Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hoyt Nursing & Rehab Centre during CMS and state inspections, most recent first.
Food Service Sanitation and Temperature Control Deficiencies: A dirty fan was blowing dust toward clean plates and wrapped silverware, a yellow discoloration was observed inside the ice machine, and a utility sink setup with an attached hose and chemical feeder was seen in the janitor's closet. During meal service, flies were observed around the steam table and serving area, the wiping cloth sanitizer bucket tested below the required QAC range, and milk was found at 55 F, above the required cold-holding temperature.
Improper storage of oxygen and respiratory equipment was observed for multiple residents with respiratory needs. A full O2 tank was left unsecured in a room, CPAP mask and tubing were found sitting out on a dresser instead of being stored in a clear bag, and a nebulizer mask and NC were left positioned above a resident’s head while the O2 concentrator was on and delivering oxygen. The DON acknowledged the unsafe and inappropriate storage/setup and referenced facility expectations for securing cylinders and storing tubing and masks when not in use.
Narcotic count and disposal deficiencies were identified when a resident was observed with a used fentanyl patch left on an overbed table, and medication cart reviews found inaccurate narcotic reconciliation, missing signatures, and unidentified loose half tablets in a narcotic drawer. An LPN signed a count sheet despite the count not matching the actual number of narcotic containers, another LPN did not sign after stating the count was completed, and the DON could not explain the discrepancies.
Medication storage and labeling were not followed in two medication carts. Surveyors found open and undated ProStat, insulin pens without resident names or identifiers, and other opened items that required dating after opening, including Budesonide inhalation suspension and blood glucose control solution. An LPN was unsure of the labeling requirements, and the DON stated that insulin pens should be labeled with the resident's name and that the unlabeled items were unacceptable.
A facility failed to maintain resident dignity by not answering call lights in a timely manner and by not consistently providing bedtime snacks. Multiple residents reported waits of about an hour or more, some said staff never came, and one confused resident could not reach the call light while in bed. Resident council complaints also described missed snacks at night, with residents saying the snack area was not stocked or accessible, leading to embarrassment, frustration, incontinence, and hunger.
Advance directive and code status documentation were not properly executed for a resident with dementia, subdural hemorrhage, subarachnoid hemorrhage, and anxiety who was documented as cognitively intact. The EMR showed a DNR form signed by the resident’s family member witness, even though there was no incompetency determination and the SSD and DON both confirmed the witness should not have signed the form.
A resident with unspecified dementia, no documented behaviors, and no psychiatric diagnosis in the EMR was receiving Seroquel 25 mg at bedtime. The MAR listed dementia without behavioral disturbance as the reason for use, but the MDS showed no psychosis, depression, or behaviors, and staff confirmed dementia without behaviors was not an indication for Seroquel. The record also lacked documented target behaviors and daily monitoring for psychotropic side effects.
A resident with dementia, confusion, and a recent femur fracture had a falls/safety care plan that included a non-slip chair mat, but staff removed the mat because it was wrinkling and the resident did not like it. The resident later fell from the chair and fractured the opposite upper leg, requiring surgery. The DON was unaware the chair pad had been removed, and the chair was later observed with only an incontinent pad on the seat and no gripper pad.
A resident with a gastrostomy, dysphagia, stroke, extensive ADL dependence, and moderately impaired cognition was observed receiving tube feeding while the HOB was only about 20-25 degrees elevated, below the physician’s order for 30-45 degrees during feeding and for 30-40 minutes afterward. An RN then raised the HOB to the appropriate level.
Failure to implement updated pain management interventions for a resident with chronic pain. The resident, who had COPD, chronic viral hepatitis C, spinal stenosis, and OA, reported ongoing back, leg, and arm pain that was only partially relieved by medication. EMR review showed repeated complaints of wrist and arm pain, physician documentation that Neurontin would be increased, and discussion of a brace for the right hand, but the MAR and orders showed no corresponding changes. An LPN confirmed no recent pain med changes or brace order, and the DON stated the updates had not been caught in note review.
A resident with dementia, confusion, and a history of falls did not have a person-centered care plan for dementia. Record review showed diagnoses including dementia, subdural hemorrhage, subarachnoid hemorrhage, and anxiety, while staff noted the resident was mostly directable and not fighting care. Social services staff confirmed the dementia diagnosis and said the resident should have a dementia care plan, but no explanation was provided for the missing individualized interventions, and the DON was unaware the care plan was absent.
Improper Dumpster Area Maintenance: The facility failed to keep the dumpster area free of unnecessary items. During an environmental tour, dirty cups, a plate, napkins, wrappers, gloves, and a plastic lid were observed on the ground around the dumpster area, while the Maintenance Director stated that housekeeping checks the area daily.
Infection control data for February 2026 was not fully completed, with multiple blank items on the Monthly Infection Control Analysis, including antibiotic use, vaccination data, respiratory and skin infection interpretation, other infection data, process surveillance, and trend/action plan sections. Staff were also observed carrying clean linen uncovered against their uniforms and entering a room with EBP precautions while a resident with an indwelling urinary catheter had the drainage bag on the floor and later attached to a wheelchair with taut tubing; the DON confirmed the bag should not touch the floor and no related care plan was in place.
A resident with a history of falls, gait impairment, and a right femur fracture was not included in quarterly care conferences, and his representative was not invited or informed about meetings. The resident and representative both reported ongoing pain after a fall, repeated x-rays that did not identify the fracture, and no staff discussion of a care plan despite the resident later going to the hospital, where the fracture was found and surgery was done. The DON confirmed the last care conference appeared to be months earlier and that quarterly conferences with guardian participation were expected.
The facility did not update its emergency preparedness policy after upgrading its backup generator, leaving staff with outdated instructions to use extension cords and red outlets for backup power, which no longer reflected the facility's current emergency power capabilities.
