Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Saginaw Senior Care And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident’s Pro-Stat was left at bedside and marked as given even though it was spilled and not ingested, another resident applied muscle rub to her vaginal area after a nurse placed it on the bedside table without an order or self-administration assessment, and a third resident’s new facial skin alteration was not timely assessed or documented. The record showed missing progress notes, missing treatment orders, and staff interviews confirmed the medication and skin issues were not handled per documented orders or assessments.
Opened multi-dose meds were found without open dates in several med carts and in the med refrigerator. An LPN and the DON observed undated ophthalmic drops, inhalers, and insulin pens stored improperly, while MAR review showed the residents were receiving the ordered meds for glaucoma and COPD.
Biohazard containers with lids were missing from soiled utility rooms on two halls, and staff said red bags might have been placed in regular trash if needed. A CNA also failed to follow infection control during toileting and peri care for a resident with dementia and total ADL dependence by handling soiled linen bags with contaminated gloves before hand hygiene. The survey also noted unused plumbing fixtures, capped lines, and spray nozzles that were not flushed.
Catheter Dignity and Infection Control Lapses: A resident with dementia, a hx of UTIs, and a suprapubic catheter was observed wheeling toward the dining room with catheter tubing dragging on the floor and no privacy bag on the drainage bag. The DON stated the facility did not have privacy bags and acknowledged the issue as a dignity and potential infection concern. The report also cited missing lidded biohazard receptacles in soiled utility rooms on two halls and improper infection control during toileting and peri care for another resident.
The facility failed to follow its controlled substance disposal process for discontinued narcotics. A resident had Tramadol orders that were discontinued and later reordered, but the proof-of-use forms had blank disposition sections and no required witness signatures. The DON stated discontinued meds were removed from carts, stored in a file cabinet, and later destroyed, with a second nurse signature obtained only at the time of destruction on a pharmacy report. Surveyors also found many other controlled substance forms with missing or single signatures.
Two residents were involved in medication administration errors that resulted in an 8% error rate. An LPN applied topical medications at times that did not match the scheduled administration times, and gave Metformin after the resident had already eaten breakfast even though it was ordered to be taken with food. In addition, an RN left a resident list/report sheet with medications and vital signs on an open med cart where it was accessible to others.
A resident with multiple complex medical conditions was found unresponsive, and staff failed to follow proper procedures during a code blue event. Staff lacked training on AED use, did not ensure only current CPR-certified personnel performed chest compressions, and failed to document the code accurately. Nursing assistants without current CPR certification participated in compressions, and documentation was incomplete or lost. The DON did not initiate an investigation following the incident.
The facility failed to prevent and manage pressure ulcers for three residents, leading to the development and worsening of wounds. A resident with severe cognitive impairment developed a Stage 3 ulcer due to inadequate repositioning. Another resident acquired an unstageable heel ulcer, indicating lapses in skin monitoring. A third resident's heel ulcer progressed to eschar, with missed dressing changes and inadequate wound care. These deficiencies highlight significant gaps in pressure ulcer prevention and management.
The facility failed to treat residents with dignity, resulting in long call light wait times and incidents of incontinence without timely assistance. A resident reported waiting an hour for help, leading to humiliation, and experienced a 6.5-hour delay on their first night. During a Resident Council meeting, residents expressed concerns about third shift staff's dismissive attitudes and lack of compassion. The HR department acknowledged complaints and noted ongoing monitoring.
The facility failed to implement baseline care plans for three residents within 48 hours of admission, leading to inadequate care planning. A resident with a history of falls experienced another fall without updated interventions, and their spouse was not notified. Another resident with complex medical needs did not receive a baseline care plan, and a third resident with severe cognitive impairment had undocumented interventions for hand contractures.
The facility failed to update care plans for four residents, resulting in discrepancies such as incorrect oxygen flow rates, unaddressed wound care, and lack of new interventions after a fall. One resident received 4 liters of oxygen instead of the prescribed 2 liters, while another developed a preventable heel wound. A third resident fell and sprained a thumb, but the care plan was not updated promptly, and the spouse was not notified due to missing contact information.
A resident in a wheelchair fell and injured their thumb due to inadequate supervision. The facility did not update the resident's fall care plan with new interventions and failed to notify the resident's spouse of the incident, as required by policy. The spouse only learned of the fall during a visit, as the facility lacked her contact information and did not ask the resident for it.
