident's existing pressure ulcer worsened due to inconsistent documentation and delayed treatment, while another developed an avoidable ulcer from oxygen tubing due to a lack of preventive measures. The facility's policies on skin management were not followed, resulting in significant deficiencies.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The facility failed to maintain food preparation areas, kitchen equipment, and food-contact surfaces in sanitary condition. During the kitchen tour, a large trash bin filled to the rim was observed sitting directly next to a food prep area where the noon meal was being prepared, with the bin top on the floor. Clean pots and pans were stored on the bottom shelf of a food prep table with food pieces and crumbs inside several of them, and the shelf itself had dried food and dust on it. A second trash bin was uncovered next to the floor mixer, and the mixer had flour and dried food particles inside the bowl, on the handle, and on the attachment area. The counter mixer also had dried food on the attachment area, and a large white plastic food container half full of panco had dried yellow drippings inside and on the outside. The back food prep area had an excessive amount of crumbs, dried food particles, and dust, and the dietary manager stated the table was dirty. Additional observations showed multiple other food-contact and nonfood-contact surfaces with soil accumulation. The flat grill area had an uncovered trash bin beside it, with food, thick grease, and papers above the rim, and staff were placing extra grease directly into the trash bin because the grease trap was stuck and could not be opened. The grease trap contained approximately an inch and a half of old grease and food pieces. Broken and loose floor tiles were observed in front of the flat grill, with the floor buckling from moisture and one tile coming up to reveal warped wood underneath. The flat top grill and stove hood vents were bent with several missing, exposing large gaps. The microwave had an excessive amount of dried food on the outside, inside, and top, the salad bar had dried lettuce and shredded cheese in the back area before salad service had begun, the scupper in the clean utensil container had dried food inside, the pop machine had dried pop around the spicket areas, and the steamer area had a large pool of water on the counter. The facility also failed to ensure that partly used or opened foods were labeled with a use-by date. Two large containers of ice cream in the ice cream freezer had been opened and partly consumed with no dates on the tops, and one had the top partly off with freezer burn noted on the ice cream. The dietary manager stated the containers should have had dates and a use-by date when opened. Other observations included peanut butter containers with peanut butter on the tops and sides, yellow residue in the ice machine interior walls, and a Pentair Everpure 7FC5-S filter for the tea machine dated 4/5/22 with another filter for the juice machine dated 10/29/24. The wiping cloth sanitizer bucket tested at zero quat, while the dietary manager stated it should be between 200 and 400. The report also noted a bee flying above the food prep area, a utility sink with a hose attached and a chemical feed dispenser downstream of an AVB in the boiler room adjacent to the kitchen, and no cleaning logs for the ice machine.
Failure to Maintain Clean Resident Rooms and Proper Temperature Control
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, safe, and comfortable environment and to perform daily room cleaning as outlined in its March 2021 “Maintaining a Clean Environment” policy. That policy required daily cleaning of resident rooms, including all horizontal and contact surfaces, high-touch items, and daily wet mopping of floors with a detergent germicide. During a confidential resident group meeting, four of six attendees reported frustration and anger that staff were not cleaning their rooms daily or, in some cases, at any time since admission. During the initial tour, surveyors observed five resident rooms with unclean conditions and, through resident interviews, confirmed that routine cleaning such as vacuuming, bathroom cleaning, and disinfection of touchable surfaces was not occurring as required. In one room, a resident with a BIMS score of 15 had small pieces of dried food and paper on the floor, dirty bathroom floor corners, and dried BM inside the toilet rim; the resident stated the room was cleaned only once a week. Another alert resident reported never seeing staff clean, vacuum, or clean the bathroom, and surveyors observed dirty floors with food crumbs and tissue under the bed and wheelchair. A resident with a BIMS of 14 stated staff did not clean the room at all, and surveyors noted paper on the floor, dust under the bed, and dust on the bathroom floor. A resident with a BIMS of 10 reported the vacuum had been used only once since admission and that the toilet had never been cleaned; surveyors observed dirty floors, paper on the floor, dirt in bathroom corners, and dried BM on the inside of the toilet rim and bowl. Another resident with a BIMS of 15 reported vacuuming only once or twice and bathroom mopping once a week, with surveyors observing many small tissue and paper pieces on the floor. Additionally, in one room, cold air was coming from the heater during snowy weather, and staff had placed three large bath blankets over the heater vents to block the cold air while the resident complained of being cold. Maintenance staff reported that second-shift staff were changing heater/AC settings, and the Director of Maintenance acknowledged the system switched from heat to AC and that he had to lock the heaters to prevent staff from turning them down. The Infection Control RN stated he was new and had not conducted or documented environmental rounds.
