Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Healthsource Saginaw, Inc during CMS and state inspections, most recent first.
A resident receiving therapy after a hip fracture reported that an unfamiliar LPN entered his room, did not verify his identity, and administered a handful of pills, a chocolate nutritional drink, and a nasal spray, despite the resident stating he did not receive a nasal spray and did not like chocolate drinks. The LPN was working an extra shift on an unfamiliar unit and later admitted she confused two side-by-side rooms occupied by residents with the same first name, giving one resident another resident’s BP and cardiac medications and intended IV antibiotic dose. The resident subsequently felt markedly “high” and informed staff and family, and review of records showed limited vital sign monitoring documented around the time of the error.
A cognitively impaired resident with Alzheimer’s, dementia, psychotic disturbances, and a history of agitation had an active care plan requiring 1:1 staff supervision for safety, but this intervention was not implemented. The resident, who required assistance with all ADLs, entered the adjacent room of another cognitively impaired resident with multiple neuropsychiatric diagnoses and agitation. Video showed a CNA seated in the hallway near both rooms using a personal cell phone while the first resident went unaccompanied into the second resident’s room, leading to the second resident yelling and being scratched in the face.
Two residents with the same first name were involved in a medication error when an LPN, working an unfamiliar assignment, entered the wrong room and administered a handful of oral medications, a chocolate nutritional supplement, and a nasal spray without using two identifiers or noting the absence of an ID bracelet. A cognitively intact resident with chronic kidney disease and recent hip fracture received another resident’s regimen, including Eliquis, Entresto, Jardiance, Lopressor, and spironolactone, in addition to his own scheduled medications, and later reported feeling lightheaded and "high." The intended recipient, a medically complex resident on IV Vancomycin with multiple cardiac and infectious diagnoses and DNR status, did not receive his prescribed doses. The facility’s policies required two-identifier verification and prohibited administering one resident’s medications to another, and its occurrence reporting policy required prompt reporting and investigation of medication-related incidents, but leadership became aware of the possible error only later in the day after staff notification.
A resident with a suprapubic catheter and ordered compression hose was repeatedly observed without the hose and with a nearly full leg bag, while the chart lacked a care plan for the hose and showed catheter care instructions that were not followed. Another resident using a motorized wheelchair had a seatbelt for trunk support with no documented initial eval, ongoing monitoring, or rationale. Two other residents had incomplete skin/wound care documentation, including undated dressings with drainage and a right axilla boil with missed treatment, no documented reason for a missed tx, and limited progress note follow-up.
Infection Control: Water Management and Legionella Monitoring Deficiencies. The facility failed to implement control measures to reduce the risk of legionella and other OPPP in its water system. Staff stated the Township tested chlorine residuals and that onsite tracking was not felt necessary because the Township did it, while records showed the most recent chlorine data in the binder were from a regional report and that chlorine sampling was only done at the kitchen. The WMP and Legionella tracking sheet documented a positive legionella shower sample in one room, with the room taken offline, the fixture changed out, and flushing increased in and around the area.
The facility did not consistently implement fall prevention interventions as outlined in the care plans for two residents at risk for falls. Observations showed that required safety equipment, such as floor mats and accessible call lights, were not in place or within reach, and staff interviews confirmed these lapses. Both residents had recent falls, and the facility's protocols for individualized fall prevention were not followed.
Failure to prevent pressure ulcers was identified for two residents who developed facility-acquired wounds while at risk for skin breakdown. One resident with severe cognitive impairment, quadriplegia, and multiple existing pressure ulcers developed new abdominal, foot, and calf wounds, with staff stating the abdominal binder likely caused abrasions and that wound documentation was missing. Another resident with severe cognitive impairment, diabetes, and Alzheimer’s disease developed a stage III calf ulcer, with staff observing that soft boots and the bed position may have placed pressure on the wound area.
Failure to document and monitor ileostomy leakage and appliance nonadherence for a resident with metastatic colon cancer and multiple comorbidities. The resident reported the appliance was leaking and sore, and leakage was observed pooling on his abdomen. Staff said the wound nurse had been using a crusting technique with cream and powder for about a week, but there was no corresponding documentation in the chart, and the MD was likely not aware of the ongoing issue.
A resident who was cognitively impaired and required ADL assistance did not have hydration fluids within reach while eating and drinking in bed. Two residents had inadequate nutrition monitoring: one had a 25-lb weight loss over 90 days with no timely identification of the decline, and another with cancer, kidney failure, and poor appetite had ongoing weekly weight loss without timely documentation or meaningful nutrition assessment. The resident also reported disliking the food and supplements, and the care plan had not been updated since admission.
A resident receiving tube feeding was observed with a feeding bag dated beyond the 24-hour use period, and an RN stated the bag should have been dated differently. Staff also found the HOB at 22 degrees despite policy requiring 30 to 45 degrees during feeding. The UM and CNA initially could not locate the bed control, although it was later seen within reach on the bed covers.
Peripheral IV Left in Place Beyond Ordered Hydration: A resident with sepsis, AKI, dementia, and other chronic conditions had a PIV placed for a one-time IV hydration order. The IV remained in the right forearm after the infusion was completed, the dressing was not dated or initialed, and staff were unsure why it was still present or when it should have been removed. The resident and his wife reported the IV had not been used for over a week, and the record showed no documented timeframe for removal, assessment, or monitoring.
Kitchen Food Safety and Dishwashing Temperature Deficiencies: The facility failed to maintain kitchen best practices during observation and record review. The dishwasher logs showed rinse temperatures below the listed requirement, the dishwasher was observed with wash/rinse temperatures below the stated standard, and dish surface temps were not routinely checked. A visibly soiled mixer was observed, and a refrigerator behind the nurses' desk had conflicting temperature readings, with staff stating the smart thermostat was the temperature recorded on the log.
A resident with a history of aphasia and cerebral infarction was found on the floor after an unwitnessed fall. A CNA observed the resident but left to attend to another upset resident, closing the door to the room. The resident's son later found his mother on the floor and became angry. Interviews revealed a lack of immediate assistance and communication among staff, contributing to the deficiency in care.
A resident with a history of falls and on anticoagulants experienced two falls shortly after admission to an LTC facility. Despite being identified as a high fall risk, the resident was inadequately supervised, leading to a fatal head injury. Staff interviews revealed communication gaps and insufficient monitoring, contributing to the incident.
A resident with multiple medical conditions developed a pressure ulcer that worsened over time due to the facility's failure to provide timely treatment and communicate with the physician. Despite signs of infection and deterioration, the facility did not initiate antibiotic treatment or report the condition to the physician, resulting in the resident developing sepsis and requiring hospital admission.
Two residents developed pressure ulcers due to inadequate preventive measures. One resident's ulcer was caused by bedding friction, and no pressure-relieving devices were used. Another resident's ulcer resulted from an AFO brace, with no initial order to monitor the skin. The facility failed to adhere to its pressure ulcer prevention policy.
The facility failed to make previous survey results and contact information for the State Hotline and Ombudsman accessible to all residents. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those unable to travel the distance from the 500 hallway/nursing unit. Additionally, the contact information was placed at a height and in a format not accessible to residents in wheelchairs, leading to complaints during a Resident Council meeting.
The facility did not ensure that the daily staff posting was accessible to all residents, as it was only available at the front desk, located 580 feet from the main corridor of the 500 nursing unit. The DON confirmed that there were no individual postings for each nursing unit. Central Staffing emailed the staff posting to the switchboard operator, who printed it and placed it in a plastic file folder on the front counter, without posting it elsewhere.