A remote annunciator for the emergency generator was installed in the back building electrical room, rather than in a location readily observed by operating personnel. This placement could result in generator alarms and conditions going unnoticed by staff, as confirmed by observation and interview with the maintenance director.
Exit and directional signs were not properly displayed or configured, with the emergency exit sign outside the Saginaw Room Dining space set up incorrectly. This left the North side of the facility without an emergency exit from resident spaces, and the exit configuration did not match the emergency placards in the corridors. These issues were confirmed by the maintenance director during the survey.
Surveyors found that a shower room door across from the 100 nurse station was an open grate type, which would allow smoke, heat, and fire to pass into the emergency egress corridor. This was confirmed by the maintenance director during the inspection, indicating non-compliance with smoke resistance requirements for corridor doors.
A resident with severe physical disabilities and cognitive impairment was physically assaulted by a new roommate with a history of aggression, resulting in a black eye and facial contusions. The incident occurred after a room transfer decision made by the IDT without proper assessment of compatibility or family notification, and in the absence of a formal bed transfer or supervision policy. The abuse was not witnessed by staff and was only discovered during routine care.
A resident with a history of sepsis and multiple chronic conditions experienced an elevated temperature and pulse, which were reported to a nurse by a CNA. The nurse failed to perform an assessment, document the change, or notify a physician for over four hours, only administering Tylenol later in the day. The resident was subsequently found unresponsive and died, with staff interviews and records confirming that required protocols for assessment and escalation were not followed.
A resident with severe cognitive impairment and a legal guardian was assigned a new roommate without prior notification to the responsible party, as required. After the roommate change, the resident was found with a black eye and facial bruising, and reported that the new roommate had made contact with his eye. The facility administrator confirmed that the responsible party was not notified before the change, and there was no specific policy in place for such notifications.
The facility failed to obtain informed consent for psychotropic medications for four residents, as required by their policy. The deficiency was identified through record reviews and interviews, revealing that psychotropic medications were administered without documented consents. The social work designee admitted to relying on verbal agreements instead of written consents, and the Social Services Director confirmed the lack of adherence to the facility's procedure for obtaining consents. This resulted in the administration of psychotropic medications without the necessary informed consents.
A resident with a Stage 2 pressure injury on the coccyx was readmitted with the wound progressed to Stage 3. The facility failed to follow its wound management policy by missing a weekly assessment and photograph of the wound. The DON acknowledged the oversight, stating that while treatment was given, the required documentation was not completed.
A resident admitted with multiple diagnoses did not receive necessary hydration for five days due to the facility's failure to input hospital discharge orders for free water flushes. The omission occurred because the order was in a separate document, which was overlooked. Interviews revealed that the admitting nurse should have inputted the orders or contacted the physician if the order was missing. The facility's policy requires documentation of total free water intake, which was not followed.
The facility failed to ensure timely call light responses, adequate communication access, and respect for residents' preferences and dignity. Residents reported long waits for call light responses, lack of access to personal phones, and unmet food preferences. Additionally, unsanitary conditions were observed, such as soiled bedding and unemptied urinals, contributing to residents' dissatisfaction and feelings of neglect.
Two residents in the facility did not receive adequate assistance with Activities of Daily Living (ADL). A resident with a history of stroke and muscle weakness had overgrown toenails and was not receiving showers as per their care plan, while another resident requiring 1:1 meal assistance was left without help, resulting in an untouched lunch tray. These deficiencies highlight lapses in care coordination and adherence to care plans.
A resident developed an unstageable pressure ulcer on the left heel due to the facility's failure to implement a comprehensive pressure ulcer prevention and skin management program. Despite the resident's inability to reposition herself and the presence of a starting pressure ulcer on the right heel, preventive interventions were not included in the care plan until after the wound developed. The physician's progress notes lacked documentation of the left heel ulcer, indicating a gap in wound assessment and management.
A resident with Multiple Sclerosis and contractures experienced a decline in range of motion due to the facility's failure to implement a comprehensive restorative nursing program. The resident, dependent on staff for all activities, received inconsistent and inadequate passive range of motion exercises, leading to worsening contractures and unnecessary pain. Observations revealed a lack of specific exercises and repetitions in the care plan, and staff documentation was inaccurate, often reflecting time spent in the room rather than on exercises.
A facility failed to ensure safety and supervision for several residents, leading to multiple deficiencies. A resident was given a shower with an improperly sized sling, risking injury. Another resident was dropped off at the wrong medical facility due to inadequate transportation procedures. A third resident, deemed unsafe to smoke, was found smoking in his room, violating the facility's non-smoking policy. Additionally, a resident's wander guard was not properly documented or checked, posing an elopement risk.
A nurse in an LTC facility prepared a Heparin injection for a resident using an incorrect needle size, initially selecting a 1 and 1/2 inch needle meant for intramuscular injections instead of the appropriate size for subcutaneous administration. The error was identified before the injection was administered, highlighting a gap in the nurse's knowledge despite previous competency assessments.
The facility failed to maintain a comprehensive infection control program, as evidenced by improper hand hygiene practices during care. A nurse did not wash hands between glove changes during wound care for a resident with multiple health conditions. Another nurse failed to perform hand hygiene before and after administering medications, including to residents under enhanced barrier precautions. These actions violated the facility's hand washing policy and highlighted deficiencies in infection prevention and control.
Food Service Sanitation and Temperature Control Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. During the initial kitchen tour, a dirty fan with dust on its surface was observed blowing directly at clean plates stored on a cart and wrapped silverware near the steam table. A yellow discoloration was also observed on the interior wall of the ice machine, and the Dietary Manager acknowledged seeing it and stated the ice would be dumped and the machine cleaned. In the janitor's closet, a utility sink with an attached hose and a chemical feeder downstream of an atmospheric vacuum breaker was observed. During lunch observation, a fly was seen flying around the steam table in the main kitchen and later around the serving area in the east kitchen. The wiping cloth sanitizer bucket near the stove tested at 100 ppm quaternary ammonium, while the facility's policy required 150-200 ppm; the Corporate Dietician stated the bucket was changed every two hours and was due to be changed shortly. Milk was also observed at 55 F, above the facility's cold-holding requirement of 41 F or below, and the Dietary Manager had it discarded after the temperature was checked.
