Caretel Inns of Tri-Cities

Inspectors wroteThis Citation Pertains to Intake Number 3066377. Based on observation, interview, and record review, the facility failed to ensure that medications were stored under proper temperature/environmental controls in one of one medication rooms, resulting in the potential for all 54 facility residents to receive medications with altered efficacy and effectiveness including medications unsafe for administration.

Inspectors wroteThis Citation Pertains to Intake Numbers 3066377 and 3063033. Based on observation, interview and record review, the facility failed to notify a resident's representative of a change in the resident's status and an alteration in treatment for one resident (Resident #701) of three residents reviewed.

Inspectors wroteThis Citation Pertains to Intake 3066377. Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure personal linens were transported and maintained in a sanitary manner for two residents (Resident #701 and Resident #703) of three residents reviewed.

Inspectors wroteThis citation pertains to Intake Number 2999812. Based on interview and record review the facility failed to implement care plan interventions and provide appropriate supervision for feeding assistance for one resident (Resident #2) of three residents reviewed for feeding assistance, resulting in Resident #2 sustaining a burn on the abdominal area.

Inspectors wroteThis citation pertains to Intake Number 2677656. Based on interview and record review, the facility failed to reconcile enteral feeding (tube feeding) orders for one resident (Resident #1) of two residents reviewed for enteral feeding resulting in approximately 19 hours of no enteral feeding/nutrition and rehospitalization.

Inspectors wroteThis citation pertains to Intake Number 2677656. Based on interview and record review the facility failed to clarify admission orders, reconcile medications, provide medications timely, and coordinate with hospice and the physician for two residents (Resident #1, Resident #3) of three residents reviewed for nursing care resulting in delayed care and rehospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food palpability and preferred temperature for a total of 8 resident's (Resident's #2, #13, #22, #26, #63 and #66), and follow provided food menu for a census of 53 of 53 resident's, resulting in the potential for weight loss, dislike of facility served foods, anger towards dietary department and management, refusing to eat served foods, and relying on family member's to bring in favored foods. Findings Include: Observation made on 8/6/25 at 10:26 a.m., in the main dining room revealed the facility food menu posted was dated July, 2025. Resident #26:Review of Face Sheet and Minimum Data Set/MDS dated 3/25, revealed Resident #26 was admitted to the facility 3/25, and was alert and able to be interviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) maintain clean wheelchairs for 5 resident's (Resident's #6, #15, #38, #41 and #44), 2) ensure a clean and comfortable environment for randomly selected resident rooms and 3 of 4 hallways (Hall's 100, 200, and 400), and 3) maintain plumbing in good repair, for a census of 53 resident's, visitors and staff, resulting in the potential for cross contamination, resident illness, complaint's of resident environment cleanliness, and flooding concerns regarding plumbing. Findings Include: DPS 2 Based on observation and interview the facility failed to maintain plumbing in good repair. This deficient practice increases the likelihood of contamination of the water supply, potentially affecting any or all staff, residents, and visitors in the facility.

Inspectors wroteBassed on observation, interview and record review, the facility failed to ensure a dignified dining experience and follow care planned interventions for 6 residents (#22, 27, 28, 29, 33, 38 and 44) out of 10 residents reviewed during dining task, resulting in no assistance offered, food spills on clothing, fluids not offered, meals not served timely and in a dignified manner with the likelihood of overall decreased nutritional intake.