The facility's kitchen, serving 162 residents, was found unsanitary with several deficiencies. Observations included a trash bin without a lid next to the grill, a microwave with dried food particles, and a can opener with dried food and chipping paint. Food items like shrimp, crackers, roast beef, and jelly lacked dates, and the brown sugar was expired. The facility failed to comply with its Food Storage policy and the 2017 FDA Food Code.
The facility failed to ensure a clean and safe environment across multiple units, with issues such as dirty CPAP machines, undated food items, and improper storage of medical equipment. Observations revealed dirty floors, incomplete temperature logs, and improper storage of personal items. The Director of Nursing and Director of Maintenance acknowledged these deficiencies, indicating a lapse in maintaining sanitary conditions as outlined in the facility's environmental services job description.
The facility failed to address resident grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration. Residents reported issues with staff behavior, including loudness, rude call light responses, and inadequate care. A Resident Council member felt deliberately excluded from a meeting with the state. The facility's records showed that several complaints were not documented or addressed, and the Director of Nursing was unaware of who was responsible for grievance follow-up.
The facility failed to provide a clean and homelike environment, with surveyors observing unclean conditions, improper storage of soiled clothes, and pest infestations in various areas. Residents expressed dissatisfaction with the use of plastic silverware and lack of condiments during meals. Staff acknowledged these issues, but immediate corrective actions were not evident.
The facility failed to provide adequate ADL care for several residents, resulting in hygiene issues such as long, dirty nails, unshaved facial hair, and unbrushed teeth. One resident reported delayed assistance with toileting, while another had severe cognitive deficits and was not receiving oral care despite having supplies. These deficiencies indicate a lack of adherence to care plans and responsibilities by CNAs.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. One resident expressed dissatisfaction with the facility's food, citing issues such as excessive pepper and overcooked zucchini. Another resident reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. A third resident complained about overly spicy food and inadequate breakfast options, while a fourth resident expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards.
The facility failed to provide adequate snacks for residents, leading to complaints about limited availability and variety. Residents, including diabetics, expressed frustration over the lack of healthy snack options and reliance on family for snacks. Observations confirmed minimal snack availability, with limited options like turkey sandwiches and a lack of fresh fruit.
The facility failed to follow infection control standards, with staff not adhering to proper PPE use, hand hygiene, and linen transport protocols. Observations included staff assisting residents without changing gloves or performing hand hygiene, and carrying clean linen against uniforms without barriers, increasing the risk of infection spread.
The facility failed to maintain resident dignity and privacy, as evidenced by inadequate privacy measures for a resident and delays in assistance. Residents reported dissatisfaction with delayed responses to call lights and inadequate grooming, leading to feelings of neglect and disrespect. Observations and interviews highlighted these deficiencies, with residents expressing frustration over the lack of timely and polite assistance.
The facility failed to incorporate PASARR Level II recommendations for specialized mental health services into the care plans of two residents with mental illness diagnoses. Despite having full cognitive abilities and requiring assistance with all care, the residents' care plans lacked any mention of specialized services. Interviews revealed a lack of communication with the Community Mental Health agency, and the facility's policy on coordinating assessments with the PASARR program was not followed.
The facility failed to update care plans for residents with complex needs, including a resident with multiple pressure ulcers and another with a history of falls and wandering. The care plans were outdated and lacked specific interventions, posing a risk of unmet care needs.
A resident with diabetes and other medical conditions experienced multiple episodes of low blood sugar, leading to hospitalization. The facility failed to monitor blood glucose levels properly and continued to administer insulin without notifying the physician, despite dangerously low readings. The care plan's instructions for managing diabetes were not consistently followed, contributing to the resident's deteriorating condition.
A facility failed to manage and monitor a resident's left arm splint, resulting in the resident having a soiled splint that had not been laundered. The resident, with a history of stroke and left-sided weakness, wore the splint at night. The Restorative Nurse noted that the splint was initially worn all the time but later changed to nighttime use. There was no clear responsibility for cleaning the splint, and a policy for hand splints was not provided. The care plan included assistive devices and skin checks but lacked details on splint usage and cleaning.
A resident with severe cognitive impairment and a history of combativeness sustained a laceration to the left eyebrow during a transfer using a Sara lift. The resident, who required assistance with all ADLs, exhibited aggressive behaviors earlier in the day. Despite this, the transfer was conducted by a single CENA, contrary to the care plan which did not specify the use of a mechanical lift.
A resident experienced significant weight loss due to the facility's failure to document food intake, provide suitable utensils, and notify the physician. The resident struggled with meal consumption due to impaired cognition and inadequate assistance, leading to numerous undocumented meals. Despite increased nutritional supplements, there was insufficient documentation of snack provision, and the physician was not informed of the weight loss.
The facility failed to properly clean, sanitize, and store respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. A resident's CPAP machine was found dirty and not stored correctly, while another resident's oxygen concentrator was alarming with tubing on the floor, not supplying oxygen. Additionally, a third resident was observed with oxygen tubing in place, but the concentrator was not turned on, and the tubing was not dated as required by facility policy.
A resident with end-stage renal disease and dependence on dialysis was not properly monitored for changes at the dialysis port site, leading to the initiation of antibiotics due to drainage. The facility lacked a policy for assessing and monitoring dialysis ports, and staff confirmed that dressings were changed weekly or as needed. An order to monitor the port site was only established after the issue was identified.
A survey found that three medication carts in the facility were not properly cleaned, with crushed pills, paper, and dust present in the drawers. Interviews with nursing staff revealed confusion over cleaning responsibilities, with the DON indicating that second shift nurses were responsible. This lack of clarity contributed to the unsanitary conditions observed.
The facility failed to document the reason for antibiotic use and track antibiotic use for two residents, leading to potential inappropriate use. One resident was prescribed Doxycycline without a documented diagnosis, and another was given Bactrim for prophylaxis without a clear reason. The Infection Prevention and Control Nurse noted that the electronic medical record system did not allow for adding diagnoses with orders, and the facility's Antibiotic Stewardship policy was not effectively implemented.
A resident fell in the bathroom, sustaining facial fractures and subacute bilateral subdural hematomas. The facility failed to complete a comprehensive fall investigation, notify the physician of X-ray results, and provide timely medical intervention, leading to a significant delay in treatment.
Wrong-Medication Administration to Resident With Same First Name
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to adequate care and treatment during medication administration, resulting in the resident receiving another resident’s medications. The resident, who was in the facility for therapy after falling in his kitchen and cracking his hip, reported that a nurse who was not his regular nurse entered his room in the morning and gave him a handful of 4–5 pills, including a blue pill, along with a chocolate nutritional drink and a nasal spray. The resident stated the nurse did not ask his name, he had no ID bracelet on, and he told the nurse he did not receive a nasal spray and did not like chocolate nutritional drinks. He also reported that the nurse appeared to be looking for an IV port and IV equipment in his room, which he did not have, while a male resident in the next room with the same first name did have an IV pole. The resident later went to therapy, where his regular nurse brought his usual medications, prompting him to realize he had received extra medications earlier. He reported feeling lightheaded and “high,” describing the sensation as if he had smoked multiple marijuana cigarettes, and his brother, who was with him, commented that he looked high. The resident stated he informed staff, but he did not recall all details because he felt “out of it.” The facility’s investigative report documented that the family raised concerns about a medication error, and that the resident reported receiving medications from one nurse and then again from another nurse that same morning, both calling him by his first name, though he only recognized his regular nurse. In a subsequent interview, the LPN who passed the wrong medications explained she had picked up an extra shift on a unit where she did not usually work and was assigned a specific medication cart and room range. She stated that two residents with the same first name were in side-by-side rooms and that she mistakenly administered medications intended for one resident, including an IV antibiotic order, to the other resident. She acknowledged that she went to the wrong room and gave the wrong medications to the wrong resident, and that the other resident did not receive those medications. Vital sign records for the affected resident showed documentation at 1:37 a.m. and then not again until early evening that day, with no vital signs recorded around the time of the morning medication error.