Improper Storage of Oxygen and Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment and oxygen supplies for residents receiving oxygen therapy and CPAP/nebulizer treatment. For Resident #13, who had COPD, hypertension, dependence on supplemental oxygen, required assistance with ADLs, and had moderately impaired cognition, a full oxygen tank was observed standing upright and unsecured in the corner behind the recliner in the resident’s room. The DON confirmed the tank was full and stated a holder would be obtained for it. The facility’s oxygen safety guidance stated that oxygen cylinders should be secured in an appropriate holder. For Resident #3, who was alert and able to be interviewed and had diagnoses including multiple sclerosis, chronic lung disease, respiratory failure, obesity, atrial fibrillation, and diabetes, the record showed an order for oxygen at 3 liters per nasal cannula and a care plan addressing oxygen exchange and tubing/device care. For Resident #9, who had obstructive sleep apnea, diabetes, depression, and dementia, the record showed an order for CPAP use at night and removal in the morning, along with a care plan noting CPAP use. Observations found the resident’s CPAP mask and tubing dry and sitting on top of the bedside dresser, with no clear plastic bag on the bedside table, despite the DON stating that masks and tubing for oxygen and CPAP should be in a clear plastic bag when not in use. For Resident #75, who had COPD, schizophrenia, dementia, bone and prostate cancer, and moderate cognitive impairment, observations showed a nebulizer machine running with the nebulizer mask positioned above the resident’s head between the headboard and mattress, and an oxygen concentrator on and delivering oxygen at 3 L/minute while the nasal cannula was also left above the resident’s head between the headboard and mattress. The resident was not receiving the supplemental oxygen during the observations. The oxygen tubing had a date written on it in sharpie marker. The DON stated that staff should stay with the resident during nebulizer treatment and that after treatment the equipment should be taken apart, rinsed, dried, and placed in a clear bag, and also stated the observed setup was inappropriate.
Narcotic Count and Disposal Deficiencies
Penalty
Summary
The facility failed to implement and operationalize processes and procedures to ensure accurate pharmaceutical services, including narcotic medication reconciliation and disposal. During a room observation, Resident #16 was found sitting upright in bed with a used fentanyl patch on the overbed table next to the bed. The resident denied pain. Nurse E entered the room and identified the item as a fentanyl patch, and Nurse N later entered, stated that patches sometimes just come off, and removed the used patch from the table. The resident also had a new fentanyl patch on the right chest wall secured with a transparent occlusive dressing. Medication cart reviews identified additional narcotic handling problems. On the 200 Hall medication cart, the narcotic count sheet documented seven narcotic medication containers, but eight were present in the cart; LPN G signed the count sheet even though the count was not accurately completed, and LPN H stated they probably were not fully awake and did not look at the sheet. On the 100 Hall medication cart, the outgoing night shift nurse had signed the narcotic count sheet, but the incoming day shift nurse had not signed it. On the 400 Hall medication cart, two loose white half tablets were found in the narcotic drawer; neither LPN I nor the DON could identify the tablets or say how long they had been there. The facility policy stated controlled substances require special handling, storage, disposal, and record keeping, with a physical inventory at each shift change and documentation of any discrepancy.
Medication carts contained undated, expired, and unlabeled medications
Penalty
Summary
Safe medication storage and labeling procedures were not implemented in two of four medication carts, resulting in undated, expired, and unlabeled medications and biologicals. During a tour of the 400 hall medication cart, surveyors found an open and undated 30 fluid ounce container of ProStat, an open box of Budesonide Inhalation Suspension for a resident that was dated as opened but had a shortened use period after opening, a Novolog Flexpen insulin pen dated as opened but with no resident name or identifier, a Humalog Kwikpen insulin pen dated as opened with only a room number written on it, and an open container of Assure Prism control solution dated as opened. When questioned, an LPN stated they were unaware the ProStat had to be used within a specific time frame after opening, did not know how long the Budesonide could be used after opening, did not know who the Novolog Flexpen belonged to because it had no resident identification, and acknowledged that labeling an insulin pen with only a room number was not best practice. During interview, the DON stated insulin pens should be labeled with the resident's name and agreed that the unlabeled insulin pens in the 400 hall cart were unacceptable. The DON also stated medications and supplies with shortened expiration dates after opening should be labeled with the date opened. A tour of the 100 hall medication cart found a Novolog Flexpen and a Lantus Solostar insulin pen dated as opened but with no resident name or identifier, an open container of Assure Prism control solution dated as opened, and an open and undated 30 fluid ounce container of ProStat. The facility policy and procedure related to medication storage and labeling was requested but not received by the conclusion of the survey.
