Hoyt Nursing & Rehab Centre

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Properly and safety store 1 E-tank (full oxygen canister), and 2) Store respiratory equipment (nasal cannula attached to concentrator and CPAP mask) when not in use for 4 residents (#3, #9, #13 and #75) of 4 residents reviewed for respiratory equipment, safety, and storage, resulting in the protentional for the oxygen tank to fall. Findings Include: Resident #13: On 7/07/2026, at 11:07 AM, Resident #13 was sitting in their recliner in their room. There was a single oxygen tank standing upright in the corner behind the recliner unsecured. On 7/07/2026, at 11:15 AM, an observation along with the Director of Nursing (DON) of Resident #13's room was conducted. The DON was asked if the oxygen tank was full and the DON stated that it's full and I will go get a holder for it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Implement and operationalize processes and procedures to ensure the provision of accurate pharmaceutical services, 2) Ensure narcotic medication reconciliation and disposal in two of three medication carts reviewed and 3) Ensure the appropriate disposal of a fentanyl (narcotic medication) patch for one resident (Resident #16), resulting in the potential for controlled substance diversion and medication errors for all 80 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that safe medication storage and labeling procedures were implemented in two of four medication carts resulting in undated, expired, and unlabeled medications.

Inspectors wroteBased on interview and record review, the facility 1. Failed to ensure dignity for 6 residents (#3, #8, #18, #20, #89 and #90) of 18 residents reviewed for dignity regarding timely call light response from staff, and 2. Failed to provide snacks at night per confidential residents' group meeting, and resident verbalizations during the initial tour, resulting in anger, frustration, incontinent episodes, embarrassment, protentional isolation and hunger at night. Findings Include:Resident #3: Review of the Face Sheet, Physician orders, Physician and Nursing progress notes, dated 7/26, and care plans, dated 6/26, revealed Resident #3 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE], after a fall with a fracture. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (AD) were executed, and code status was obtained per professional standards for one resident (Resident #48) of one resident reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure that psychotropic medications were used with adequate indications for use and for treatment of a diagnosed condition for one resident (Resident #48) of five residents reviewed.

Inspectors wroteThis citation pertains to Intake Number 3053493. Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #45) of 19 residents reviewed for care plans had a comprehensive safety care plan (dated 02/24/26 and updated on 05/30/26) in place, resulting in the discontinued use of a non-skid chair mat. Findings Include: Resident #45: Review of the Face Sheet, Nursing and Physician notes dated 5/30/26 through 7/7/26, physician orders dated 2/24/26 through 6/16/26 and Hospital records dated 6/11/26, revealed Resident #45 was 85 years-old, confused, admitted to the facility on [DATE], required assist with all transfers and was a fall risk upon admission due to a recent fall outside of the facility resulting in a fracture of the right upper leg/femur. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain physician's orders and maintain the head of the bed safely for one resident (Resident 7) of one resident reviewed for enteral feeding, resulting in the likelihood of aspiration and/or illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely management and implementation of updated interventions for pain management for one resident (Resident #5) of one resident reviewed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for one resident (Resident #48) of one resident reviewed for dementia, resulting in the potential for lack of services and care.

Inspectors wroteBased on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure that the Infection Control data was fully analyzed for February 2026, 2) Ensure that clean linen was transported with a cover on it, and 3) Ensure that 1 of 2 urinary catheters reviewed for infection control standards was sanitarily maintained, resulting in the protentional for cross contamination, increased risk for urinary tract infection with antibiotic usage, incorrect infection rate and incorrect data analysis for the month of February 2026. Findings Include: On 7/07/2026, at 10:31 AM, CNA M was observed in the hallway near room [ROOM NUMBER] with multiple bed pads uncovered tucked under their arm. The linen was touching their uniform. CNA M entered an enhanced barrier precautions (EBP) room; [...]

Inspectors wroteThis Citation pertains to Intake Number 2995609. Based on interview and record review, the facility failed to ensure that quarterly care planning meetings were accomplished and that the resident and resident's representative were included in the care planning allowing them to make informed decisions regarding healthcare and treatment options for one resident (Resident #1) of one resident reviewed for care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a facility-acquired, Stage IV pressure ulcer for one resident (Resident #58) of two residents reviewed, resulting in the development of a new left heel pressure injury, while residing in the facility with the potential for pain /discomfort, prolonged illness, and infections.