Failure to Implement One-on-One Supervision Care Plan Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement an active care plan intervention for one-on-one supervision for a cognitively impaired resident with a history of agitation and behavioral issues. Resident #103, a 79-year-old with Alzheimer’s, dementia, psychotic disturbances, agitation, and depression, had a BIMS score of 3 and required staff assistance with all ADLs. The resident’s behavioral care plan, dated 10/21/25, specified that the resident would have 1:1 staff supervision for safety, and this intervention had not been discontinued at the time of the incident. On the date of the incident, video review showed that Resident #103 left her room and entered the adjacent room of Resident #106 without being accompanied by staff, despite the active 1:1 supervision care plan. Resident #106, an 82-year-old with Alzheimer’s, dementia, Parkinson’s, schizophrenia, bipolar disorder, stroke, and agitation, also had a BIMS score of 3 and required assistance with all ADLs. According to the incident report, when Resident #103 entered Resident #106’s room, Resident #106 yelled for her to get out, and Resident #103 scratched him in the face. Video observation showed CNA C seated in the hallway next to both residents’ rooms, using her personal cell phone to text and scroll, with a portable computer positioned in a way that blocked her from the view of the nursing station. During this time, Resident #103 went into Resident #106’s room without intervention from CNA C. Interviews confirmed that Resident #103 was care planned for 1:1 supervision for safety at the time and that this intervention remained active and had not been discontinued, yet it was not being implemented when the resident-to-resident interaction and resulting scratches occurred.
Wrong-Resident Medication Administration Due to Failure to Verify Identity
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors when an LPN administered a set of medications intended for one resident to another resident with the same first name. The facility’s own "Medication Administration General Guidelines" policy required that residents be identified using a minimum of two identifiers before medication administration and that medications supplied for a specific resident not be administered to others. During the incident, the nurse did not verify the resident’s identity with two identifiers, and the resident who received the wrong medications did not have an ID bracelet on his arm at the time. The nurse entered the wrong room and provided a handful of 4–5 pills, a chocolate nutritional supplement, and a nasal spray to the resident, who reported that he does not receive a nasal spray and does not like chocolate supplements. The resident who received the wrong medications (Resident #101) had been admitted with diagnoses including prosthetic left hip joint fracture, nondisplaced subtrochanteric fracture of the left femur, abnormal gait and mobility, chronic kidney disease, benign prostatic hyperplasia, and asthma. His MDS showed he was cognitively intact with a BIMs score of 15/15, and his advance directives indicated full code status. After receiving the medications, he reported feeling lightheaded and "high," describing feeling as if he had smoked multiple marijuana cigarettes, and stated he did not recall everything that happened because he was "out of it." He later informed staff that he believed he had received extra medications that morning. Vital sign documentation for him on the day of the incident showed a blood pressure of 113/70, pulse 95, and respirations 19 in the early morning, with no further vital signs recorded until the evening. The medications administered in error to Resident #101 were identified through pharmacy review as Eliquis 5 mg (anticoagulant), Entresto 24-26 mg (antihypertensive cleared through kidneys), Jardiance 10 mg (for diabetes/heart failure, cleared through kidneys), Lopressor 50 mg (beta blocker antihypertensive), and Spironolactone 25 mg (diuretic antihypertensive cleared through kidneys). These medications belonged to another resident (Resident #102), who had multiple serious medical diagnoses including MRSA, sepsis, bacteremia, pneumonia, long-term IV Vancomycin therapy, embolism and thrombosis, cardiomyopathy, left bundle branch block, tachycardia, heart failure, hypertension, hyponatremia, dysphagia, autistic disorder, epilepsy, anemia, and anxiety disorder, and whose advance directives indicated DNR status. The LPN involved acknowledged in interview that she made a mistake by giving the wrong medications to the wrong resident with the same first name and stated that the other resident did not receive his medications. The pharmacist, when asked if this constituted a significant medication error, stated it was a subjective, simple mistake and noted that resident rights of medication administration are a nursing issue at the point of administration. The facility’s occurrence reporting policy required reporting and investigation of medication-related incidents and harmful unintended results caused by taking medications, but the report documents that the ADON became aware of the possible medication error only later that evening after staff notification.
Failure to Provide Ordered Catheter Care, Seatbelt Monitoring, and Wound Treatment
Penalty
Summary
The facility failed to provide ordered care and monitoring for multiple residents. One resident with Alzheimer’s dementia, Parkinson’s disease, frequent UTIs, a suprapubic catheter, and dependence for all ADLs was observed without ordered compression hose while the hose were hanging on the walker, and the resident’s urinary leg bag was repeatedly observed nearly full of urine with taut tubing. The resident’s family member stated staff did not regularly put on the hose or empty the leg bag, and the record showed orders for Ted hose use, catheter care every shift, and care plan instructions to empty the catheter bag and ensure the tubing was not pulling on the insertion site. Facility staff acknowledged there was no care plan for the hose and that the catheter care plan had not been followed. A second resident who used a motorized wheelchair had a seatbelt observed in place for trunk support and was able to unfasten it without assistance. The record review found no documentation of an initial evaluation, ongoing safety monitoring, or rationale for the seatbelt’s use. A nurse manager stated the wheelchair came from home and initially believed there was no evaluation or care plan, and later reported that a self-release evaluation and care plan were completed after the issue was identified. Two additional residents had incomplete assessment and treatment documentation for skin and wound issues. One resident had four pink dressings on both arms, including visible brown drainage and one dressing that was not adhering to the skin; the wound nurse later found two areas were an old puncture wound and scabbed-over skin tear, while two other areas required new treatment orders. Another resident with a right axilla abscess/boil reported that the area had burst, that dressing changes were not always completed, and that the night nurse had refused to apply a dressing because it needed air. The treatment record showed a wound care order for daily and PRN care, but one scheduled treatment was marked not completed without a documented reason, and the chart lacked physician progress notes or other documentation showing ongoing assessment of the boil between the earlier note describing yellow drainage and odor and the later note when new orders were obtained.
Infection Control: Water Management and Legionella Monitoring Deficiencies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not implement control measures to reduce the risk of legionella and other opportunistic pathogens of premise plumbing. During interview, the Facility Supervisor stated that Saginaw Township had tested chlorine a couple of times since he had been there and that testing occurred monthly or every two weeks. On another interview, he stated that the results in the water management plan binder were the most recent chlorine residual results. Record review showed the Drinking Water Quality Report for the Saginaw Region in the water management binder contained 2022 chlorine residual averages of 1.06 ppm, with a range of 0.94 to 1.17 ppm. The Water Management Plan listed responses to legionella distal site positivity of less than 30% as engineering controls, proactive clinical surveillance, and additional environmental sampling. The Legionella testing tracking sheet documented that after a positive legionella sample from a shower in one room on 7/14/25, the room was taken offline, the fixture was changed out, and flushing was increased in and around the area. A Facility Quality Assurance staff member stated they did not feel the need to track chlorine residual onsite because the Township did it, and said additional water lines were being removed and remediation was still in progress. The Legionella Environmental Assessment Form stated Saginaw Township sampled chlorine residual at the kitchen only and that the facility relied on the Saginaw County Health Department for those records.