Delayed Call Light Response and Missed Bedtime Snacks
Penalty
Summary
The facility failed to ensure dignity for six residents by not providing timely response to call lights and by not consistently providing bedtime snacks. Residents #3, #8, #18, #20, #89, and #90 were identified in the report as affected by delayed call light response, with several residents stating that staff took about an hour or longer to answer, and one resident reporting that staff sometimes did not come at all. One resident with multiple sclerosis, chronic lung disease, diabetes, respiratory failure, obesity, atrial fibrillation, and a recent fracture said the delay led to urinating on self and feeling embarrassed, while another resident with stroke-related weakness and depression reported long waits on weekends when staffing was lower. The report also documented that a confused resident with dementia, anxiety, depression, seizures, heart disease, stroke, and diabetes had a call light clipped to the upper left side of the pillow but could not locate or reach it when observed in bed. Other residents with stroke, seizures, kidney disease, Parkinson’s disease, cancer treatment, brain bleed, and other diagnoses reported similar delays and embarrassment related to wetting themselves while waiting for assistance. The nurse manager acknowledged that call lights were taking too long to answer, and the administrator stated that 10 to 15 minutes was an appropriate response time, while the facility call report summary showed 26 instances over two days where call lights were not answered within 15 minutes. Resident council complaints and resident interviews also described ongoing problems with bedtime snacks. Residents stated that snacks at night were not consistently brought, that the snack fridge was not stocked, and that staff sometimes blamed the kitchen or kept the snack room locked. Facility resident council minutes reflected repeated concerns about call lights and snacks, and the administrator was informed that residents were not always receiving bedtime snacks. The report states these issues resulted in anger, frustration, incontinent episodes, embarrassment, potential isolation, and hunger at night.
Advance Directive and Code Status Documentation Not Properly Executed
Penalty
Summary
The facility failed to ensure advance directives were executed and code status was obtained according to professional standards for one resident. Resident #48 was admitted and readmitted with diagnoses including dementia without behavioral disturbance, subdural hemorrhage, subarachnoid hemorrhage, and anxiety. The MDS assessment identified the resident as cognitively intact and needing supervision to moderate assistance with all ADLs except eating. The EMR contained a signed Code Status Form dated 3/24/26 indicating DNR, but the form was signed by the resident’s family member witness, Witness V. The record also showed the resident had DPOA advance directive documentation naming Witness V as the DPOA if the resident was unable to make medical decisions, but there was no determination of incompetency in the EMR. During interview, the SSD confirmed the resident had not been deemed incompetent and acknowledged the form should not have been signed by Witness V. The DON stated a DPOA takes effect when a resident is unable to make their own decisions and confirmed a resident must be deemed incompetent for the DPOA to be activated; the DON also stated Witness V should not have signed the DNR code status form and that the resident should have completed and signed it.
Unnecessary Psychotropic Medication Use Without Documented Indication
Penalty
Summary
The facility failed to ensure that psychotropic medication was used with an adequate indication and for treatment of a diagnosed condition for one resident. Resident #48 was admitted and readmitted with diagnoses including unspecified dementia without behavioral disturbance, subdural hemorrhage, subarachnoid hemorrhage, and anxiety. The MDS assessment dated [DATE] showed the resident was cognitively intact, required supervision to moderate assistance with ADLs except eating, had no signs or symptoms of depression, no indicators of psychosis, and no behaviors. The resident did not have a mental health and/or psychiatric diagnosis present in the facility EMR. Despite this, the July 2026 MAR showed the resident was receiving Seroquel 25 mg at bedtime for unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, with a start date of 3/26/26. The EMR contained a behavior/trauma care plan and a separate care plan related to insomnia and acute metabolic encephalopathy that included monitoring for potential side effects of psychotropic meds, but no further care plans or daily monitoring documentation for psychotropic side effects was noted. The SSD stated the diagnosis should not be unspecified dementia and that dementia was not a reason to take Seroquel, and the DON stated dementia without behaviors was not a reason for Seroquel and that the documented reason, lack of behaviors, and lack of non-pharmacological interventions were not okay. The facility policy stated a resident will not receive psychotherapeutic medications unless needed to treat a specific condition diagnosed and documented in the clinical record with clearly defined target behaviors and ineffective non-pharmacological interventions.
Failure to Maintain Safety Care Plan for Chair Fall Prevention
Penalty
Summary
The facility failed to ensure that Resident #45 had a comprehensive safety care plan in place when the resident’s non-skid chair mat was discontinued. Resident #45 was 85 years old, confused, and required assistance with all transfers. The resident had been admitted after a recent fall outside the facility that caused a fracture of the right upper leg/femur, and the resident’s diagnoses included difficulty walking, heart disease, dementia, Alzheimer’s disease, end stage kidney disease, diabetes, and anemia. The resident’s falls/safety care plan dated 2/24/26 included the non-slip mat on the resident’s chair, but the mat was discontinued by the facility on 5/30/26. Three days after the mat was removed, Resident #45 fell from the chair and fractured the left upper leg, which required surgical intervention. During observation, the resident was in bed, confused, and unable to answer questions about the fall; the chair beside the bed had an incontinent pad on the seat and no gripper pad. The Nurse Manager stated the environment needed to be re-looked at to prevent another fall, the DON was not aware the resident no longer had a non-slip chair pad, and an RN stated the dycum was wrinkling up and the resident did not like it, so it was removed. The facility policy stated that a baseline care plan must include instructions needed to provide effective, person-centered care that meets professional standards of quality care.
Improper Head-of-Bed Position During Tube Feeding
Penalty
Summary
Failure to maintain physician’s orders and keep the head of the bed safely elevated during enteral feeding was identified for Resident #7, who had a gastrostomy, dysphagia, stroke, extensive ADL dependence, and moderately impaired cognition. On observation, the resident was lying in bed with tube feeding infusing through the abdominal tube while the head of the bed was only about 20 degrees elevated, and a second observation with Nurse N showed the head of the bed at 25 degrees. Nurse N then elevated the head of the bed to the appropriate level for safe enteral feeding infusion. The resident’s physician order directed that the head of the bed be elevated to 30-45 degrees during feeding and for at least 30-40 minutes after feeding was stopped.