Failure to Offer and Deliver Daily Snacks
Penalty
Summary
The facility failed to ensure daily snacks were offered and delivered in accordance with resident needs, preferences, and requests, despite a snack policy dated February 2014 stating that between-meal snacks are to be offered daily except when contraindicated and that snack consumption should be documented. During a confidential resident group meeting held on 3/24/26 at 11:10 a.m., 6 of 6 attendees verbalized anger and frustration that they did not know they could have snacks, were not being offered daily snacks, and were not receiving any snacks. The report also states that the facility failed to offer and deliver snacks to residents documented to receive evening snacks.
Failure to Maintain Current, Resident-Specific Care Plans for Skin and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to maintain up-to-date, resident-specific care plans with measurable interventions, as required by its comprehensive care plan policy. For one resident with sepsis, multiple fractures, non‑weight‑bearing status, and a facility-acquired pressure ulcer on the right foot, physician orders dated 3/10/26 directed use of an air cast and specific cleansing and dressing of a newly acquired pressure ulcer on the right inner ankle. The resident’s skin care plan, initially dated 2/25/26 and updated 3/10/26, listed an actual Stage 1 pressure area to the inner right ankle and right bunion and small red areas to the right small toe, but contained no documented interventions addressing the newly developed pressure ulcer on the right inner ankle. During review of the care plans with the DON, the DON acknowledged that new interventions for the actual skin impairment should have been added to the skin care plan. Another resident was admitted with a 16 French indwelling Foley catheter and milky discharge at the penile insertion site. Observations documented the catheter drainage bag and spout touching the floor, with the clear plastic Urometer and catheter bag repeatedly found resting on the floor and the tubing under the bed, and no privacy bag in place. A family member reported that the catheter had been hanging in this manner since admission and that no covering bag had been used. The ICP stated that catheter bags should not rest on the floor, that privacy bags should be used, and that staff are aware of this expectation, and also acknowledged that he had not rounded in this resident’s room. The facility’s indwelling catheter care policy requires inspection of catheter and tubing, use of a securement device, keeping the drainage bag below bladder level, ensuring the bag and tubing are not on the floor, and placing drainage bags in a privacy bag. The resident’s care plan, initiated on admission, did not include an indwelling catheter care plan until two days later, despite the catheter and drainage issues noted in progress notes. A third resident had multiple medical diagnoses including chronic kidney disease, congestive heart failure, and pressure-induced deep tissue damage of the sacral region. The admission assessment documented two open areas with dressings on the left knee and scattered bruising. Observations over multiple days showed the resident in bed with heels resting on the footboard or flat on a standard mattress, without an air mattress, positioning devices, extra pillows for heel off‑loading, or devices to relieve pressure from the tailbone, despite the resident’s repeated reports that both heels were sore and painful and that she had a sore on her tailbone. A family member reported that staff did not assist with basic care and that the bathroom was dirty, and was later observed independently showering the resident without staff present. Review of the resident’s care plan, developed shortly after admission, identified potential/actual impairment to skin integrity related to fragile skin and actual open areas to the lower left extremity, with interventions focused on skin hygiene, moisture control, nail care, lotion use, and following facility skin treatment protocols, but no interventions for an air mattress, positioning devices, or a turning schedule, contrary to the facility’s policies on baseline skin assessment and comprehensive care planning.