Failure to Implement Fall Prevention Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for fall safety prevention for two residents identified as being at risk for falls, accidents, and hazards. For one resident, who had a history of falls, dementia, and was receiving hospice care, the care plan required a blue floor mat to be placed next to the bed in the low position. However, multiple observations throughout the day revealed that the floor mat was not in place as required, instead being found leaning against the wall at the end of the bed. There was also no physician's order for a floor mat, despite the care plan directive. The Director of Nursing confirmed that the floor mat should have been in place according to the care plan. For another resident with severe cognitive impairment, Alzheimer's disease, and recent decline on hospice care, the care plan required the call light to be within reach at all times and a floor mat to be placed next to the bed. Observations over several days showed the call light was consistently coiled around the grab bar, out of the resident's reach, and the resident reported calling out for help instead of using the call light. The floor mat was also found folded and pushed away from the bed on one occasion. Staff interviews confirmed that the call light and floor mat were not positioned as required by the care plan, and that residents with limited ability to use call lights should be monitored more frequently. Record reviews indicated both residents had recent falls, and the facility's fall prevention program required individualized interventions to be implemented and monitored for effectiveness. Despite these protocols, the care plan interventions for fall prevention were not consistently followed, as evidenced by the observations and staff interviews.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for two residents who developed facility-acquired pressure ulcers/injuries while in the facility. The facility-generated CMS-802 Resident Matrix dated 7/29/2025 identified both residents as high risk for pressure ulcers stage 2-4, but did not identify either resident as having a new or worsened stage 2-4 pressure ulcer. One resident had severe cognitive impairment, quadriplegia, aphasia, neurogenic bladder, and seizure disorder, and the MDS documented multiple pressure ulcers, including stage IV ulcers. During observation, staff identified additional facility-acquired wounds on the abdomen, right lateral foot, and right lateral calf, including an open stage III abdominal wound with drainage, a right lateral foot wound with black/dark tissue and eschar, and an open left lateral/back mid-calf wound with drainage. During interview, the wound care LPN stated the abdominal wounds were facility acquired and believed they started as abrasions from the abdominal binder, which had been in use since the beginning of July. The LPN stated she had just observed the mid-line abdominal wound for the first time on 7/30/2025 and could not locate documentation showing when the wound started or when dressing changes began. She also stated there should be nursing assessments to look under the abdominal binder for integrity. The resident’s PEG site was also observed with green/yellow bile drainage saturating the gauze and binder. The second resident had severe cognitive impairment, diabetes, and Alzheimer’s disease. The quarterly MDS documented a stage III pressure ulcer on the right calf that was not present on admission. During observation, the resident was lying in bed with bilateral soft protective boots in place, and the wound care LPN stated the boots could be causing pressure at the wound area. The bed was observed to tip downward at the foot, with the bend of the bed at the point of the right calf pressure area, and the LPN stated someone may have left the resident in that position too long, causing the pressure ulcer to develop. The facility’s in-house pressure ulcer form also listed multiple facility-acquired wounds for another resident, including foot wounds and unstageable abdominal wounds, and noted there was no documentation of the left mid-calf pressure ulcer to the lateral aspect of the calf.
Failure to Document and Monitor Ileostomy Leakage
Penalty
Summary
The facility failed to assess, monitor, and document continued seepage and nonadherence of one resident’s ileostomy appliance. Resident #7, who had diagnoses including rectum cancer, kidney failure, diverticulitis, malignant ascites, ileus, and depression, reported that his ileostomy was not adhering and was leaking. During observation, leakage was seen pooling on his abdomen, and he stated the area was sore. The resident also reported that the appliance had been changed that morning, but he was unsure how long it had been leaking. Record review showed an ileostomy treatment order for dressing changes every 3 days, but there was no order for as-needed changes and no documentation located in progress notes, physician notes, or wound management records regarding the ongoing leakage or appliance seal problems. Staff interviews indicated the wound nurse had been using a crusting technique with cream and powder for about a week and that the issue had been ongoing, but this was not documented. The wound nurse stated the physician was most likely not aware of the continued ileostomy issues, and the nurse manager stated he was not aware of the sealing problems until informed by staff.
Hydration and Nutrition Monitoring Deficiencies
Penalty
Summary
Hydration fluids were not kept within reach for Resident #13, who was observed actively eating and drinking by herself while sitting up in bed with her bedside table pushed in front of her. The resident was later reviewed in the electronic medical record and was documented as having diagnoses including CVA with hemiplegia, dysphagia, and dementia, with impaired cognition and requiring assistance with all ADLs. Her care plan stated that she ate meals in her room or café and required set-up and supervision assistance for meals. Nutrition status monitoring was not completed for Resident #10 despite a significant weight loss. Quarterly MDS records showed a weight of 183 pounds and later 158 pounds, reflecting a 25-pound loss in 90 days. Another weight record in the electronic medical record showed 176 pounds on 07/29/2025. The resident was observed taking all meals in her room in bed, but the record review identified the weight loss without timely identification or evaluation of the change in nutritional status. Resident #7 also had no timely nutrition monitoring and intervention despite ongoing weight loss. The resident stated the food was not good, portions were smaller on weekends, and he had lost a lot of weight since admission because he did not like the food. Record review showed diagnoses including rectum cancer, kidney failure, diverticulitis, malignant ascites, and depression, with nutrition risk noted due to acute renal failure, poor appetite, pro-cal malnutrition, weight loss over the past 3 years, and cancer. Weekly weights showed losses of 15.2 pounds in week 2 and 7.6 pounds in week 3, but there was no facility documentation related to weekly weight loss until three weeks after admission, and the care plan had not been updated since admission.
Expired Tube Feeding Solution and Improper HOB Positioning
Penalty
Summary
The facility failed to provide enteral tube feeding per nursing standards for one resident, Resident #107, who was observed receiving tube feeding through a tube connected to the abdomen. During observation, the tube feeding solution bag hanging on the pump was dated 7/28 at 0500, and Nurse X stated that the bag should have been dated the 29th. The resident was also observed with the head of the bed at 22 degrees when the facility policy required elevation of 30 to 45 degrees during feeding. Further observation and interview showed that Unit Manager T could not initially locate the bed control and, with assistance from CNA V, staff were unable to find it and stated the resident did not have a bed control, although later the resident was observed with a bed control within reach on top of the bed covers. The report also states that according to the manufacturer, Nutren 2.0 should be refrigerated and consumed within 24 hours after opening, and if not used within that timeframe, it should be discarded.