A facility failed to monitor and document the weight loss of a hemodialysis resident, leading to significant weight fluctuations without proper follow-up or physician notification. The resident's weight dropped from 281 to 208 pounds over several months, with inconsistencies in the weight log and a lack of dietary notes or re-weighs. The Registered Dietitian acknowledged the reliance on dialysis weights but admitted the facility did not consistently document or review these weights.
A resident was administered tube feeding without a physician's order due to an incorrectly inputted readmission order. The resident, with multiple diagnoses, was observed receiving tube feeding at an incorrect rate. The Corporate RD found the order did not carry over to the MAR, and nurses administered the feeding without documentation. A 72-hour pump history showed the resident received nutrition, but it was not documented, violating facility policy.
A resident with severe cognitive impairment was administered oxygen at an incorrect flow rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was observed over two days, and the Clinical Care Coordinator was informed, who then verified the incorrect setting.
A facility failed to timely respond to pharmacy recommendations and did not follow medication administration parameters for a resident with multiple diagnoses. Pharmacy recommendations to adjust Pantoprazole dosage, document blood pressure for Cozaar administration, and obtain lab tests were not acted upon. The resident's blood pressure was not consistently checked before Cozaar administration, with 21 instances of non-compliance noted. Lab tests were delayed until August despite earlier requests.
A resident with Major Depressive Disorder was prescribed three antidepressants without documented clinical rationale. The social worker noted stabilization on the current regime, but no provider documentation was found. Facility policy discouraged duplicative therapy but lacked guidance on documenting multi-drug therapy rationale.
The facility failed to dispose of expired supplies and supplements in the medication storage rooms on the 100 Hall and 400 Hall. Expired items included vacutainers, Ensure Plus drinks, sterile gauze pads, and lubricating jelly. The facility's policy did not address the management of expired supplies, leading to their availability for use.
A resident with multiple health issues tested positive for Covid-19 but did not receive timely medication or proper assessment, leading to their death. The facility failed to notify the family, implement infection control measures, or document the resident's condition and treatment. An LPN administered albuterol without physician consultation and left the resident unattended, resulting in the resident becoming unresponsive and dying.
Medication Handling and Skin Assessment Deficiencies
Penalty
Summary
Medications were left at bedside and not administered in accordance with orders for one resident, and another resident’s new skin alteration was not timely assessed, documented, or monitored. The report also identified that a resident applied the wrong topical medication to her vaginal area after a nurse placed a medication cup on her bedside table instead of directly handing it to her, and that there was no current order or self-administration assessment for that topical medication. Resident #24 was observed with a medicine cup containing Pro-Stat spilled on the floor near the bed and wheelchair. The resident stated she had accidentally knocked it over. Review of the record showed Pro-Stat 30 mL twice daily was marked as administered on the MAR, but there were no progress notes documenting that the resident did not ingest it or that it was readministered. The DON stated the resident was not assessed to administer her own medications and medications should not be left at bedside. Resident #28 reported that she requested peri cream for discomfort, but a nurse placed a medication cup on her bedside table while she was in the bathroom. The resident believed it was the peri cream and applied the contents to her vaginal area, later realizing it was muscle rub. The record contained no order for the muscle cream and no self-administration assessment. There were also no progress notes documenting the incident, the immediate response, or ongoing assessment of the area. For Resident #9, the resident was observed with redness and drainage to the left eye and multiple clustered sores on the face near the mouth and jaw. The physician had assessed redness and drainage to the eye and prescribed antibiotic eye drops, but the record contained no progress notes or treatment orders for the facial skin alteration, and staff interviews indicated the area had not been clearly assessed or documented when first noted.