Failure to Implement Updated Pain Management Interventions
Penalty
Summary
The facility failed to ensure timely management and implementation of updated pain interventions for a resident with chronic pain. The resident was admitted with diagnoses including COPD, chronic viral hepatitis C, spinal stenosis, and osteoarthritis, and the MDS indicated the resident was cognitively intact, used a wheelchair, and received daily medication for pain. The care plan addressed pain management related to chronic viral hepatitis C, spinal stenosis, osteoarthritis, and opioid medication use, with interventions including medications as ordered, assessment for signs and symptoms of distress or pain unrelieved by ordered medications, and discussion of pain concerns with the MD and consulting pharmacist as needed. The resident reported ongoing pain in the back, legs, and arm, and stated that medication helped but did not take the pain away. The resident also stated that the physician had said the resident would get a brace for the right hand and have medications changed, but that nothing had been provided. EMR review showed complaints of wrist and arm pain beginning on 6/10/26, including reports of right wrist pain, bilateral wrist and forearm pain, right hand pain with swelling, and continued pain with a mass in the right wrist/arm. Nursing notes documented contact with the physician regarding x-ray and doppler requests for the right wrist/arm due to ongoing pain and swelling. The physician documented on 6/28/26 that the resident had evidence of osteoarthritis in multiple joints, had increased pain, and that Neurontin would be increased to improve pain and function. However, review of the HCP orders and MAR showed no medication changes after that note, and the resident continued to receive gabapentin 300 mg twice daily, Tylenol 650 mg every six hours, and Suboxone 2/0.5 mg twice daily listed for pain. An LPN confirmed there had been no recent pain medication changes and no brace order in the EMR. The DON stated awareness of the resident's complaints was lacking and later said the Neurontin increase and brace had not been ordered because it should have been caught in morning meeting and note review.
Missing Dementia Care Plan for a Resident with Confusion and Falls
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with dementia. Resident #48 was observed sitting in the room with a family member present and was pleasantly confused, with the family member stating the resident has dementia and is confused at times. Record review showed diagnoses including dementia without behavioral disturbance, subdural hemorrhage, subarachnoid hemorrhage, and anxiety. The resident’s MDS assessment indicated the resident was cognitively intact and required supervision to moderate assistance with all ADLs except eating. Review of the resident’s EMR showed progress notes describing the resident as alert with some confusion, and a physician note stated the resident had dementia, was mostly directable by staff, and was not fighting with staff about care at that time. Further review showed the resident had falls at the facility and did not consistently call for staff assistance. Social services staff confirmed the resident had dementia and stated the resident should have a care plan for dementia because the resident had had it for a long time, but they did not provide an explanation for the missing care plan or individualized interventions. The DON was also unaware the resident did not have a dementia care plan and could not explain individualized care and interventions related to the resident’s dementia.
Improper Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area free of unnecessary items. On 07/07/2026 at 9:46 AM, dirty cups, a plate, napkins, wrappers, gloves, and a plastic lid were observed on the ground surrounding the dumpster area. During an environmental tour on 07/08/2026 at 9:40 AM, the Maintenance Director stated that housekeeping checks the area and that the dumpster area is checked daily. The report cited FDA 2022 Food Code 5-501.115, which requires refuse storage areas and enclosures to be maintained free of unnecessary items.
Infection Control Program Not Fully Implemented
Penalty
Summary
The facility failed to fully analyze the Infection Control data for February 2026. Review of the Monthly Infection Control Analysis dated 2/26 showed multiple blank responses throughout the document, including unanswered questions on antibiotic use, community risk factors, influenza and pneumonia vaccination data, respiratory data interpretation, skin infection interpretation, other infection data interpretation, process surveillance, trends in knowledge deficit, summary of trends and correction action plan, and QA committee questions. The Infection Control Nurse stated the questions were not all filled in for February 26 and that she was not at the facility at the time. The facility also failed to ensure clean linen was transported with a cover on it. On 7/7/26, a CNA was observed in the hallway carrying multiple bed pads uncovered under an arm, with the linen touching the uniform, and entering an EBP room before leaving with some of the linen still uncovered under the arm. Later that same morning, another CNA was observed carrying clean linen/bed sheets tucked under the left arm, uncovered, with the linen touching the uniform, entering a resident room, and then exiting without the linen. The Infection Control Nurse was alerted to these observations on 7/9/26. The facility further failed to ensure sanitary maintenance of one resident's indwelling urinary catheter. Resident #75, who had diagnoses including bone and prostate cancer, COPD, schizophrenia, and dementia, was observed with the catheter drainage bag directly on the floor beside the bed and later hooked to the bottom of a wheelchair with the tubing visibly taut and stretched. The resident's MDS showed moderate cognitive impairment and the presence of an indwelling urinary catheter. The DON confirmed that drainage bags should not touch the floor and that the resident did not have a care plan related to placing the drainage bag on the floor.
Failure to Include Resident and Representative in Quarterly Care Planning
Penalty
Summary
The facility failed to ensure that quarterly care planning meetings were completed and that the resident and the resident’s representative were included in care planning so they could make informed decisions about healthcare and treatment options. The deficiency involved one resident who had been admitted to the facility with diagnoses including fracture of the right femur, history of falling, unsteadiness on feet, and abnormalities of gait and mobility. A Minimum Data Set assessment showed intact cognition and that the resident required substantial to maximal assistance with rolling and was dependent for transfers. The resident’s representative reported that after a fall in November 2025, the resident continued to complain of pain in his leg and hip, but the facility only provided pain medication and did not resolve the concern. The representative stated that the resident called 911 himself because he was fed up with the lack of action, and the resident later went to the hospital where a fracture was found and surgery was performed. The representative also stated she was not familiar with care conferences, had not been invited to any meetings, and had not been contacted by staff to discuss the resident’s ongoing pain or a plan of care. The resident similarly reported that he had ongoing pain after the fall, that x-rays were done at the facility and did not show anything wrong, and that he asked for more testing such as an MRI. He stated that no care conferences or meetings were held with staff and his guardian to discuss his care, and that he was not aware of any request for his guardian to attend a meeting. The acting DON reviewed the record and stated the last care conference form and note appeared to be from September, confirmed care conferences should occur quarterly or every three months, and stated the guardian would be invited to attend. The facility policy required resident and family or representative involvement in care planning and timely invitation to the care plan conference.