Peripheral IV Left in Place Beyond Ordered Hydration
Penalty
Summary
The facility failed to timely remove a peripheral IV for a resident whose IV hydration had been ordered as a one-time infusion. On 07/29/2025, the resident was observed in his room with a peripheral IV in his right forearm, and he stated it had not been used in over a week. The IV dressing was not dated or initialed. When the Nurse Manager observed the IV later that day, he believed it was for IV hydration, and the resident’s wife stated the resident had received IV hydration the prior week and was supposed to have follow-up lab work, but she was not certain whether it had occurred. Record review showed the resident was admitted with diagnoses including sepsis, acute kidney failure, dementia, venous insufficiency, hyperlipidemia, hypertension, and anxiety. On 07/24/2025, the physician was notified of lab results, Bumex was discontinued, and one liter of normal saline was ordered to infuse at 80 cc/hour; the resident’s wife was present when the 22-gauge PIV was inserted that evening. The MAR documented the sodium chloride 0.9% order as a one-time infusion initiated on 07/24/2025. On 07/31/2025, the Nurse Manager stated it would have been the nurse’s responsibility to obtain information from the physician about when the IV should be removed. The resident’s IV remained in place for an additional five days without assessment, monitoring, or a timeframe for removal.
Kitchen Food Safety and Dishwashing Temperature Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the kitchen during observation, interview, and record review. On a kitchen tour with the Regional Director of Operations and the General Manager, the high-temp dishwasher log showed rinse temperatures ranging from 154 to 193 degrees Fahrenheit even though the document listed 180 degrees Fahrenheit as the required rinse temperature. The dishwasher was also observed with temperatures of 184 degrees Fahrenheit final, 164 degrees Fahrenheit wash, 161 degrees Fahrenheit rinse, and 173 degrees Fahrenheit dual rinse. Later, the dishwasher was observed at 154 degrees Fahrenheit and 157.8 degrees Fahrenheit with dishware being used on the tray line, and the General Manager stated that dish surface temperatures were not ever taken. Additional observations showed a visibly soiled mixer with residue, and the Regional Director of Operations stated it should be cleaned every day. A refrigerator in the Gardens hallway behind the nurses' desk was observed at 46 degrees Fahrenheit by the thermometer inside the unit, while the smart thermostat read 37 degrees Fahrenheit; the General Manager stated the smart thermostat was the temperature recorded on the log and said the thermometer inside the refrigerator was never checked. The facility's dishwasher temp log instructions stated that surface temperature should reach 180 degrees Fahrenheit using a thermo-label or digital waterproof thermometer, and the General Manager later presented a black test strip showing dish surface reached 160 degrees Fahrenheit. Record review also cited Food Code requirements for hot and cold holding and for cleaning food-contact surfaces and utensils.
Inadequate Post-Fall Assistance for Resident
Penalty
Summary
The facility failed to provide adequate post-fall assistance to a resident, resulting in feelings of sadness and tearfulness. The resident, who is non-verbal and has a history of aphasia, cerebral infarction, anxiety, and depression, was found sitting on a floor mat next to the bed after an unwitnessed fall. The incident occurred when a CNA observed the resident on the floor but chose to attend to another resident across the hall who was upset, leaving the resident unattended. The CNA closed the door to the resident's room to diffuse the situation between the resident and the other upset resident, which led to the resident's son entering the room and becoming angry upon finding his mother on the floor. Interviews with staff revealed that the LPN was in a nearby room and was alerted by yelling, while the CNA who initially found the resident on the floor did not stay with the resident or seek immediate help. Another CNA, who was the primary caregiver, was under the impression that the first CNA would stay with the resident. The Director of Nursing stated that the expectation is for staff to call for help and leave the resident in the position they were found until a nurse arrives. The lack of immediate assistance and communication among staff contributed to the deficiency in care provided to the resident after the fall.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise and prevent a fall for a resident with a known history of falls and anticoagulant use, resulting in a fatal incident. The resident, who was admitted to the facility from an assisted living environment, had a documented history of falls and was on medications with blood-thinning effects, such as Plavix and aspirin. Upon admission, the resident was assessed as a high fall risk due to factors including confusion, impulsivity, and the need for assistance with mobility. On the day of admission, the resident experienced two falls within a short period. The first fall occurred when the resident attempted to pick up spilled items from the floor, resulting in no visible injury. Despite being identified as a high fall risk, the resident was placed in a wheelchair and moved to the dining/day room due to restlessness. The second fall happened in this area, where the resident fell from the wheelchair, sustaining a significant head injury, including a large hematoma and bleeding. The staff's response to the resident's condition was inadequate, as there was a lack of consistent monitoring and documentation of neuro checks following the falls. The resident's condition deteriorated, leading to hospitalization and subsequent death due to complications from the head injury. Interviews with staff revealed a lack of clear communication and understanding of the resident's needs, contributing to the failure to prevent the falls and provide appropriate supervision.
Failure to Provide Timely Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with a pressure ulcer, leading to severe complications. The resident, who had multiple medical conditions including diabetes, a history of stroke, and a tracheostomy, developed a pressure ulcer on the coccyx that worsened over time. Despite being at high risk for pressure ulcers, the facility did not adequately monitor or report the deterioration of the wound to the physician, resulting in the resident developing sepsis and requiring hospital admission. The facility's records indicate that the resident's pressure ulcer was first identified as a stage II wound, which later became unstageable with necrotic tissue and slough. Nursing notes documented the worsening condition of the wound, including increased size, foul odor, and bleeding, yet there was no evidence of timely communication with the physician or initiation of antibiotic treatment. The resident's condition continued to decline, with signs of infection such as fever and elevated heart rate, until they were eventually transferred to the hospital. Interviews with facility staff revealed a lack of appropriate action and communication regarding the resident's condition. The RN acknowledged a delay in treatment and failure to assess the situation adequately. The Infection Control Nurse and the Wound Nurse both admitted that they did not contact the physician despite the worsening condition of the pressure ulcer. The Director of Nursing and Assistant Director of Nursing recognized the issue as a significant problem, indicating a systemic failure in the facility's response to the resident's needs.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in two residents, resulting in discomfort and the need for ongoing wound care. Resident #415, who was admitted with multiple health issues including dementia and chronic pain, developed a pressure ulcer on the right heel due to shearing from bedding. Despite the wound care being performed according to orders, no pressure-relieving devices were used to keep the heel off the bed, which was a contributing factor to the ulcer's development. The facility's policy required the use of such devices, but this was not adhered to, as observed during the dressing change. Resident #75, admitted with conditions such as sepsis and rheumatoid arthritis, developed a pressure ulcer on the right heel due to friction from an ankle-foot orthosis (AFO) brace. Although the resident was provided with an air mattress and pillows to elevate the feet, there was no initial physician's order to monitor the skin around the AFO. The wound care nurse confirmed that an order should have been in place upon admission, but it was only entered after the issue was highlighted during the survey. The facility's policy on pressure ulcer prevention and treatment emphasizes the need to protect against pressure, friction, and shear, and to open a care plan for residents at risk. However, the lack of timely interventions and monitoring for both residents led to the development of pressure ulcers, indicating a failure to adhere to the established standards of care.
Inaccessible Survey Results and Contact Information
Penalty
Summary
The facility failed to ensure that previous survey results, State Hotline, and Ombudsman contact information were accessible to all residents. During a Resident Council meeting, members expressed their inability to locate the survey results and contact information for the Ombudsman and State Hotline. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those who could not travel the .11 miles/580 feet from the 500 hallway/nursing unit to the lobby. Additionally, the contact information for the State Hotline and Ombudsman was placed at a height and in a format that was not accessible to residents in wheelchairs, as it was positioned approximately 5 feet high and not in large print. Interviews with the Director of Nursing (DON) and Activity Director (AD) confirmed the location of the survey results binder and the accessibility issues. The DON stated that the binder was visible to anyone entering through the front door, but did not acknowledge the distance issue. The AD noted that some residents were independent with their wheelchairs, but did not address the accessibility for all residents. An observation with the AD revealed that the contact information was not easily visible or readable for residents in wheelchairs, further contributing to the residents' complaints about not knowing how to contact the Ombudsman or access the State Hotline number.
