Caretel Inns of Linden: Pressure Ulcer Failures - MI
Resident 67 was discharged to the hospital on August 8, 2025 and never returned to the facility. By then, the person had developed pressure ulcers on the left ear, sacrum and left elbow — wounds that weren't documented in care plans until the day of hospital transfer.
The resident's left elbow wound measured 2 centimeters by 1.5 centimeters with "100% firmly adherent yellow slough" — dead tissue — covering the entire wound bed, according to a health status note from August 7. Moderate drainage seeped from the full-thickness injury.
Two separate wounds opened along the resident's spine. The upper sacral ulcer measured 1.8 centimeters by 1 centimeter, described as a full-thickness opening with dead tissue completely covering the wound bed. The lower wound measured 1.6 centimeters by 0.8 centimeters, also full-thickness, with the wound bed "50% non-granulated" and covered in adherent dead tissue.
A third pressure ulcer had developed on the resident's left ear by August 3.
None of these wounds appeared in the resident's care plans until August 8 — the day of hospital discharge. Even then, the care plan failed to mention the ear wound entirely.
The resident had been readmitted to the facility earlier in 2025 with multiple serious conditions including diabetes, stroke history, dementia, pulmonary embolism, Parkinson's disease, heart failure and pneumonia. A cognitive assessment from July revealed a score of 9 out of 15, indicating moderate mental decline.
Staff documented dramatic weight loss throughout the resident's stay. Between April 22 and August 1, 2025, the person lost 10 pounds. But over a longer period from October 2024 to August 2025, the resident had lost 70 pounds total.
A dietary review from April noted "weight loss of 10% x 5 weeks & x 5 months." The resident returned from a hospital stay on July 10, 2025 with a feeding tube.
Despite these risk factors — significant weight loss, feeding tube placement, immobility requiring extensive assistance from two staff members, and cognitive impairment — the facility's care plans remained largely unchanged.
The resident's skin integrity care plan had been created in October 2024 with basic interventions: daily skin checks, a pressure redistribution mattress, and reminders to reposition frequently. These measures weren't revised even as the person's condition deteriorated.
An activities of daily living care plan noted the resident needed "extensive assist of 2" for bed mobility due to "limited mobility, debility, and impaired balance." This plan was last updated in January 2025, months before the pressure ulcers developed.
Only on August 8 — as the resident was being transferred to the hospital — did staff finally add a care plan noting "alteration in skin integrity" with pressure injuries to the sacrum and left elbow. The plan identified contributing factors as "immobility" and "incontinence" but made no mention of the ear wound.
A July assessment had indicated the resident was at risk for developing pressure ulcers, yet marked "no" when asked if the person currently had any pressure injuries.
Confidential Person J told inspectors on September 9 that Resident 67 had developed all three pressure ulcers while at the facility.
Federal inspectors found the facility failed to ensure the resident received proper treatment and services to prevent pressure ulcer development, despite documented risk factors including cognitive impairment, immobility, weight loss and the need for extensive physical assistance.
The resident never returned from the hospital transfer on August 8, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Caretel Inns of Linden from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Caretel Inns of Linden in Linden, MI was cited for violations during a health inspection on September 9, 2025.
Resident 67 was discharged to the hospital on August 8, 2025 and never returned to the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.