Inspectors wroteBased on interview and record review the facility failed to consistently provide scheduled showers to four (#15, #35, #35, #37) residents of four reviewed for Activities of Daily Living. Resulting in, unmet care needs and feelings of frustration. Findings Include: Resident #15On 8/6/2025 at approximately 8:20 AM, Resident #15 reported her shower days are Mondays and Thursdays, but she did not receive one this Monday. She continued if she does not ask if she is being showered on her scheduled day, many aides will not mention anything about it. Resident #15 stated she did refuse one shower as it was closer to midnight when the aide offered. On 8/6/2025, a review of the last 30 days of Resident #15's showers were completed. Within the 30-day period, Resident #15 was provided with one shower on 7/20/25. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure 3 of 4 medication carts were maintained clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications. Findings Include: Observation was made on [DATE] at 11:32 a.m., with Nurse, LPN I of the 300 Hall medication cart. During the observation the following was found: -Resident's #1 and #16 had partly used insulin pen's with no expiration date written on the sticker (sticker with open and expiration date spaces to fill in) on the pen. During an interview done on [DATE] at 11:32 a.m., Nurse I was unable to tell this surveyor when the insulin's expired, and why there was no expiration date on the resident's insulin pens. Nurse I stated yes, they need a expiration date. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness of clean linen and sanitary supply storage. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, for any residents in the 100 and 300 hallways.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (#6) of one reviewed for behavioral health had an accurate mental health diagnosis. Findings Include:On 8/7/2025 at 10:40 AM, Social Worker P was queried regarding Resident #6's diagnosis of paranoid schizophrenia and current medication regime. She reported he is not prescribed any medications for his schizophrenia diagnosis. She was asked to provide further documentation on if his diagnosis was long standing or newly added. We reviewed his diagnosis list that revealed the Paranoid Schizophrenia diagnosis was initiated upon admission and the physician note dated 5/3/24 that stated, history of paranoid schizophrenia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food items per scheduled menu for all residents and failed to provide milk per menu for Resident's #22, 63, 64, 65 and 66) of a census of 53 out of 53 residents who eat facility provided meals, resulting in frustration, no breakfast egg, no milk and overall likelihood of hunger.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preferences and food allergies for two (Resident #38 and 66) out of two residents reviewed for food allergies and preferences, resulting in frustration of allergy food items being served, the likelihood of food allergy reactions and overall decreased nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Prevent bruising and sling indentations on both thighs during a mechanical transfer for 1 resident (Resident #102), and 2) Ensure that 1 resident (Resident 106) was free of injury of an unknown origin (fracture of the leg) of 2 residents observed for transfer and injury of unknown origin, resulting in 2 sling indentations on the thighs and a bruise on the outer right knee with the possibility of developing skin breakdown and a fracture of the leg, pain and hospitalization. Findings Include:Resident #102: Review of the face Sheet, care plans dated 6/25, nursing notes dated 7/23/25 and physician orders dated 7/23/25, revealed Resident #102 was [AGE] years old, alert but not able to make her own healthcare decisions, immobile, and totally dependent on staff for all Activities of Daily Living/ADL’s. [...]

Inspectors wroteThis Citation Pertains to Intake Numbers 1256062 and 2564418. Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for two residents (Resident #101 and Resident #105) of three residents reviewed, resulting in a lack of planned interventions, a lack of implementation of meaningful interventions to prevent falls, resulting Resident #101 and Resident #105 experiencing falls with injuries necessitating emergency medical treatment, unnecessary pain, and a decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to update and/or revise individualized, person-centered care plans to reflect the changing care needs for 1 resident (Resident #106), of 8 residents reviewed for care plans, resulting in the potential for unmet care needs. Resident #106:Record review of Resident #106's electronic medical record revealed and elderly female with medical diagnoses of: muscle weakness, dysphagia, protein calorie malnutrition, diabetes, mood disorder, insomnia, major depressive disorder, Alzheimer's, gastro-esophageal reflux disorder, hypertension, peripheral vascular disease, irritable bowel syndrome, osteoarthritis, heart disease. Observation and interview on 7/22/2025 at 11:58AM with Resident #106 in regard to her tibia and fibula (leg bones) fractures revealed: I don't know what happened, it just started hurting. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00153516. Based on observation, interview and record review, the facility failed to prevent two (2) Stage II (blisters) pressure injuries for one resident (Resident #102) of 3 residents reviewed for pressure ulcers, resulting in two (2) upper left shoulder, Stage II pressure ulcers, pain/discomfort, wound treatments and the likelihood for a decline in overall health.

Inspectors wroteThis Citation pertains to Intake Number MI00153516. Based on observation, interview and record review, the facility failed to prevent an injury of unknown origin for one resident (Resident #102) of 3 sampled residents, resulting in Resident #102 sustaining a fractured tibia and fibula of the right leg while residing in the facility, unnecessary pain/discomfort, and likelihood for decline in overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food served to residents was palpable, had a good appearance and was at a preferred temperature for 2 residents (#104 and #105) of 4 residents observed at the noon meal, and per the facility's confidential Resident Council Group notes dated 3/21/25, 5/20/25, and 6/5/25. Findings Include: Observations made on 6/13/25 at 12:20 p.m., at the noon meal in the main dining room: Resident #104: Review of the Face Sheet and care plans dated 5/25, revealed Resident #104 was [AGE] years old, admitted to the facility on [DATE], was alert and able to be interviewed, and dependent on staff for ADL's. The resident's diagnosis included, Cognitive communication deficit, metabolic encephalopathy, anxiety, adjustment disorder and lack of coordination. [...]