Undated Opened Medications Found in Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to accepted professional principles because multiple opened multi-dose medications were found without open dates in medication carts and the medication refrigerator. During observation and interview, Resident #83’s ophthalmic drops, timolol 5% and latanoprost 0.005%, were open in the 100 hall medication cart with no open dates on the boxes or bottles, even though the MAR showed both medications had been administered repeatedly for glaucoma. In the 400 hall medication cart, Resident #62 had two opened fluticasone-salmeterol inhalation devices with broken seals and no open or used dates on the devices or boxes, while the MAR showed the inhaler was being given twice daily for COPD. In the 300/500 hall medication cart, Resident #84’s albuterol inhaler, Resident #57’s Anoro Ellipta inhaler, and Resident #38’s Symbicort inhaler were all opened and undated, and the facility pharmacy storage list stated that inhalers, nasal sprays, nebulizer treatments, and ophthalmic/otic medications are to be dated when opened. The medication storage observation also identified two insulin pens placed on the bottom surface of the 100/200 hall medication room refrigerator. The DON stated that the pens should not have been on the bottom of the refrigerator and should have been stored on the shelf with the other insulins, but she did not know why they were resting on the floor of the refrigerator. The report documents that these storage and labeling issues were observed across multiple medication carts and the refrigerator during surveyor observation and interview, with record review confirming that the affected residents were receiving the medications as ordered.
Missing Biohazard Containers, Improper Linen Handling, and Unused Plumbing Fixtures
Penalty
Summary
The facility failed to maintain adequate biohazard receptacles with lids in the soiled utility rooms on the 300 and 500 halls. During observation, a cardboard box with trash and a tied-off red biohazard bag was seen on the floor in the 300 hall soiled utility room without a top. Staff interviews confirmed that both the 300 and 500 hall biohazard containers were missing, and two CNAs stated they would have placed a red bag in the regular trash bin if they had one at that time. The Infection Control Nurse stated the biohazard container had been taken to the dumpster, and the DON stated she was not aware the containers had been removed from the soiled utility rooms. The facility also failed to follow proper infection control procedure during toileting and peri care for a resident who was [AGE] years old, admitted with dementia, behavioral disturbances, visual deficit, chronic kidney disease, malnutrition, psychosis, and adjustment disorder, and who required assistance with all ADLs. During observation, a CNA toileted the resident, performed peri care, dressed the resident while wearing gloves, placed soiled linens in a clear plastic bag on the bathroom floor, picked up the bag with gloves still on, then removed the gloves and washed hands before directly picking up the three bags of soiled linens and carrying them to the soiled utility room. The resident’s care plans identified total dependence on staff for toileting, dressing, and hygiene care. The report also documented environmental findings related to plumbing and water fixtures. During the environmental tour, uncapped shutoff valves and an unused atmospheric vacuum breaker were observed in the shower room on the 200 hall. In the housekeeping and laundry areas, an unused hopper with a spray nozzle was observed, along with an unused atmospheric vacuum breaker, capped plumbing lines, and a spray nozzle with accumulated dust in the 500 hall soiled utility room. The Maintenance Director stated the spray nozzle was not flushed, and the Housekeeping and Laundry Manager stated the hopper was not used. The facility’s Dead End Water Pipe Policy and CDC guidance on flushing low-flow piping runs and dead legs were also reviewed.
Catheter Dignity and Infection Control Lapses
Penalty
Summary
Failure to maintain the resident water program properly was identified along with infection control and dignity concerns related to catheter care and soiled utility room biohazard receptacles. Resident #18 was [AGE] years old, readmitted after a hospital transfer, required assistance with all ADLs, had a history of UTIs, and was confused with decreased cognition. The resident’s diagnoses included dementia, diabetes, vascular disease, neuromuscular dysfunction of the bladder, and a feeding tube with a suprapubic catheter. Physician orders and nursing progress notes showed the resident was started on doxycycline for a UTI, and the care plan directed staff to check the suprapubic catheter every shift, including tubing placement and use of a privacy bag. During observation, Resident #18 was seen wheeling slowly down hallway 500 toward the main dining room with catheter tubing dragging on the floor under the wheelchair. The catheter bag had no privacy bag, and the resident was headed to lunch. The DON stated the facility was supposed to change the catheter when the resident returned from the hospital and that the facility did not have any privacy bags, adding that they needed to order some. The DON agreed this was a dignity and potential infection concern. The report also states the facility failed to maintain adequate biohazard receptacles with lids in the 300 and 500 hall soiled utility rooms, and failed to follow proper infection control procedure during toileting and peri care for Resident #72.