Failure to Update Emergency Power Loss Policy After Generator Upgrade
Penalty
Summary
The facility failed to update its Emergency Preparedness policies and procedures following an upgrade to the emergency backup generator. Although the generator was enhanced to cover the power load of the entire facility, the written policy still instructed staff to use extension cords and red outlets to provide backup power only to certain resident rooms and treatment areas. This outdated information did not reflect the current capabilities of the upgraded generator. During a record review and interview with the maintenance director, it was confirmed that the utility power loss policy had not been revised to align with the new generator system. The continued reference to outdated procedures in the policy could cause confusion among staff during a power outage emergency, as the instructions no longer matched the facility's actual emergency power resources.
Emergency Generator Annunciator Not Readily Observable
Penalty
Summary
The facility failed to ensure that the remote annunciator for the emergency generator was installed in a location that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the new emergency generator annunciator was placed in the back building electrical room, rather than in a more visible area. This placement could result in alarms and generator conditions going unnoticed by facility staff. The deficiency was confirmed through an interview with the maintenance director at the time of observation. No specific residents or patient medical histories were mentioned in the report, and the deficiency was identified through direct observation and staff interview.
Deficient Exit Signage and Egress Configuration
Penalty
Summary
Exit and directional signs in the facility were not displayed in accordance with regulatory requirements, as observed during a survey. Specifically, the emergency exit sign outside the Saginaw Room Dining space had an incorrect emergency egress configuration, resulting in the North side of the facility lacking an emergency exit from resident spaces. Additionally, the exit configuration did not match the emergency placards displayed in the corridors. These findings were confirmed through an interview with the maintenance director at the time of observation. This deficiency could affect 35 occupants in the event of an emergency evacuation, as noted in the report.
Non-Compliant Corridor Door Allows Smoke Passage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke, as required by NFPA 19.3.6.3. Specifically, during an inspection, it was found that the shower room door located across from the 100 nurse station consisted of an open grate design. This type of door would allow smoke, heat, and fire to transfer from the shower room into the emergency egress corridor, compromising the intended fire and smoke barrier. The deficiency was confirmed through an interview with the maintenance director at the time of observation. The report does not mention any specific residents or their medical conditions being directly involved or affected at the time of the deficiency. The finding was based solely on the physical observation of the door and its non-compliance with regulatory requirements for smoke resistance.
Failure to Prevent Resident-to-Resident Abuse Following Inappropriate Room Assignment
Penalty
Summary
A resident with severe physical disabilities, including bilateral lower limb amputations and upper extremity contractures, was subjected to physical abuse by another resident. The abused resident was totally dependent for all care and had a history of vascular dementia, bipolar disorder, depression, and schizophrenia. The incident resulted in the resident sustaining a black eye and facial contusions. The resident was unable to defend himself due to his physical limitations and required assistance for all activities of daily living. The facility failed to prevent the abusive incident, which occurred after a room transfer placed the aggressive resident as a roommate with the vulnerable resident. The aggressive resident had a history of verbal aggression and was known to be manipulative, with staff and social services noting concerns about his behavior. The decision to pair these two residents was made by the interdisciplinary team, but staff later acknowledged that it was not a good fit. There was no evidence that the family of the vulnerable resident was notified of the new roommate, and the facility lacked a formal bed transfer policy. Staff interviews revealed that the incident was not witnessed, and the injury was only discovered during routine care. The facility also lacked a supervision policy for monitoring resident safety, and there was no documentation of a behavioral assessment or increased supervision for the aggressive resident prior to the incident. The event was reported to the police, and both residents exhibited physical signs consistent with an altercation. The facility's failure to properly assess roommate compatibility, notify families, and implement appropriate supervision contributed to the occurrence of resident-to-resident abuse.
Failure to Assess and Respond to Change in Condition Leads to Resident Death
Penalty
Summary
A deficiency occurred when a nurse failed to perform a timely, complete, and accurate assessment of a resident who experienced a change in condition. The resident, who had a complex medical history including sepsis, pneumonia, acute respiratory failure, heart failure, and other chronic conditions, was dependent on staff for activities of daily living and was on oxygen and a feeding tube. On the day of the incident, a CNA reported to the nurse that the resident had an elevated temperature of 101°F and a pulse of 110 at 9:00 a.m. Despite this report and the resident's history of sepsis, the nurse did not conduct a physical or cognitive assessment, nor did she document any such assessment in the medical record between 9:00 a.m. and 5:35 p.m. The nurse delayed any intervention for over four hours, only administering Tylenol at 1:17 p.m. for the increased temperature, without notifying the physician or considering hospital transfer. Interviews confirmed that the nurse acknowledged not performing an assessment or contacting the physician, despite facility policies requiring such actions in response to changes in condition. The Director of Nursing and other staff corroborated that the nurse did not act on the reported vital sign changes and failed to follow established protocols for assessment and escalation. Later that day, the resident was found unresponsive and cold to the touch, with no pulse, and a code blue was called. Despite resuscitation efforts, the resident died. The facility's policies and job descriptions clearly outlined the expectation for timely assessment and physician notification in the event of a change in condition, which were not followed in this case.