Infection Control Failures in CPAP Handling, Hand Hygiene, and Catheter Management
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to respiratory equipment, hand hygiene during medication administration and meal service, and urinary catheter management. For one resident using CPAP therapy, the facility’s own policies required staff to clean CPAP masks weekly and store them in a plastic bag when not in use. Surveyors twice observed this resident’s dry CPAP mask sitting on the nightstand next to a dirty urinal, with an empty, dated plastic storage bag hanging on the wall above the bed. The resident reported that he had used the CPAP mask during the night and removed it early in the morning, and that no staff placed it in the bag or cleaned it; instead, a family member cleaned the mask. In a phone interview, the family member confirmed she was the only one who cleaned the mask and knew it should be stored in the plastic bag, while the infection control nurse stated all CPAP masks were to be cleaned and stored in a sealed plastic bag when not in use. Additional deficiencies were identified during medication pass observations. One RN retrieved medications from an in-room cabinet, prepared them on the medication cart, and administered them without any mention of hand hygiene before or between these steps. Another RN left an unlocked medication cart and treatment cart unattended in the team room when walking away at shift change, and a review of the controlled medication shift change log showed a missing off‑going nurse signature on a prior date, despite the form stating discrepancies should be reported to nursing administration; instead, staff reported using a sticky note to remind the nurse to sign later. On another unit, an LPN began a medication pass without performing hand hygiene, unlocked an in‑room medication cabinet, prepared medications on the cart, administered them, and then donned gloves for eye drops, removed the gloves, and continued handling the medication cabinet and cart without documented hand hygiene between tasks. A different LPN prepared and administered oral medications and nasal sprays without hand hygiene prior to preparation, washed hands only after oral medication administration, then donned gloves for nasal spray application, used the resident’s remote control, changed gloves, but did not wash hands between glove changes, while commenting on staffing shortages and frequent call lights. Dining service and urinary catheter care also reflected infection control lapses. During meal tray delivery, kitchen staff plated food with gloves and loaded trays into insulated carts, but when trays were passed to residents in their rooms, no hand hygiene was offered to the residents before meals. For another resident with a 16 French Foley catheter, admission documentation noted milky discharge at the catheter insertion site of the penis, and observations included that the catheter bag was not kept off the floor, contrary to infection control standards. Collectively, these observations and interviews showed the facility did not consistently follow its own policies and procedures for hand hygiene during medication administration and meals, proper storage and cleaning of CPAP equipment, and appropriate handling of urinary catheter equipment, as cited by surveyors as increasing the risk for cross contamination, respiratory infection, and contamination during meals and medication administration with risk of resident illnesses and hospitalization.
Failure to Provide Daily ADL Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident #35 received daily ADL care. Resident #35 was receiving hospice services two times per week for ADL care, had chronic pain, received PRN narcotic pain medication for end-of-life pain, and was unable to participate in ADL care or express needs. The resident’s care plan dated 3/13/26 directed staff to assist with bed mobility, bathing, dressing, and personal hygiene. On 3/23/26, the resident was observed sleeping in bed with family present, with an odor and a white tee-shirt that had a large area of dried food on the top left side. The resident was unable to be interviewed because he was in the actively dying stage. On 3/24/26, the resident was again observed sleeping in bed with the same soiled white tee-shirt and an odor. Family members stated the resident had not been cleaned up and that staff told them they waited for Hospice, scheduled twice weekly, to provide ADL care. Family members also stated they had been at the facility with the resident 24 hours a day and that staff would not clean him up, saying they waited for the Hospice aide. A nurse stated the resident should have been cleaned up and that staff were waiting for Hospice to come, while a CNA stated she cleans everyone up daily. The DON stated she had received a call during the night and instructed the nurse to go into the resident’s room and care for him.
Incomplete Psychotropic Medication Consents
Penalty
Summary
The facility failed to ensure that two residents were fully informed, per consent, of the dosage and frequency of the psychotropic and/or antidepressant medications they were receiving. For one resident, record review showed an MDS with a BIMs score of 13 out of 15 and diagnoses including anemia, hypertension, peripheral vascular disease, gastroesophageal reflux disease, renal insufficiency, wound infection, diabetes, arthritis, malnutrition, depression, and COPD. That resident was receiving Mirtazapine 7.5 mg by mouth at bedtime, started on 3/2/2026, and the signed consent for the antidepressant did not include the dosage or the frequency/times per day. For the second resident, psychiatry notes documented bipolar disorder, anxiety, and depression. The March 2026 MAR showed hydroxyzine pamoate 50 mg for anxiety, trazodone 50 mg for depression, lurasidone 20 mg for mental disorder, and duloxetine 60 mg for depression. The consent dated 5/6/2025 covered all four medications on one form, but it did not identify the dosage or frequency of administration and did not identify the side effects of antidepressants. The facility policy defined psychotropic medications to include antipsychotics, antidepressants, anti-anxiety medications, and hypnotics, and the psychotropic consent form stated that residents would be monitored for side effects and medications discontinued if serious effects developed.
Unsafe AMA Discharge Without Follow-Up Planning
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #53, who had a hospital discharge diagnosis of dementia along with chronic cellulitis of the legs, chronic wounds, acute kidney injury, chronic heart failure with reduced ejection fraction of 45-50%, aortic stenosis, atrial fibrillation, heart block with pacemaker, and a history of deep vein thrombosis and pulmonary embolism. On admission, the resident had a Brief Interview of Mental Status score of 6 out of 15, indicating severe cognitive impairment, and was later noted to have periods of confusion. The resident became upset, refused medications and blood pressure checks, and stated he had used the call light 47 times, waited 3 hours for a toothbrush, and was leaving the facility. The resident signed AMA paperwork, and the assistant director of nursing was present to witness the signature. The resident’s daughter and ex-wife were notified and stated they were not picking him up. The record showed no adult protective services referral, no community welfare check referral, no discharge summary, and no home care referral. The social worker stated she was not at the facility when the discharge occurred and did not review the discharge when she returned, and the RN who discharged the resident stated there was no documentation of what time the resident left, who he left with, how he left, or where he was going to live.