Controlled Substance Disposal Documentation Not Completed
Penalty
Summary
The facility failed to follow its policy for the disposal of discontinued controlled substances, including the required documentation and witness signatures. Record review showed that the facility’s policy required controlled substances remaining after discontinuation or discharge to be disposed of by two licensed nurses or a licensed pharmacist, with the disposition documented on the controlled substance count sheet, including date of destruction, resident name, medication name and strength, quantity destroyed, and witness signatures. However, the controlled substance proof-of-use forms reviewed in the large binder repeatedly had the disposition of unused drugs section left blank, and many forms had only a single signature or no witness signatures at all. Resident #19’s record showed multiple Tramadol orders during 2025, including a scheduled opioid pain medication that was discontinued and later reordered. The resident’s controlled substance proof-of-use forms for Tramadol showed tablets being signed out and remaining quantities documented, but the forms did not include the required signatures for removal or disposal of the remaining medication. Additional Tramadol proof-of-use forms for the resident also had the disposition section blank. Similar blank disposition sections were also noted for Morphine sulfate liquid (Roxanol) forms stored in the DON’s office. During interview, the DON stated that discontinued narcotics were removed from medication carts by the DON, stored in a file cabinet until disposal, and later destroyed using a drug buster chemical substance. The DON explained that the medications were punched into trash bags and discarded, and that a second nurse signature was obtained only at the time of actual destruction on a pharmacy-generated report. The DON also stated that the medications were not witnessed by floor nurses when removed from the carts, and the surveyor observed that the large binder contained hundreds of controlled substance proof-of-use forms with no two-nurse signatures documented.
Medication administration errors and unsecured resident information
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% when two medication errors were observed during 25 medication administration opportunities for two sampled residents, resulting in an 8% error rate. For Resident #70, on 12/3/2025 at 9:37 AM, LPN Q applied Ammonium Lactate External Cream 12% to the resident’s back while the resident was seated in a chair at bedside, and applied Voltaren 1% gel to both knees while oral medications were given at the same time. The medication administration audit report showed Ammonium Lactate External Cream 12% to the back was scheduled for 7:00 AM and Voltaren arthritis pain external gel 1% was scheduled for 8:00 AM, with the administration time documented as 9:30 AM. For Resident #83, on 12/3/2025 at 9:03 AM, LPN Q administered Metformin 1000 mg by mouth for diabetes after the resident had already eaten breakfast. The medication administration audit report showed Metformin 1000 mg by mouth twice daily for diabetes, to be taken with food, was scheduled for 8:00 AM, and the administration time was documented as 9:03 AM. The facility’s Medication Administration-General Guidelines policy stated medications are administered within 60 minutes of the scheduled time, and the DON reviewed the records and stated scheduled medications can be given 1 hour before and 1 hour after the designated time. During observation on 12/3/2025 at 8:21 AM, RN O also left a resident list/report sheet with medications and vital signs on top of the open medication cart, accessible to residents, staff, and visitors, and stated she should have turned over the papers before leaving the cart.
Failure to Ensure Proper Staff Training and Response During Code Blue Event
Penalty
Summary
The facility failed to ensure that staff were properly educated and prepared to respond to a full code situation, resulting in confusion and improper execution of CPR and AED use for a resident who was found unresponsive without a pulse or respirations. The resident, who was alert, able to make her own healthcare decisions, and dependent on staff for all ADLs, had multiple significant diagnoses including acute and chronic respiratory failure, pneumonia, heart failure, diabetes, vertebral fracture, morbid obesity, alcohol abuse, and mood and anxiety disorders. When the resident was found unresponsive, the nurse initiated a code blue and CPR, but there was a lack of clear procedure and role assignment among staff. During the code, staff demonstrated inadequate knowledge and training regarding the use of the AED, as one nurse admitted to never being trained on the device and was observed misplacing the AED pads on a manikin. Additionally, the AED machine's instructions were disregarded based on EMS direction, and there was no clear documentation of the code events. Nursing assistants, who had not been educated on their roles during a code or on CPR procedures, participated in chest compressions despite not holding current CPR certification. No facility nurse intervened to ensure only certified staff performed compressions, and documentation responsibilities were unclear and not fulfilled, with notes left unattended and ultimately lost. Interviews revealed that staff were uncertain about their responsibilities during the code, and the Director of Nursing did not initiate an investigation into the incident, citing being off duty at the time. The lack of staff education, improper use of emergency equipment, and failure to ensure only qualified personnel performed critical life-saving interventions contributed to the deficiency, as did the absence of proper documentation and post-incident review.