Inspectors wroteThis citation pertains to Intake Number MI00151886. Based on interview and record review the facility failed to timely and accurately complete a new resident's admission and administer medications timely for one resident (Resident #502) of one resident reviewed for admission procedures. Findings Include: Resident #502: On 5/8/2025 at approximately 12:00 PM, the administrator was asked for all of Resident 502's concern forms from admission (most recent) to discharge from the facility. The administrator had no concern forms on file for Resident #502. On 5/8/2025, review was conducted of Concern & Suggestions Form for Resident #502 completed on 2/24/2024 (attached to the complaint). It stated, .no meds until 10 PM .patient was sent from hospital on Sunday afternoon . patients meds arrived with night delivery . [...]

Inspectors wroteThis citation pertains to Intake Number MI00150236. Based on record review and interview, the facility failed to assess, identify, and treat wounds to the feet and a urinary tract infection for one resident (Resident #2) of three residents reviewed for a change in condition.

Inspectors wroteThis citation pertains to Intake Number MI00150236. Based on interview and record review, the facility failed to follow policy and procedures for catheter care and obtain urinalysis testing for three residents (#2, #4, and #5), of three residents reviewed for catheter care.

Inspectors wroteThis citation pertains to intake Numbers MI00149500 and MI00149604. Based on observation, interview and record review, the facility failed to implement appropriate interventions timely to prevent a pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in an unstageable coccyx pressure injury (full-thickness pressure injury where the base of the wound is covered by a layer of dead tissue, making it impossible to determine the stage of the injury), pressure ulcer infection and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper Personal Protection Equipment (PPE) use and ensure hand hygiene during care for one resident (Resident #2) of one resident who required enhanced barrier precautions, resulting in cross contamination of uniforms, no hand hygiene, gloves being stored in uniform pockets and no gown use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 3 of 3 medication carts were neat and clean (100 Hall, 200 Hall, & 300 Hall), and ensure that no medications were left at the bedside of one resident (Resident #2). resulting in medication not being taken, checking on medications, non-sanitary medication carts, lost or not counted medications and the likelihood for contamination. Findings Include: During an observation made on 7/15/24 at 11:14 a.m., accompanied by Nurse, LPN M the following was found: Medication Cart 300: -The large second drawer was found to have crushed pills and papers in the bottom. -The Third and fourth drawers were found to be dirty with dust, papers, crushed pills and dried liquids on the bottom of the drawers. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 50 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that the residents' refrigerator was cleaned, and all food items were labeled and dated, and 2) Failed to analyze monthly infection control data, resulting in the high likelihood for resident infections, communicable disease outbreaks, increased antibiotic usage with continued infections and hospitalizations. Findings Include: Review of the facility Infection Prevention and Control Program dated 6/1/2020, stated The facility has a system in place (e.g., notification of IP by clinical laboratory) for early detection and management of potentially infectious symptomatic residents, including implementation of precautions as appropriate. Any unusual case or cluster of cases that may indicate a public health hazard. [...]

Inspectors wroteThis citation has two Deficient Practice Statements (DPS). Deficient Practice Statement 1 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 50 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview and record review the facility failed to implement a baseline care plan for oxygen administration for one resident (Resident #261) of one resident reviewed for oxygen administration resulting in the lack of a care plan for oxygen and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to label oxygen tubing with the date it was changed for one resident (Resident #261) of one resident reviewed for oxygen administration resulting in tubing that was not labeled and the likelihood for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure correct staging of a pressure injury, documentation of accurate pressure injury measurements, and weekly documented pressure injury assessments in accordance with facility policy and standard of practice for one resident (Resident #1) of three residents reviewed for pressure injuries.

Inspectors wroteBased on interview and record review, the facility was placed in Immediate Jeopardy on [DATE]. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) and call Emergency Services (911) for one resident (Resident #1) who began choking during medication administration resulting in Resident #1's death. Immediate Jeopardy (IJ): The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE]. The abatement plan was received on [DATE]. The Immediate Jeopardy was removed on [DATE]. The abatement plan was verified on [DATE].