Inaccessible Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting was accessible for all residents, which could lead to residents being uninformed about the available staff. On a specific day, the staff posting was located at the front desk, which was .11 miles or 580 feet away from the main corridor hallway of the 500 nursing unit. The Director of Nursing confirmed that the staff posting at the front desk was for the entire building and that individual nursing units did not have their own postings. Central Staffing personnel indicated that they fill out the staff posting and email it to the switchboard operator daily. The switchboard operator then prints the posting and places it in a plastic file folder on the front counter, without posting it elsewhere in the building.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Arbor Cafe's kitchen, which serves a census of 162 residents. During an inspection, several deficiencies were observed, including a large trash bin without a lid next to the grill, a microwave with dried food particles, and a large can opener with dried food and chipping paint. Additionally, a clean pan was found wet inside another pan, and a large trash bin was open behind baked cookies. The freezer floor had small pieces of food and papers, and various food items in the cooler and freezer were found without dates, including shrimp, crackers, roast beef, and jelly. Further observations revealed that a large white plastic container of corn starch had an excessive amount of corn starch on top and no dates, while the brown sugar container was expired. The toaster had an excessive amount of crumbs, and a large tray of uncovered fruit with no dates was found in the back refrigerator. In the dry storage room, an opened bag of noodles was found without dates. These findings indicate a failure to adhere to the facility's Food Storage policy and the 2017 FDA Food Code, which requires equipment food-contact surfaces and utensils to be cleaned when contamination may have occurred.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across multiple units, including Wheels, Patriot, and Garden. During an environmental tour, several deficiencies were observed, such as a dirty CPAP machine and tubing not stored properly in a clear plastic bag, and an oxygen nasal cannula found on the floor. In the day room, a water/ice machine had calcium build-up, and opened food items without dates were found in the freezer. Additionally, a resident's refrigerator contained undated and partly used ice cream. The Director of Nursing indicated that dietary staff were responsible for cleaning neighborhood refrigerators. Further observations in the Patriot Neighborhood revealed towels and razors improperly stored, a dirty shower room floor, and a fan with dust-covered blades. Undated meat, cheese, and fish were found in a resident's refrigerator, and temperature logs were incomplete. In the day room, dirty brooms and a dustpan were left near confused residents. Similar issues were noted in the Garden Neighborhood and the Activity room, where undated food items were stored in refrigerators. The Director of Maintenance acknowledged that resident room refrigerators should be checked before use, but this was not done. The facility's environmental services job description emphasized maintaining clean and sanitary facilities, which was not upheld.
Failure to Address Resident Grievances and Exclusion from Meetings
Penalty
Summary
The facility failed to ensure timely follow-up on grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration among residents. During a Resident Council meeting, residents expressed dissatisfaction with the facility's response to their complaints, particularly regarding staff behavior. They reported that staff were loud in the hallways, responded rudely to call lights, and often did not return after canceling them. Residents also mentioned issues such as being left in soiled conditions, being forced to go to bed early due to staffing shortages, and missing church services for the same reason. A private interview with a Resident Council member revealed that they were not informed about a meeting with the state and felt deliberately excluded. The member expressed that they were often left out of meetings and believed it was because they were vocal about their concerns. The facility's records showed that several complaints raised in Resident Council meetings over the months were not documented or addressed, including issues with staff loudness, inadequate response to call lights, and concerns about staff training and shortages. The review of grievances over the past year indicated that the most recent concern form was from May 2024, which highlighted issues with call light response times and staff friendliness. However, the facility's response did not address the call light concern adequately. When questioned, the Director of Nursing was unaware of who was responsible for following up on council grievances, indicating a lack of accountability and oversight in addressing resident concerns.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and cluttered conditions in various rooms and common areas. During a tour, surveyors noted a urine-soaked wash rag on the floor, strong odors of urine, and soiled clothes improperly stored under sinks, which posed infection control issues. Additionally, several rooms had visible dirt, food debris, and residue on shower curtains and caulking, along with missing drywall and laminate chips, contributing to an unkempt environment. The presence of pests, specifically spiders and webs, was observed in multiple areas, including resident rooms, the media center, and the main dining room. These areas also had piles of dead insects, and staff acknowledged the presence of spiders. The Environmental Services Director attributed the presence of silverfish to external factors but did not address the immediate pest control needs. The Director of Nursing was informed of the pest issue but did not take immediate action to resolve it. Residents expressed dissatisfaction with the dining experience, specifically the use of plastic silverware, which hindered their ability to eat meals comfortably. During resident council meetings, complaints were made about the lack of proper silverware and condiments, with residents having to use plastic utensils to cut through tough food items. Staff confirmed these issues, and the Hospitality Director acknowledged that new silverware had been ordered but did not explain why it was not yet in use, leading to ongoing resident dissatisfaction.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for several residents, resulting in various hygiene issues. Resident #135, who is non-verbal and has dementia, was observed with facial hair and dirty nails on multiple occasions. The care plan for this resident indicated that they should receive weekly nail care and assistance with shaving, but these needs were not met. An activity aide confirmed that certified nursing assistants (CNAs) are responsible for these tasks and acknowledged ongoing issues with nail care and shaving, which had been previously reported to the infection control nurse. Resident #59, who has full cognitive abilities but requires assistance with all care, reported that her call light was not answered timely, sometimes taking up to five hours for assistance. The resident's room had a strong smell of urine, and she mentioned that her blankets were not changed frequently enough. Her care plan included interventions for urinary tract infection prevention and assistance with toileting every two hours, which were not adequately provided. Resident #117, with severe cognitive deficits, was observed with unbrushed teeth despite having supplies brought in by a family member. The care plan indicated that the resident should receive assistance with oral care, which was not being provided. Additionally, Resident #60 and Resident #62 were observed with long, dirty nails and facial hair, respectively, despite care plans specifying regular nail care and assistance with facial hair removal. These observations highlight a pattern of neglect in providing essential ADL care to dependent residents.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. Resident #23 expressed dissatisfaction with the facility's food, citing issues such as excessive pepper, tough baked chicken, and overcooked zucchini. The resident also mentioned a lack of responsiveness to concerns since a previous chef left the facility. Resident #26 reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. The resident also noted a lack of menu options and inconsistent meal preparation. Resident #42 complained about overly spicy food and inadequate breakfast options, including dry toast without butter or jelly, despite being on a renal/carb consistent diet that allowed for sausage. The Registered Dietitian (RD) confirmed the resident's diet should have included sausage but was unsure why it was not provided. Resident #79 expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The RD acknowledged the resident's carb-consistent diet but had not followed up on her concerns due to being new to the facility. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards. The Director of Hospitality and the RD were aware of the issues but had not effectively addressed them, partly due to recent staffing changes. The lack of a Certified Dietary Manager and the newness of the RDs may have contributed to the oversight in addressing residents' dietary preferences and needs.