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents, resulting in facility-acquired pressure ulcers, including a Stage 3 ulcer. Resident #25, who was admitted with severe cognitive impairment and existing wounds, developed an in-house acquired pressure ulcer on the left ischial tuberosity, which worsened from MASD to a Stage 3 wound within a week. Despite interventions in the care plan for repositioning every two hours, observations revealed that the resident was often left lying supine, and the wedge cushion intended for use was not utilized. The resident's refusal to be repositioned was noted, but the facility did not effectively manage this behavior to prevent further skin breakdown. Resident #15 developed an unstageable pressure ulcer on the right heel, which was not present upon admission. The wound was identified as in-house acquired, with a blood-filled blister noted in the nurse's progress notes. Despite the care plan's directive to observe skin daily and report findings, the development of the wound suggests a lapse in monitoring and intervention. The resident reported significant pain from the wound, indicating a lack of timely and effective preventive measures such as floating heels or using protective boots. Resident #33 also developed an unstageable pressure ulcer on the right heel, which was not documented upon admission. The wound progressed to eschar before being identified, indicating a failure in daily skin assessments and reporting by CNAs. The resident's dressing was not changed as scheduled, leading to drainage soaking through the dressing and onto the sheets. The facility's lack of timely intervention and appropriate wound care contributed to the deterioration of the resident's condition, as evidenced by the need for debridement treatment.
Deficiency in Resident Dignity and Staff Responsiveness
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by long call light wait times and incidents of incontinence without timely assistance. Resident #317, who is cognitively intact, reported waiting an hour for assistance over a weekend, resulting in an accident and humiliation in front of guests. Additionally, the resident experienced a significant delay on their first night, having to sit in urine for 6.5 hours. The care plan indicated that the resident required assistance with transfers, highlighting the necessity for prompt staff response. During a Resident Council meeting, ten residents unanimously expressed concerns about the third shift staff, citing inconsistent water distribution, dismissive attitudes, and lack of compassion. Residents reported feeling like burdens and feared reprisal if they advocated for themselves. Interviews with other residents corroborated these issues, with reports of long waits for assistance and disrespectful behavior from staff. The Human Resources department acknowledged complaints about the third shift staff's disrespectful behavior and noted ongoing monitoring and disciplinary actions.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to implement and distribute baseline care plans for three residents within 48 hours of their admission, as required by their policy. Resident #63, an elderly male with a history of falls and multiple medical diagnoses, experienced a fall in the facility. The facility did not update his fall care plan with new interventions, and his spouse was not notified of the fall due to the facility not having her contact information. Additionally, the baseline care plan was not provided to the resident or family within the required timeframe. Resident #65, who had a complex medical history including post concussional syndrome and chronic kidney disease, was admitted to the facility but did not receive a baseline care plan within 48 hours. The facility's process involves the MDS assessment nurse initiating the baseline care plan, which should be printed and given to the resident or family. However, this was not done for Resident #65, indicating a lapse in the facility's adherence to its own policy. Resident #38, with severe cognitive impairment and multiple diagnoses, was observed with a contracted right hand and a rolled towel placed in it, but there was no physician order or care plan for this intervention. The therapy manager confirmed that the resident was on a maintenance program for range of motion but acknowledged that there should have been an order and care plan for the towel and therapy services. This oversight highlights the facility's failure to properly document and plan for the resident's care needs, as required by their restorative program policy.
Failure to Update Care Plans and Notify Family Members
Penalty
Summary
The facility failed to revise and update care plans for four residents, leading to several deficiencies. For one resident, the care plan indicated an oxygen flow rate of 2 liters per minute, but observations showed the resident receiving 4 liters per minute. This discrepancy was not addressed until a surveyor pointed it out, indicating a lack of timely updates to the care plan as the resident's condition changed. Another resident had a right heel wound with eschar that was not documented in the care plan. The Director of Nursing acknowledged that the wound was preventable and that interventions such as floating heels and repositioning were not implemented in time. The care plan had not been updated to reflect the resident's current skin condition, which was initially assessed as having no concerns. A third resident experienced a fall, resulting in a sprained thumb, but the care plan was not updated with new interventions until two days later. The resident's spouse was not notified of the fall due to a lack of contact information, and the incident report noted that the resident was not wearing footwear at the time of the fall. These oversights highlight the facility's failure to promptly update care plans and communicate with family members.