Failure to Notify Responsible Party of Roommate Change Resulting in Resident Injury
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a roommate change, which resulted in a new roommate being moved into the resident's room without prior notification. The resident involved had severe cognitive impairment, a legal guardian, and multiple medical diagnoses including vascular dementia, bipolar disorder, depression, schizophrenia, and bilateral lower limb amputation. Following the roommate change, the resident was observed with a black eye and facial bruising, and an incident report documented that the resident stated another resident made contact with his eye, while the other resident denied the action. Both residents involved had cognitive impairments, with one having a BIMS score indicating severe impairment and the other slight impairment. The Nursing Home Administrator acknowledged that there was no specific policy for bed or roommate changes and that the facility relied on regulatory guidance and interdisciplinary team meetings to make such decisions. The administrator admitted that the responsible party for the resident was not notified of the roommate change, which was a failure on the facility's part. Facility documentation and state guidance both require notification of the resident's representative prior to any room or roommate change, but this was not done, leading to the incident and subsequent injury.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications used to treat mood and behavior disorders for four residents. The deficiency was identified through observation, interviews, and record reviews, revealing that informed consents were not obtained prior to the initiation or change in dosage of psychoactive medications. The facility's policy requires that residents do not receive psychotherapeutic medications unless needed to treat a specific condition, with documented target behaviors and ineffective non-pharmacological interventions. Additionally, informed consent from the resident or responsible party, along with education regarding potential side effects, is required. For Resident #101, the Medication Administration Record (MAR) showed multiple psychotropic medications prescribed without documented consent. The social work designee admitted to not obtaining written consents, relying instead on verbal agreements, and acknowledged the absence of consent forms in the medical records. Similarly, Residents #102, #103, and #104 had psychotropic medications administered without updated consents for medication changes or new medication initiations. The Social Services Director confirmed the lack of consents and the failure to follow the facility's procedure for obtaining them. The report highlights that the facility's process for managing psychotropic medications was not followed, as evidenced by the absence of consent documentation in the residents' medical records. The interviews with the social work designee and Social Services Director revealed a lack of adherence to the facility's policy, resulting in the administration of psychotropic medications without the necessary informed consents. This deficiency indicates a systemic issue in the facility's handling of psychotropic medication consents, affecting the care and treatment of the residents involved.
Failure to Adhere to Wound Management Policy
Penalty
Summary
The facility failed to adhere to its wound management policy for a resident who was admitted with a Stage 2 pressure injury on the coccyx. Upon readmission from the hospital, the wound had progressed to a Stage 3 pressure injury. The facility's policy required weekly documentation and photographic assessment of pressure ulcers, but a weekly assessment was missed between 10/28/2024 and 11/11/2024. This oversight was acknowledged by the Director of Nursing (DON), who confirmed that while treatment was administered, the necessary documentation and photographic evidence were not completed. The resident, who is of advanced age and has diagnoses including age-related physical debility, reduced mobility, cerebral infarction, and hypertension, was noted to have moderately impaired cognition with a BIMS score of 12. The failure to conduct a weekly assessment and take a picture of the wound as per the facility's policy resulted in a missed opportunity to monitor the wound's progression accurately. This lapse in protocol potentially contributed to the worsening of the resident's pressure injury, as noted by the DON during an interview.
Failure to Provide Adequate Hydration for Resident on Enteral Nutrition
Penalty
Summary
The facility failed to provide adequate hydration for a resident receiving enteral nutrition feedings, resulting in the resident not receiving appropriate hydration for five days. The resident was admitted with several diagnoses, including Hypomagnesemia, Atrial Fibrillation, Gastrostomy Infection, Dysphagia, Anxiety, and a Solitary Pulmonary Nodule. Upon admission, the hospital discharge orders included a recommendation for free water flushes every four hours, but this order was not inputted into the facility's system. Consequently, the resident did not receive the necessary hydration from the time of admission until five days later when the Registered Dietitian completed an initial assessment and added the free water flush order. Interviews with facility staff revealed that the omission of the free water flush order was due to it being in a separate document from other discharge medications, which was overlooked. The Clinical Care Coordinator stated that the admitting nurse should have inputted the enteral nutrition orders based on the hospital discharge summary, and if the free water flushes were not listed, the nurse could have contacted the physician to obtain the order. The facility's policy on enteral nutritional feeding requires the physician's order to include the total amount of free water intake to be consumed in 24 hours, which was not followed in this case.
Deficiencies in Call Light Response, Communication Access, and Resident Care
Penalty
Summary
The facility failed to ensure that residents' call lights were available, within reach, and answered in a timely manner. This deficiency affected multiple residents, including one who reported that their call light was often not answered for hours, leading to difficulties in receiving assistance. Another resident was unable to reach their call light due to physical limitations, and it was observed to be out of reach on multiple occasions. The facility's policy stated that call lights should be answered within 15 minutes, but this was not consistently adhered to, as evidenced by resident complaints and observations. Additionally, the facility did not provide adequate access to communication devices for residents. One resident reported not having a phone available for personal use, which was confirmed by staff who were unable to locate a portable phone for resident use. This lack of access to communication devices hindered residents' ability to maintain contact with family and friends, contributing to feelings of isolation and frustration. The facility also failed to honor residents' food preferences and maintain a clean and dignified environment. One resident expressed dissatisfaction with not receiving their preferred food items, such as eggs, despite having no dietary restrictions. Another resident's bedding was found to be soiled with drainage from a wound, and their urinal was not emptied in a timely manner, leading to unsanitary conditions. These failures in providing personalized care and maintaining cleanliness further contributed to residents' dissatisfaction and feelings of being treated without dignity and respect.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, resulting in unmet care needs. Resident #9, who has a history of stroke, dysphagia, and muscle weakness, was found with severely overgrown toenails and had only been receiving showers once a week, contrary to their care plan. The resident's medical record indicated they required extensive assistance with ADLs, yet they had not seen a podiatrist since admission, and their shower schedule was not updated to include a second weekly shower. This oversight led to discomfort and potential hygiene issues for the resident. Resident #47, who required 1:1 assistance during meals, was observed with an untouched lunch tray, indicating they had not been assisted with their meal. The CNA responsible for Resident #47 was occupied with another resident and was unaware that the resident had not eaten. The DON was informed of the situation and instructed the kitchen to prepare a new meal. This incident highlights a lapse in ensuring that residents with specific assistance needs are adequately supported during meal times.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement a comprehensive pressure ulcer prevention and skin management program for a resident, resulting in the development of an unstageable pressure ulcer on the resident's left heel. The resident, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Hypertension, Atrial Fibrillation, and Mood Disorder, required staff assistance with Activities of Daily Living (ADLs). Despite the presence of a starting pressure ulcer on the right heel noted on May 1, 2024, and subsequent orders for wound care, there was no mention of a left heel pressure ulcer in the physician progress notes until later. The wound was identified as unstageable and in-house acquired, with various stages of slough, eschar, and drainage documented over time. The Unit Manager acknowledged noticing a reddened circle on the resident's left heel on May 1, 2024, which began to spread by May 7, 2024. The resident was unable to reposition herself in bed, and interventions such as 'heels up' were implemented only after the wound developed. The care plan lacked interventions for the prevention of pressure ulcers until after the wound's appearance. Additionally, there was no documentation indicating that the wound had been assessed by the physician, highlighting a gap in the facility's pressure ulcer prevention and management practices.