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks, including bedtime snacks, for a group of residents, leading to complaints about the lack of availability and variety of snacks. Residents, including those with diabetes, expressed dissatisfaction with the limited snack options, such as the absence of healthy snacks like applesauce, peanut butter, fruit, or cheese. They reported having to rely on family and friends to bring in snacks, which caused feelings of frustration, sadness, and hunger. The residents also mentioned that the unit refrigerators were often empty, and there was no personal choice of snacks available. During observations and interviews, it was noted that the facility's snack provisions were inadequate. The Hospitality Director confirmed that residents could only access certain snacks without charge if they were included on their meal trays, otherwise, they would incur a cost. The floor stock list and always available menu were reviewed, revealing limited options such as turkey sandwiches and a lack of fresh fruit or other desired items. Observations of the Americana and Patriot cafes showed minimal snack availability, with one yogurt brought in by a family member and a sign indicating 'STAFF ONLY' access, further highlighting the deficiency in snack provision for residents.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to Infection Prevention and Control standards, specifically in the use of Personal Protective Equipment (PPE), hand hygiene, and linen transport. On multiple occasions, staff members were observed not following proper protocols. For instance, a Certified Nursing Assistant (CENA) was seen assisting a resident with incontinence care and then offering a drink without removing dirty gloves or performing hand hygiene. Another CENA was observed leaving a resident's room without doffing PPE or performing hand hygiene before entering another room, and then returning to the original room with the same PPE. Additionally, issues were noted with the transport of clean linen. Staff members were seen carrying clean linen against their uniforms without using a barrier, which is against standard practice. Furthermore, another CENA entered a resident's room to assist with bed mobility and perineal skin observation without performing hand hygiene upon entry and improperly handled gloves by pulling them from their pocket without ensuring cleanliness. These actions demonstrate a lack of adherence to infection control protocols, potentially increasing the risk of infection spread among residents.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of its residents, as evidenced by several observations and interviews. Resident #56 was found exposed in their room without adequate privacy measures in place, as a nurse entered the room without ensuring the resident's body was covered. This lack of privacy was a direct violation of the resident's right to a dignified existence. Additionally, the facility did not provide timely and polite assistance to residents, as noted in the case of Resident #6, who expressed dissatisfaction with the delay in being assisted out of bed, and Resident #11, who reported that their call light was not within reach, leading to delays in receiving necessary help. The facility also failed to ensure proper grooming and personal hygiene for its residents. Observations revealed that female residents, such as Resident #135 and Resident #136, were not shaven, despite care plans indicating the need for assistance with facial hair. This neglect in personal grooming contributed to a lack of dignity and respect for the residents. Furthermore, Resident #28 was observed with unkempt hair and facial hair, indicating a failure to provide adequate grooming assistance as outlined in their care plan. The facility's response time to call lights was consistently delayed, as evidenced by the call light timing reports, which showed a significant percentage of call lights taking longer than the acceptable 15-minute response time. This delay in response was corroborated by the Resident Council meeting, where residents expressed frustration over the staff's failure to respond promptly to their needs. The combination of these deficiencies resulted in an environment where residents felt neglected and disrespected, leading to verbalizations of concern and anger, as well as feelings of shame and isolation.
Failure to Incorporate PASARR Recommendations for Specialized Mental Health Services
Penalty
Summary
The facility failed to incorporate recommendations for specialized mental health services from a Preadmission Screening and Annual Resident Review (PASARR) Level II assessment into the care plans of two residents. Resident #26, who was admitted with diagnoses including bipolar disorder and depression, had a PASARR Level II evaluation indicating the need for specialized mental health services. However, the resident's care plan did not include any mention of these specialized services, despite the resident having full cognitive abilities and requiring assistance with all care. Similarly, Resident #59, admitted with diagnoses such as bipolar disorder and a history of suicidal thoughts, also had a PASARR Level II evaluation recommending specialized mental health services. The care plan for this resident lacked any reference to a specialized mental health plan, even though the resident was on antidepressant and antipsychotic medications and had full cognitive abilities. Interviews with the facility's social worker revealed a lack of communication and follow-up with the Community Mental Health agency regarding the specialized mental health plans for both residents. The facility's policy on coordinating assessments with the PASARR program was not adhered to, resulting in the absence of specialized mental health services in the residents' care plans.
Failure to Update Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing care needs of three residents, leading to potential unmet care needs. Resident #16, who has a history of brain injury, quadriplegia, and multiple pressure ulcers, was observed with severe cognitive decline and dependency on all care. Despite having chronic and new wounds, the care plans for Resident #16 were outdated and did not include specific interventions identified by the wound nurse, such as the use of a low air loss mattress and heel boots. The care plans had not been updated to reflect the current wound status and necessary interventions. Resident #117, diagnosed with Alzheimer's disease and a history of falls, experienced multiple falls within the facility. The resident was found on the floor in other residents' rooms on several occasions, indicating a pattern of wandering. The fall care plan for Resident #117 was outdated and did not include interventions to address the resident's wandering behavior or the use of proper footwear, as recommended by the facility. The Assistant Director of Nursing noted that staff were to monitor the resident and perform frequent room checks, but these interventions were not documented in the care plan. The deficiencies in updating care plans for both residents highlight a lack of timely revision and inclusion of specific interventions to address their current needs. The failure to update care plans with relevant and individualized interventions poses a risk of unmet care needs and potential harm to the residents. The facility's oversight in maintaining accurate and current care plans for residents with complex medical conditions and behavioral issues is a significant concern.
Failure to Monitor and Treat Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor and treat blood glucose levels for a resident, leading to a significant change in the resident's condition and subsequent hospitalization. The resident, who had a history of diabetes, end-stage kidney disease, and other medical conditions, experienced multiple episodes of low blood sugar over a period of several days. Despite these episodes, insulin was administered without proper documentation of blood glucose levels or physician notification, contributing to the resident's deteriorating condition. The resident's medical records revealed that insulin was given even after low blood sugar levels were recorded, and there were instances where blood glucose levels were not documented before insulin administration. On several occasions, the resident's blood sugar dropped to dangerously low levels, requiring the administration of glucagon, a medication used to treat severe hypoglycemia. The facility's staff failed to notify the physician of these repeated low blood sugar episodes, preventing timely medical intervention and assessment. The facility's care plan for the resident included specific instructions for managing diabetes, such as holding insulin if blood sugar was below a certain threshold and notifying the primary care provider if blood glucose was critically low. However, these interventions were not consistently followed, as evidenced by the lack of physician notification and continued insulin administration despite low blood sugar readings. The facility's policy on resident change in condition emphasized the importance of contacting the physician when a resident's condition changes, but this protocol was not adhered to in this case.
Failure to Maintain Cleanliness of Resident's Splint
Penalty
Summary
The facility failed to ensure proper management and monitoring of a left arm splint for a resident, resulting in the resident having a soiled hand splint that had not been laundered. The resident, who was admitted with multiple diagnoses including dementia, stroke history, and left-sided weakness, was observed with a very soiled splint that he wore at night. The resident confirmed that he did not have a second splint and was unsure if the existing one had ever been washed. The Restorative Nurse indicated that the resident was initially wearing the splint all the time, but it was later changed to nighttime use only. The nurse acknowledged that there should be an order for the splint and that nurses were responsible for assisting the resident with it. However, there was no clear responsibility for ensuring the splint was cleaned, and a policy for hand splints was not provided. The resident's care plan included the use of assistive devices and skin checks, but did not specify when the splint should be worn or cleaned.