Failure to Prevent Heel Skin Breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident #56. The resident’s admission skin assessment noted two open areas with dressings to the left knee and scattered bruising. During observation on 03/23/2026, the resident was seen with both heels resting on the footboard of the bed while the head of the bed was elevated high and the resident was scrunched down toward the end of the bed while eating breakfast. The resident stated both heels hurt and that the pain woke her up, and she said she had told a nurse and cream was applied. The resident also stated she had a sore on her tailbone, and no extra pillows were noted in the room to keep the heels off the mattress. Later observations showed the resident’s feet flat on the mattress with no pillows noted for positioning off the tailbone or for heel elevation, and the resident continued to state that both heels hurt. On 03/24/2026, the resident’s family member provided a shower because the resident was sweaty and “gross,” stating staff could not be found to assist. At 10:50 AM, the surveyor observed red areas on the back of each heel, estimated to be the size of a golf ball, and the resident stated both heels were sore and painful to touch. The care plan addressed fragile skin, open areas to the lower left extremity, scratching, moisture, skin cleansing, lotion, and facility skin treatment protocols, but it did not include an air mattress, positioning devices, or a turning schedule. Facility policies reviewed stated residents at risk of pressure ulcers should receive interventions to reduce risk, including devices to relieve heel pressure by raising the heels and using pillows under the lower legs to suspend the heels.
Arbitration Agreements Lacked Required Venue Information
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements clearly identified a venue that was convenient to both parties for 2 residents, Resident #14 and Resident #43. During an interview on 03/24/2026, RN P stated she was responsible for obtaining signatures on the arbitration form, did not know whether the arbitration process had ever been used to resolve disputes, and was not involved in corporate legal information. She stated she reviewed the form with residents, explained that the facility used a third-party mediator for legal disputes, and told them there was a section allowing cancellation or changes to the agreement. Record review showed that both residents had signed arbitration agreements, but the agreements did not identify any venue. The facility's Binding Arbitration Agreement Policy, dated 3/2024, stated that the agreement must provide for selection of a venue convenient to both parties.
Failure to Provide Scheduled Showers for Residents Requiring ADL Assistance
Penalty
Summary
The facility failed to provide scheduled showers for two residents who required assistance with activities of daily living (ADLs). One resident, who required two-person assistance for bathing, was not showered according to the facility's schedule and was documented as having gone 15 days between showers. Documentation showed that many scheduled shower days were marked as 'NA' (not applicable), and the resident was reported to have remained in the same clothing for five days. When the issue was brought to the attention of nursing staff, the resident was only given a partial hygiene intervention rather than a full shower as scheduled. Another resident, who required substantial assistance for bathing and had a PICC line, received only two showers during her stay, despite being scheduled for showers twice weekly. The resident was uncertain about her bathing schedule and reported receiving sponge baths. Review of documentation with the Administrator and DON revealed infrequent showers and unclear use of 'NA' in records, with no clear explanation for the lack of adherence to the scheduled bathing routine.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to effectively monitor and manage psychotropic medications for four residents, leading to improper indications for usage and duplicate therapy without documented rationale. Resident #6 was prescribed Buspirone and Duloxetine for anxiety disorder, but the indication for Duloxetine was not appropriately documented for its intended use for depression. Resident #91 was receiving both Nortriptyline and Duloxetine for depression without any documented rationale for the duplicate therapy. Resident #137 was prescribed Quetiapine for Alzheimer's, despite not having a diagnosis of Alzheimer's, and there was no clear necessity for the antipsychotic medication in her clinical record. Resident #138 was prescribed Duloxetine for mental health, but the indication should have been for depression, which was not accurately documented. The facility's policy on psychotropic medication assessment and monitoring, revised in April 2019, states that such medications should only be prescribed when necessary to treat specific diagnoses and documented conditions. However, the social worker interviewed was unaware of the rationale for the duplicate therapies and incorrect indications, and admitted to not monitoring the indications for usage of residents' psychotropic medications. This lack of oversight and documentation led to the deficiencies identified in the report.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as ensure all open and partly used foods were dated. During an inspection, several deficiencies were observed in the kitchen area. The large can opener blade had dried food on it, and the dishwasher had a crusting of food on its interior surfaces. Refrigerator #1 contained dried milk and food particles, while the small ice machine had a light orange build-up near the water line. The microwave was found with dried food inside, and the juice machine had a build-up of dried juice between the spigots. Additionally, two open and partly used breads were found without any dates, and the stove, fryer, and kitchen floor had excessive dried food, grease, and spills. Further observations revealed a trash bin filled to the top with trash next to clean plates, and the grill in use was coated with dried foods and spills. The large can opener had paint chipping off the blade, and the floor mixer and Kitchen Aid counter mixer had dried food particles at the attachment areas. Despite these issues, the facility's kitchen duty list indicated that all kitchen duties had been completed. The kitchen policy required cleaning checklists to be reviewed and completed at the end of each shift, but the observed conditions suggested these procedures were not effectively followed.