Inadequate Restorative Nursing Program Leads to Resident's Decline
Penalty
Summary
The facility failed to implement a comprehensive restorative nursing program for a resident with multiple medical conditions, including Multiple Sclerosis, functional quadriplegia, and contractures. The resident was dependent on staff for all activities of daily living and had impaired range of motion in both upper and lower extremities. Despite being cognitively intact, the resident experienced a decline in range of motion and worsening contractures due to inconsistent and inadequate passive range of motion exercises. The facility's documentation was inaccurate, and the resident expressed discontentment with the care provided, indicating that exercises were only performed upon request. Observations and interviews revealed that the facility did not have a dedicated restorative CNA, and the staff did not perform specific passive range of motion exercises as part of the resident's care plan. The documentation in the electronic medical record was inconsistent, with an average of only 4.35 minutes of range of motion exercises documented daily, and often recorded as the total time spent in the resident's room rather than the actual time spent on exercises. The lack of specific joint exercises and repetitions in the care plan contributed to the resident's decline in range of motion. Interviews with the therapy director and nursing staff highlighted a lack of coordination and communication regarding the resident's restorative care needs. The therapy director confirmed that the resident had experienced a decline in range of motion since admission, but there was no formal process for therapy staff to refer or recommend restorative nursing interventions. The facility's failure to provide detailed and purposeful passive range of motion exercises, along with inadequate documentation and communication, resulted in the resident's unnecessary pain and increased risk for further decline.
Multiple Safety and Supervision Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment for Resident #14 during a shower, as observed on June 13, 2024. The resident, who was non-ambulatory and required assistance with all activities of daily living, was transferred using a Hoyer lift with a sling that was too small for his size. This resulted in the resident almost sliding out of the shower chair multiple times, causing him to yell in pain. The staff struggled to manage the situation, indicating a lack of proper guidance and assessment for the appropriate sling size, as no documentation or instructions were available for the staff. Resident #51 experienced an unsafe transportation incident when she was dropped off at the wrong medical facility for an appointment. The contracted transportation company failed to follow the correct procedure, leading to confusion and potential distress for the resident. The facility did not have a comprehensive process or procedure in place to ensure the safe transportation of residents, nor did they provide adequate training or instructions to the transportation drivers, increasing the likelihood of similar incidents occurring in the future. Resident #67 was found smoking in his room, which is against the facility's non-smoking policy. Despite being deemed safe to smoke in previous assessments, a recent evaluation revealed that the resident was unsafe to smoke due to tremors and burns on his fingers. The facility failed to update the resident's care plan to reflect his smoking status and did not adequately supervise or control the possession of smoking materials, leading to a dangerous situation. Additionally, Resident #43's wander guard was not properly documented or checked for functionality, posing a risk of elopement for the resident with severe cognitive impairment.
Medication Administration Error with Heparin Injection
Penalty
Summary
The facility failed to ensure the safe administration of a subcutaneous injection for a resident, leading to the potential for significant medication errors. During a medication administration task, a nurse prepared a Heparin injection for a resident using an incorrect needle size. The nurse initially selected a 1 and 1/2 inch needle, which is typically used for intramuscular injections, instead of the appropriate needle for a subcutaneous injection. This error was identified when the nurse was questioned about the needle size before administering the injection. The nurse demonstrated a lack of knowledge regarding the appropriate needle size for subcutaneous versus intramuscular injections, as evidenced by their inability to recall the correct needle lengths for each type of injection. Despite having been deemed competent in injections in November 2023, the nurse's actions during this incident indicated a gap in their understanding. The resident involved had an active physician order for Heparin to be administered subcutaneously every eight hours, and the incorrect preparation of this medication posed a risk of decreased efficacy and potential side effects.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by the lack of accurate tracking and surveillance of infections among residents. During an interview with the Infection Control Registered Nurse (RN C), it was revealed that the facility did not maintain documentation of tracking residents with potential infections or those with infectious organisms not receiving antibiotics. This deficiency was further highlighted by the observation of improper hand hygiene practices by staff members during care procedures. Specific incidents included a nurse performing wound care on a resident with multiple health conditions, including a pressure ulcer, without washing hands between glove changes. Additionally, another nurse failed to perform hand hygiene before and after administering medications to residents, including those under enhanced barrier precautions. These lapses in hand hygiene were contrary to the facility's hand washing policy, which mandates hand hygiene before and after glove use, and contributed to the overall failure in infection prevention and control.
What surveyors are citing around you — mapped
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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 301 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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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) |
|---|---|---|---|---|
| Adira Nursing And Rehabilitation | 1.5 mi | ★★★★★ | 12 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 1.9 mi | ★★★★★ | 8 | 0 |
| Great Lakes Rehabilitation Center | 3.3 mi | ★★★★★ | 24 | 0 |
| Covenant Skilled Nursing And Rehabilitation At Wel | 3.8 mi | ★★★★★ | 15 | 0 |
| Healthsource Saginaw, Inc | 4.9 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.