Resident Safety Compromised During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident with severely impaired cognition and a history of combativeness, resulting in an accident that caused a laceration to the resident's left eyebrow. The resident, who had diagnoses including Dementia, Parkinson's Disease, and Alzheimer's, required assistance with all Activities of Daily Living (ADLs) and had documented behaviors of swinging and kicking at staff. On the day of the incident, the resident was involved in two separate events where they exhibited aggressive behaviors. At 11:30 AM, the resident was found on the floor and was combative when staff attempted to assist them. Later, at 1:00 PM, while being transferred from the bathroom to bed using a Sara lift, the resident hit their left eyebrow against the lift due to continued aggressive behavior. The Assistant Director of Nursing (ADON) confirmed that the resident was a one-person assist for transfers and ADL care, and the care plan did not mention the use of a Sara lift. However, the resident was assisted with the lift by just one Certified Nursing Assistant (CENA) despite having exhibited aggressive behaviors earlier that day. The ADON acknowledged the resident's behaviors and the recent changes in psychotropic medication but did not provide clarity on why the mechanical lift was used with only one staff member present, especially given the resident's recent behavioral history.
Failure to Document and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately document food acceptance, provide suitable utensils, and assess, monitor, and notify the physician of a significant weight loss for a resident. Observations revealed that the resident's meals were often left untouched, and there was a lack of staff assistance during meal times. The resident struggled with using the provided utensils, which were sometimes plastic, and had difficulty consuming meals independently. Despite the resident's impaired cognition and need for setup or clean-up assistance, there was no documented effort to assist the resident during meals, leading to numerous undocumented meal consumptions. The resident experienced a significant weight loss of 5.08% over a month, with a steady decline in weight from 205.6 pounds to 187 pounds over several weeks. The nutrition progress notes indicated that the resident's appetite had declined since admission, and there was inconsistent documentation of meal and snack consumption. The dietary staff increased nutritional supplements but failed to document the provision of snacks adequately. Additionally, there was no documented notification to the physician regarding the resident's significant weight loss, and the physician was unaware of the issue during a visit.
Improper Management of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning, sanitization, and storage of respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. Resident #624's CPAP machine was found dirty and not stored in its designated bag, despite physician orders requiring daily cleaning. Additionally, there was no care plan addressing the resident's CPAP or apnea needs. Resident #60's oxygen concentrator was alarming, and the oxygen tubing was on the floor, not supplying oxygen to the resident, indicating a lack of proper equipment management. Resident #2 was observed with oxygen tubing in place, but the oxygen concentrator was not turned on, leaving the resident without supplemental oxygen for an extended period. The tubing was also not dated, contrary to facility policy requiring weekly changes and labeling. The Director of Nursing confirmed the requirement for labeling and dating the tubing, highlighting a lapse in adherence to the facility's oxygen delivery system policy.
Failure to Monitor Dialysis Port Leads to Antibiotic Use
Penalty
Summary
The facility failed to assess and monitor the dialysis port for a resident, resulting in the resident starting on antibiotics. The resident, who is of advanced age, was admitted with diagnoses including end-stage renal disease, hypertensive chronic kidney disease, heart failure, and dependence on renal dialysis. Observations revealed a dressing on the resident's upper right chest where the dialysis port is located, but there was no physician order to assess and monitor the dialysis port for any changes. The resident was receiving antibiotics at the dialysis center, but was unsure of the reason. Further record review showed that the resident had been started on Vancomycin on a previous date due to drainage noted at the dialysis port site. An order to monitor the port site for signs or symptoms of infection every shift was only dated after the issue was identified. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility did not have a policy for assessing and monitoring dialysis port sites or shunts, and that dressings were changed every seven days or as needed, unless altered at dialysis.
Medication Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and organization of medication carts, as observed during a survey. Three out of eight medication carts were found to contain crushed pills, pieces of loose paper, silver shards of foil from medication cartridges, and dust at the bottom of the drawers. This was observed during multiple inspections of the medication carts on different days, with the presence of these contaminants indicating a lack of proper cleaning and maintenance. The deficiency was noted in the medication carts located in the Patriot and Wheels units, specifically affecting the second, third, and fourth drawers of the carts. Interviews with nursing staff revealed a lack of clarity regarding the responsibility for cleaning the medication carts. Nurses RN I, LPN J, and RN K each stated that they had cleaned the carts during their previous shifts but were unsure who was responsible for regular cleaning. The Director of Nursing indicated that second shift nurses were supposed to clean the medication carts, suggesting a possible communication breakdown or lack of adherence to cleaning protocols. This lack of clear responsibility and oversight contributed to the unsanitary conditions observed in the medication carts, posing a risk of cross-contamination and potential medication errors.
Failure to Document Antibiotic Use and Indications
Penalty
Summary
The facility failed to ensure that antibiotic orders for two residents included the reason for use and that antibiotic use was tracked, leading to potential inappropriate antibiotic use. Resident #23, who had a history of stroke, epilepsy, and hypertension, was prescribed Doxycycline without a documented diagnosis or indication for its use. The physician's notes and the Infection Control Log did not provide any information on why the antibiotic was prescribed, and the resident was not listed as having an infection or receiving antibiotics in the relevant months. Similarly, Resident #79, with diagnoses including diabetes, morbid obesity, and a stage 4 sacral pressure ulcer, was prescribed Bactrim for prophylaxis without a clear reason documented in the physician's orders. Although there was a note about recurrent UTIs, this was not reflected in the orders, and the progress notes did not mention the antibiotic. The Infection Prevention and Control Nurse acknowledged the lack of documentation for the antibiotic use during an interview, stating that the electronic medical record system did not allow for adding diagnoses with the orders. The facility's Antibiotic Stewardship policy, which aims to promote appropriate antibiotic use and reduce adverse events, was not effectively implemented, as evidenced by the lack of documented indications for antibiotic orders. The report highlights the facility's failure to adhere to its own policy and the CDC's guidelines on antibiotic use, which could contribute to antibiotic resistance and other adverse effects.
Failure to Complete Comprehensive Fall Investigation and Notify Physician
Penalty
Summary
The facility failed to complete a comprehensive fall investigation and notify a physician of X-ray results for a resident, resulting in significant delays in medical treatment. The resident fell in the bathroom, hitting his face on the floor, and sustained a nasal bone fracture and a fracture on the left side of the maxilla. Despite these injuries, the facility did not send the resident to the hospital immediately, nor did they order imaging until the following day. The X-ray results, which recommended a CT scan, were not communicated to the physician for seven days, during which the resident developed subacute bilateral subdural hematomas. The facility's documentation surrounding the incident was incomplete and inconsistent. The fall event report lacked critical details, including the identity and statements of the CNA and nurses involved, the resident's statement, and the specifics of the X-ray order and results. Additionally, several sections of the fall event report were left incomplete, such as pain observation, neurological checks, and possible contributing factors. This lack of thorough documentation contributed to the delay in appropriate medical intervention. Interviews with facility staff and family members revealed discrepancies in the accounts of the fall and subsequent actions taken. The CNA involved in the incident initially left the resident alone in the bathroom, contrary to the care plan that required one assistance for toileting. The facility's failure to notify the physician promptly and the lack of clear and consistent documentation led to a significant delay in the resident receiving necessary medical evaluation and treatment for his injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 208 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 Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covenant Skilled Nursing And Rehabilitation At Wel | 1 mi | ★★★★★ | 15 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 2.4 mi | ★★★★★ | 26 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 3 mi | ★★★★★ | 8 | 0 |
| Great Lakes Rehabilitation Center | 3.1 mi | ★★★★★ | 24 | 0 |
| Adira Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 13 | 0 |
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