Failure to Supervise Resident and Notify Family After Fall
Penalty
Summary
The facility failed to maintain adequate supervision for a resident who was up in a wheelchair, resulting in a fall and injury to the resident's left thumb. The resident, who was cognitively intact and had a history of falls and a fracture, was not provided with updated interventions in their fall care plan following the incident. Additionally, the facility did not notify the resident's spouse of the fall and injury in a timely manner, as required by their 'Unusual Occurrence' policy. The spouse only learned of the incident upon visiting the facility, as the facility did not have her contact information and failed to ask the resident for it. The facility's 'Fall Reduction Program' policy was not effectively implemented, as evidenced by the lack of new interventions in the resident's care plan following the fall. Furthermore, the facility did not adhere to its 'Baseline Care Plans' policy, as the resident's care plan was missing a general statement indicating that a copy of the baseline care plan was provided within 48 hours of admission. The Director of Nursing confirmed the oversight in communication with the spouse and the absence of updated interventions in the care plan.
Failure to Monitor and Document Weight Loss in Hemodialysis Resident
Penalty
Summary
The facility failed to adequately monitor and document the weight loss of a resident undergoing hemodialysis, identified as Resident #33. The facility's policy required weights to be documented upon admission and subsequently on a weekly basis for four weeks, then monthly unless otherwise indicated by a physician or the resident's condition. However, there were inconsistencies in the weight log for Resident #33, who experienced significant weight fluctuations. The resident's weight dropped from 281 pounds to 240.3 pounds within a month, and further to 208 pounds over a 24-day period, without any dietary notes or re-weighs being performed by the facility. The Registered Dietitian (RD) acknowledged that the facility relied on dialysis weights but failed to document these consistently or perform necessary re-weighs. Interviews and record reviews revealed that the facility did not follow up on abnormal weight changes or notify the physician of significant weight loss, particularly the 22-pound loss in August. The RD admitted that the process should involve monitoring weights from each dialysis treatment and reviewing them weekly, but this was not done. The lack of documentation and follow-up on Resident #33's weight changes resulted in a failure to identify potential nutritional deficiencies and a decline in the resident's overall health.
Failure to Administer Tube Feeding per Professional Standards
Penalty
Summary
The facility failed to administer tube feeding per professional standards for a resident, resulting in the administration of enteral feed without a physician's order. Resident #8 was observed with a tube feed infusing at 60 ml per hour, despite the order indicating it should begin at 65 ml per hour at a later time. Upon review, it was found that the resident was readmitted with several diagnoses, including Acute Cystitis, Sepsis, Dementia, Dysphagia, Atrial Fibrillation, Hypertension, and Major Depressive Disorder. The resident's enteral nutrition order was inputted incorrectly, and the facility staff administered the feed without a physician's order, leading to uncertainty about whether the resident received proper nutrition over the past week. The Corporate Registered Dietitian discovered that the readmission tube feed order did not carry over to the MAR due to incorrect categorization. Despite this, the facility nurses continued to administer the tube feeding without an order or documentation. A 72-hour history from the resident's pump indicated that the resident received enteral nutrition during this period, but it was not documented in the medical record. The facility's policy requires that administration of tube feeding and water flushes be documented, and medications be administered according to written orders, which was not followed in this case.
Improper Oxygen Administration Due to Unupdated Physician Order
Penalty
Summary
The facility failed to revise and update a physician's order for oxygen administration for a resident, resulting in the improper flow rate of oxygen being administered. The resident, who is severely cognitively impaired with a BIMS score of 0, was observed on multiple occasions receiving oxygen at a flow rate of 4 liters per minute via a nasal cannula, despite the physician's order specifying a flow rate of 2 liters per minute. This discrepancy was noted during observations on two consecutive days, with the oxygen tubing dated from the day before the first observation. The issue was brought to the attention of the Clinical Care Coordinator, who verified the incorrect flow rate and indicated they would check the resident's oxygen level and notify the physician. The facility's policy on oxygen administration emphasizes the importance of adhering to physician orders and includes procedures for ensuring safe oxygen therapy. However, the failure to follow the physician's order for the correct oxygen flow rate led to the deficiency identified in the report.