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident, who was admitted for rehabilitation and had a diagnosis of cervical spinal stenosis, wore the prescribed cervical collar while sitting up in a wheelchair. Observations during a medication pass and a resident council meeting revealed that the resident was not wearing the collar, despite physician orders and care plans indicating it should be worn while sitting up and during transfers. The resident was observed hunched over in the wheelchair, with her head angled down, indicating a lack of adherence to the prescribed treatment plan. Another deficiency involved a resident who had a wound on her right great toe. The facility failed to perform wound care as per physician orders, which required daily dressing changes. The resident's wound dressing was dated two days prior to the observation, and there was a discrepancy between the initials on the dressing and the nurse who documented the dressing change in the Treatment Administration Record (TAR). The nurse admitted to not completing the dressing change and failing to correct the TAR entry. Additionally, the facility did not accurately document the admission assessment for a resident who was readmitted with an IV in place. The IV was not noted in the admission skin assessment or progress notes, and upon removal, it was found that the internal catheter was folded into the dressing. This oversight indicates a failure to conduct a thorough baseline skin assessment as required by the facility's policy.
Medication Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and sanitation of medication carts, as observed during a survey. On [NAME] Hall, the fourth medication drawer was found with dried liquid medications, crushed medication-like substances, and small pieces of paper. A Pro-State bottle had leaked, leaving dried drips on the sides and bottom of the drawer, and a Milk of Magnesia bottle also had dried medication drippings. During an interview, an LPN stated uncertainty about who was responsible for cleaning the medication cart, and the Director of Nursing admitted that the facility lacked a specific policy for cleaning the inside of medication carts. Another observation on [NAME] Hall revealed a medication drawer with black dust, small pieces of paper, and crushed-like medications at the bottom. An LPN mentioned that they clean the medication cart on their own. The facility's existing Cleaning Medication Storage Areas policy, dated January 2010, only addressed cleaning the top of medication and treatment carts, refrigerators, medication rooms, and floors, but did not specify who should clean the inside of the medication carts. This lack of clear guidelines and responsibility led to the potential for cross-contamination among the 34 residents receiving medications.
Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to prevent the development and worsening of pressure injuries for two residents, resulting in significant deficiencies in wound care management. Resident #201 was admitted with a Stage II pressure ulcer on the sacral region and required assistance with activities of daily living. Despite this, the facility did not consistently reposition the resident or provide timely and appropriate wound care treatments. The documentation of wound locations and treatments was inconsistent, making it difficult to track the progression and management of the wounds. The facility's records showed that there was no treatment order for Resident #201's left buttock wound until 26 days after admission, and the treatments provided did not align with the documented wound assessments. Resident #205 developed an avoidable Stage II pressure ulcer behind the ear due to the lack of preventive measures for the oxygen tubing. The resident, who was cognitively intact, reported discomfort from the oxygen tubing, but the facility failed to implement foam ear protectors until after the ulcer developed. Even after the protectors were added, they were not consistently used, as observed during a surveyor's visit. The facility had the necessary preventive equipment available but did not utilize it in a timely manner to prevent the pressure ulcer. Interviews with staff, including the wound nurse and the facility administrator, revealed awareness of the discrepancies in wound care documentation and treatment implementation. The facility's policy on skin management required appropriate interventions and documentation for residents with skin impairments, but these were not followed, leading to the deficiencies observed. The administrator acknowledged the concerns raised by the surveyors, indicating a recognition of the facility's failure to adhere to its own policies and procedures.
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Illustrative
What surveyors actually found near you
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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.
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Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthsource Saginaw, Inc | 1 mi | ★★★★★ | 3 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 2 mi | ★★★★★ | 8 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 2.2 mi | ★★★★★ | 26 | 0 |
| Adira Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 13 | 0 |
| Great Lakes Rehabilitation Center | 2.6 mi | ★★★★★ | 24 | 0 |
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