Inspectors wroteBased on interview and record review, the facility failed to follow the wishes of one resident (Resident #5) for Full Resuscitation of five residents reviewed for Code Status, resulting in full code status wishes not being documented for 2 days.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision to prevent falls/accidents for five residents (Resident #5, Resident #6, Resident #37, Resident #155, Resident #203,), resulting in injuries, pain, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely store foods brought to residents by family and visitors for Resident #16 and all facility residents that utilize the resident refrigerator in the Day Room, resulting in Resident #16's personal refrigerator being unmonitored with inappropriate temperature to cool food adequately and several food/ beverages within the residents' refrigerator in the Day Room that were opened, undated and/or expired and the potential for facility wide foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to: (1.) Ensure that proper personal protective equipment (PPE) was worn entering droplet precautions room [ROOM NUMBER]. (2.) Ensure that infection rates were identified in monthly infection control reports from January through April 2023. (3.) Ensure that recommendations for staff education was noted on the reports; (no peri care education for recurrent UTI). (4.) Ensure that an employee's illness was followed up on (diarrhea in the kitchen), and (5.) Ensure that clean linen was transported to residents' Rooms 206, 212 and 214 in an appropriate manner, resulting in the likelihood for cross contamination, staff illness, prolonged illness, and hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a person-centered comprehensive cardiac care plan for one resident (Resident #10), resulting in the Medtronic cardiac monitor and pacemaker checks not being care planned appropriately, nursing staff not knowing how to use the Medtronic cardiac monitor and with the likelihood of cardiac complications going unnoticed.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, monitor, and document cardiac monitor usage for one resident (Resident #157), resulting in Resident #157's cardiac monitor being attached to her chest on 7/12/2023 without appropriate physician's orders, monitoring and documentation. Findings Include: Resident #157: During Resident Council on 7/202/2023, Resident #157 was observed to have a device affixed to her chest. She reported it's a heart monitor. On 7/21/2023 at approximately 11:15 AM, a review was completed of Resident #157 medical records, and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included; Acidosis, Diabetes, Orthostatic Hypotension and Hyperlipidemia. Resident #157 is cognitively intact and able to make her needs known but does require some staff assistance. Further review revealed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat severe pain timely for one resident (Resident #207), resulting in uncontrolled severe pain at a level of 10 and Resident #207 going nine hours without any pain medication, experiencing frustration and with the likelihood of ongoing pain taking longer to get under control.

Inspectors wroteThis Citation pertains to Intake Numbers MI00137261 and MI00136381. Based on observation, interview, and record review the facility failed to provide professional, responsible and sufficient staffing for 58 residents who resided in the facility, resulting in confidential staff and Resident Council complaints on continuous unmet care needs on the 3rd shift, incontinent episodes, extended call light wait times, unwillingness of staff to provide quality care to assigned residents during third shift and facility untimeliness in addressing the insurmountable resident and staff concerns. Findings Include: On 7/19/2023 at approximately 2:20 PM, Resident #23 was observed watching television in his bed. His call light had already been activated about 5 minutes prior to this writer entering the room. Resident #23's IV pump was alarming as his antibiotic had finished infusing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide emergency/back-up supplied diabetic injectable insulin and medications timely and per physician's order for two residents (Resident #17, Resident #207), resulting in a medication error rate of 17 percent, elevated blood sugar not being treated timely, unmanaged medical conditions requiring therapeutic drugs with the likelihood of complications such as a blood clot, stomach complications and increased untreated blood glucose levels.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that meals were served at an appropriate temperature for facility residents and provide breakfast to Resident #156, resulting in Resident #156 not receiving her breakfast, Resident #5, Resident #26 and Resident Council attendees' meals being served at an unpalatable temperature, redundancy in menu choices, improper kitchenette steam table temperatures, and overall dissatisfaction with the meal experience. Findings Include: Resident #156: On 7/19/2023 at 1:05 PM, Resident #156 was observed visiting with her daughter in her room. Resident #156 and her daughter were asked how her meals have been at the facility. They reported on Monday afternoon a dietary aide took her meal order for dinner that evening and her meals the following day. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an Infection Preventionist certificate in the building for the Infection Control Program for half the month of May and all of June 2023, resulting in the likelihood for outbreak of illness, lack of employee health illness follow up, and likelihood for cross contamination of resident linens.