Inspectors wroteBased on interview and record review the facility to timely update and formulate advance directives for two residents (#37 and #239) of two residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time). Findings Include: Resident #37: On [DATE] at 3:20 PM, a review was conducted of Resident #37's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease, Diabetes, Hypertension, Dementia, Orthopedic aftercare, Anxiety and Depression. Further review of Resident #37's chart showed there had been no discussion with the resident or her daughter regarding formulating advance directives. Social Services Assessment [DATE]: -No mention of advance directives nor is there is section within this assessment to address it. Progress Notes: [DATE] at 02:27: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plans for one resident (#69) of two residents reviewed, resulting in a failure to add interventions for timely reweighs of Resident #69 to prevent weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to document and notify the physician of a popped/ruptured boil/skin condition for one resident (Resident #36), resulting in Resident #36 having a right anterior neck boil that was 'popped by a staff member with no physician's order, no documentation of the wound site and drainage, with the potential for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to implement continuation of preventative mobility services for one resident (#37) of one resident reviewed for restorative therapy services. Findings Include: Resident #37: On 5/20/2025 at 2:55 PM, Resident #37 was observed sitting in her wheelchair in her room. She stated she was waiting on a ramp and bathroom handrails to be installed at her daughter's home and then she would be discharged home. Resident #37 expressed concern that since being cut from therapy on 5/13/25, she is scared she will lose the advances she made, which will make the transition back home more difficult. Resident #37 was asked if she is in a restorative program, and she stated she is not. She reported facility staff only get her out of bed, assist with care and help her in /out of the wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the prevention of cross contamination during colostomy care for 2 resident's (Resident's #40 and #69) of 2 resident's reviewed for ostomy care, resulting in the high potential for cross contamination, resident and staff illness with possible hospitalization. Findings Include: Resident #40: Review of the Face Sheet, care plans dated 6/24, and diagnosis list, revealed Resident #40 was [AGE] years old, admitted to the facility on [DATE], had a Guardian in place for medical and finical decisions, and was dependent on staff for all Activities of Daily Living/ADL's. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure supervision, follow care-planned interventions and physician's orders for one resident (Resident #81) of one resident reviewed for NPO status (nothing by mouth), resulting in access to water at bedside, resident's admitted consumption of the water with the likelihood of asymptomatic aspiration going unnoticed/unassessed.

Inspectors wroteBased on observation, interview and record the review the facility failed to prevent medication errors and missed admission medication doses for one resident (Resident #240) of one resident reviewed for new resident admission.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) for one resident (Resident #49) of one resident reviewed for mood, resulting in a lack of an attempt at a GDR for psychotropic medications, Cymbalta and Trazadone.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and discard medications for 4 of 5 medication carts reviewed, resulting in a lack of dating of multi-dose medications (insulins/Inhalers/eye drops), accu-check solution and sticks opened and undated.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) ensure that the kitchen walk-in freezer was properly maintained (excessive ice build-up on 2 of 3 fans and ceiling frozen condensation). Findings Include: During the initial kitchen tour done on 5/20/25 at 9:30 a.m., accompanied by Culinary Specialist G, the following observations were made: On 5/20/25 starting at 8:15 a.m., a walk through done in the kitchen with Culinary Specialist G, the following was observed: -At 8:16 a.m., observation was made of 4 silver metal containers with food in them sitting in the food warmer with no dates on any of them. -At 8:17 a.m., 2 clean and ready for use silver metal pans were found wet inside (they were stacked inside one another). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure 1 residents' (Resident #19) urinary catheter bag was not on the contaminated floor of 2 residen's reviewed for urinary catheters, and 2) ensure 1 resident's (Resident #76) nebulizer equipment was stored properly when clean, dry and not in use of 3 residents' reviewed for proper respiratory equipment storage. Findings Include: Resident #19: Review of the Face Sheet, diagnosis list, care plans dated 7/20 with re-admission of 5/12/25, revealed Resident #19 was [AGE] years old, not able to make her own healthcare decisions, receiving Hospice services, and totally dependent on staff for all Activities of Daily Living/ADL's. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an operational resident call system for two residents (#10 and #16) of ten residents reviewed for call system functionality. Findings Include: During Resident Council on 5/21/2025 at 10:20 AM, Resident #16 stated her call light was not functioning properly, as it would not illuminate outside her door when she pressed it for assistance. About two weeks ago, maintenance staff had to fix it as it was not working appropriately. She expressed if she required something of staff, they were not aware she needed assistance. On 5/21/2025 at 3:40 PM, Maintenance Director H conducted a test of Resident #16's call light for functionality. Director H engaged the call light from the resident's bed and the light outside of her door did not turn on. He proceeded to test the bathroom call light which worked as it should. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00151907 and MI00152097. Based on observation, interview and record review, the facility failed to prevent resident-to-resident abuse/assault of one resident (Resident #101), resulting in Resident #101, who was totally dependent for all care and had bilateral lower limb amputations and upper extremities contractures, receiving a black eye with facial contusions while residing in the facility.