Failure to Respond to Pharmacy Recommendations and Adhere to Medication Parameters
Penalty
Summary
The facility failed to respond in a timely manner to pharmacy recommendations and did not adhere to medication administration parameters for a resident. The resident, who was admitted with multiple diagnoses including heart failure, anxiety, schizoaffective disorder, hypertension, and major depressive disorder, had pharmacy recommendations from January to September 2024 that were not acknowledged by the facility. These recommendations included reducing the dosage of Pantoprazole due to potential risks, adding blood pressure documentation for Cozaar administration, and obtaining various lab tests. Despite these recommendations, the facility did not make the suggested changes or document the necessary information. The facility's inaction resulted in the resident's blood pressure not being checked or documented according to the hold parameters before administering Cozaar, with 21 instances of non-compliance noted. Additionally, the recommended lab tests were not completed until August 2024, despite initial requests in January and follow-up requests in February and May. The facility's policy required that recommendations be acted upon and documented, but this was not followed, leading to the deficiency.
Lack of Documentation for Triple Antidepressant Therapy
Penalty
Summary
The facility failed to document the clinical rationale for prescribing triple drug therapy to a resident diagnosed with Major Depressive Disorder. The resident was observed resting in bed without reporting any pressing concerns. Upon reviewing the resident's medical records, it was found that she was prescribed three antidepressant medications: Sertraline HCI, Trazadone HCI, and Wellbutrin XL, all for the same diagnosis. There was no documented evidence to support the necessity or benefits of using multiple medications from the same class or with similar therapeutic effects. An interview with the social worker revealed that the resident was stabilized on the current medication regime, as previous dose reductions led to increased isolation, tearfulness, and a need for extensive encouragement to get out of bed. However, the social worker was unable to locate any documented rationale from the provider to support this claim. The facility's policy on the use of psychotherapeutic medications, revised in 2016, stated that duplicative drug therapy should be discouraged and closely monitored, but it did not address the need for clinical rationale when multi-drug therapy is utilized.
Expired Supplies and Supplements in Medication Storage Rooms
Penalty
Summary
The facility failed to properly dispose of expired supplies and supplements in the medication storage rooms on the 100 Hall and 400 Hall. During an observation, it was found that the 100 Hall medication storage room contained expired items, including a case of purple top vacutainers, eight Ensure Plus supplement drinks, and nine sterile gauze pads. These expired items were verified with a Registered Nurse. Additionally, the 400 Hall medication storage room was found to have a box of lubricating jelly that had expired, which was verified with the Nursing Home Administrator. The facility's policy on Medication Storage in the Facility did not address the management of expired supplies and supplements, contributing to the availability of these expired items for use and consumption.
Failure to Provide Timely Care and Infection Control for Covid-19 Positive Resident
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident diagnosed with Covid-19, resulting in a lack of accurate infection control surveillance and the resident not receiving medications as ordered. The resident, who had multiple diagnoses including Multiple Sclerosis and paraplegia, was cognitively intact and required assistance with daily activities. Despite testing positive for Covid-19, the resident did not receive the antiviral medication Paxlovid as ordered, and there was no comprehensive assessment or documentation of their condition following the diagnosis. The resident experienced difficulty breathing, and an LPN administered albuterol without contacting a physician or conducting a thorough assessment. The LPN left the resident unattended for approximately an hour, during which time the resident became unresponsive and subsequently died. The facility did not notify the family promptly about the resident's Covid-19 status, and there was confusion among staff regarding visitation policies and the use of personal protective equipment. The facility's infection control data was incomplete due to the recent resignation of the infection control nurse, and there were no documented assessments or physician visits for the resident after testing positive for Covid-19. The facility also failed to implement appropriate transmission-based precautions, and there was a lack of documentation regarding the resident's symptoms and treatment response. The death certificate indicated the resident died from Covid-19 and respiratory failure, with the manner of death listed as natural.
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Illustrative
What surveyors actually found near you
We read the 203 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
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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 | 0.7 mi | ★★★★★ | 13 | 0 |
| Hoyt Nursing & Rehab Centre | 1.9 mi | ★★★★★ | 1 | 0 |
| Covenant Skilled Nursing And Rehabilitation At Wel | 2 mi | ★★★★★ | 15 | 0 |
| Great Lakes Rehabilitation Center | 2.4 mi | ★★★★★ | 24 | 0 |
| Healthsource Saginaw, Inc | 3 mi | ★★★★★ | 3 | 0 |
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