Inspectors wroteThis Citation pertains to Intake Number MI00151904. Based on interview and record review, the facility failed to 1) Ensure that a timely, complete and accurate resident assessment was done for a change of condition and 2) Transfer a resident to the hospital in a timely manner for 1 resident (Resident #101) of 5 residents reviewed for quality of resident care, resulting in a failure to transfer to the hospital during an acute change of condition, decreased blood pressure, increased pulse rate, increased temperature, and, subsequently, death. Findings Include: Resident #101: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00151907. Based on observation, interview and record review, the facility failed to notify a resident's responsible party of a roommate change for one resident (Resident #102) of 2 residents reviewed, resulting in Resident #102 having a new roommate moved into his room without the responsible party's notification prior to the move, which resulted in a resident-to-resident injury.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure informed consent for psychotropic medications used to treat mood and behavior disorders for 4 residents (#101, #102, #103, #104) of 4 sampled residents, resulting in the lack of informed consents prior to the initiation or change in dosage of a psychoactive medication and the likelihood for uniformed care and a knowledge deficiency related to medication.

Inspectors wroteThis citation pertains to Intake Number MI00148622. Based on interview and record review the facility failed to operationalize the facility policy for wound management for one resident (R4) of three residents reviewed for wounds, resulting in a missed weekly skin picture, a missed weekly assessment and the potential for the wound to worsen.

Inspectors wroteThis Citation pertains to Intake Number MI00146711 Based on interview and record review the facility failed to order free water flushes (additional water provided to help meet daily fluid needs) for one resident (Resident #701) of two residents reviewed for enteral nutrition feedings, resulting in Resident #701 not receiving appropriate hydration from 07/12/2024 to 07/16/2024 (five days) with the possibility of dehydration. Findings Include: Resident #701: On 9/5/2024 a review was completed of Resident #701's records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Hypomagnesemia, Atrial Fibrillation, Gastrostomy Infection, Dysphagia, Anxiety and Solitary Pulmonary Nodule. Further review revealed the following: Hospital Discharge Tube Feed Orders: [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that five residents' (Resident #11, Resident #14, Resident #33, Resident #58 and Resident #62), call lights were available, within reach, and answered in a timely manor, 2) Failed to ensure that two residents (Resident #33 and Resident #62) were treated in a respectful and dignified manor, 3) Failed to ensure that one resident's (Resident #17) bedding was clean and the urinal emptied, 4) Failed to ensure that one resident (Resident #14) had a phone available for use, and 5) Failed to ensure that two residents' (Residents #11 and Resident #58) food requests were honored, resulting in verbalization of anger regarding phone availability and undignified communication from staff, having no call light available or within reach for requests or emergencies with the likelihood of injury due to no assistance [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activities of Daily Living assistance for two residents (Resident #9, Resident #47) of five residents reviewed for ADL assistance, resulting in overgrown toenails, lack of showers, missed lunch meal with the likelihood of decreased mood and hunger.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive pressure ulcer prevention and skin management program for one resident (Resident # 66) of two residents reviewed, resulting in Resident #66 developing an unstageable (unknown depth) pressure ulcer, unnecessary pain, and the likelihood for a decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive restorative nursing program for one resident (Resident #1) of one resident reviewed, resulting in a lack of consistent Range of Motion (ROM) joint measurements, a lack of a well-defined and planned interventions and implementation of ROM for a resident with contractures, inaccurate documentation of Passive ROM (PROM) exercises, Resident #1 verbalizing discontentment and experiencing a decline in ROM, worsening contractures/ROM, unnecessary pain, and the likelihood for further decline.

Inspectors wroteThis Citation pertains to Intake Number MI00144673 for Resident #51. Based on observation, interview and record review, the facility failed to ensure a safe shower for one resident (Resident #14), care plan and ensure a functioning wander guard for one resident (Resident #43), ensure proper supervision for one resident (Resident #67) who was smoking in his room, and ensure a safe transportation to a medical appointment for one resident (Resident #51), resulting in an unsafe shower with the likelihood for a fall with injury and verbalization of pain during the shower, an unsafe Wanderguard with the likelihood of elopement and injury, a dangerous environment for a census of 76 residents due to a resident smoking in the facility, and a resident being dropped off for a medical appointment at the wrong facility, with the likelihood of injury, and fear of being driven to further appointments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe subcutaneous injection for one resident (Resident #14), resulting in the likelihood of decreased efficacy, unwanted side effects of an intramuscular injected blood thinner (Heparin) into the abdomen, bruising and/or a hematoma.

Inspectors wroteResident #14: Proper Hand Hygiene: Review of the face Sheet, MDS dated [DATE]/2024, progress notes dated 5/25/2024 through 6/12/2024, and physician orders dated 5/25/2024, revealed Resident #14 was [AGE] years old, alert and his own person, non-ambulatory and was admitted to the facility on [DATE], from acute care and required staff assistance with all ADLs'. The resident's diagnosis included, pressure ulcer on coccyx, hematoma (bruising) of soft tissue, Parkinson's Disease, morbid obesity, muscle weakness, Lymphedema, reduced mobility, chronic pain, Acute Kidney Disease, high blood pressure, Diabetes, and heart disease. An observation was done on 6/13/24 at 12:05 p.m., of wound care done by Nurse, LPN F. During the wound care, Nurse F cleaned the resident's coccyx wound, removed her dirty gloves and immediately put on a new pair of gloves. [...]