Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lodge Of Saginaw Health And Wellness during CMS and state inspections, most recent first.
Incomplete Documentation of Bruising on Weekly Skin Assessment: A resident with severe cognitive impairment, CVA history, and anticoagulant therapy had bruising documented on shower sheets on multiple occasions, including bilateral arm and forearm bruising. However, the Weekly Wound Progress Report and wound care notes did not document the bruising, and the DON and Treatment Nurse stated they did not believe further assessment or documentation was required.
Failure to Change Gloves and Perform Hand Hygiene During Wound and Incontinent Care: A wound nurse did not change soiled gloves or sanitize hands when moving from dirty to clean steps during wound care for two residents, including one with a stage 4 sacral pressure ulcer and one with surgical wounds and bilateral amputations. A CNA also did not change gloves during incontinent care for a resident. The DON, LVN, and staff interviews confirmed that gloves should be changed and hands sanitized when moving between dirty and clean tasks, and the facility policy required handwashing before and after resident care and after removing gloves.
Call Light Not Kept Within Reach: A resident with muscle weakness, gait and mobility abnormalities, and severe cognitive impairment had a call light observed on the floor while he was in bed. His care plan directed staff to keep the call light within reach, and staff interviews confirmed the bell should always be accessible, but it was not in place at the time of observation.
A resident with bilateral lower leg amputations and surgical wounds did not receive stump wound care as ordered when an RN cleansed the left AKA stump, applied Betadine, and covered it with bordered gauze that was not included in the physician order to leave the area open to air. The wound nurse stated the extra dressing was applied per the resident’s request without first obtaining an order, and the DON stated treatment requests required physician authorization before being carried out.
Fall precautions were not maintained for two residents with significant fall risk factors. One resident with muscle weakness and severe cognitive impairment was observed in bed with the fall mat leaning against the wall instead of beside the bed. Another resident with Parkinson’s disease, dementia, prior fractures, and recent falls was observed with the bed not in the lowest position until a CNA lowered it after the issue was pointed out. Staff interviews confirmed that the fall mat and low bed position should have been in place.
Improper Storage of Oxygen Tubing and BiPAP Mask: Two residents receiving respiratory therapy were observed with oxygen tubing not stored in a bag when not in use, and one resident’s BiPAP mask was also left unbagged on a nightstand. Both residents had COPD and orders for oxygen therapy, and staff stated the facility policy required tubing and masks to be bagged when not in use to prevent contamination.
A facility failed to provide appropriate continence care for one resident who was found in bed with urine-soaked linens and two briefs on, despite staff stating double briefing was not allowed and incontinent residents should be checked every 2 hours. The facility also failed to have a physician order for another resident’s Foley catheter, including the catheter size and related care, even though the resident’s chart and care plan referenced catheter use and monitoring for UTI signs.
Two residents missed scheduled medication doses when the morning med pass was delayed after an agency med aide did not report and staffing was shifted between halls. One resident with chronic pain and Alzheimer’s disease did not receive a scheduled opioid dose, and another resident with HTN, fractures, and dementia did not receive a scheduled hydralazine dose. Staff reported miscommunication about coverage, and the DON stated other nurses were available but were not used in time.
Unsealed and Unlabeled Food Stored in Kitchen: Food in the kitchen walk-through fridge and freezer was found open to air, not sealed, and missing labels and disposal dates. A Dietary Mgr identified several items as leftovers, while other foods in original packaging were also exposed and undated. The Dietary Mgr said kitchen staff were responsible for labeling, dating, and removing items past the 7-day time frame, and the Admin stated he was unaware the food had been stored in this condition.
Incomplete CNA Annual In-Service Training: The facility failed to provide evidence that two CNAs completed the required 12 hours of annual in-service training, including dementia care, abuse prevention, and care of cognitively impaired residents. The ADON, DON, and Regional Corporate RN stated monthly in-services and a computerized tracking system were used, but the complete training hours for the two CNAs could not be found in the records reviewed.
A resident with a g-tube, BIMS 10, HTN, stroke, and anxiety had orders for oral KCL and PRN clonidine despite being NPO and receiving tube feeding. The pharmacy consultant flagged both orders for clarification because they read to give by mouth, but the follow-through was not completed; the MAR showed KCL was given daily and clonidine was not administered.
Two Spanish-speaking residents with moderate cognitive impairment and complex medical needs were unable to fully participate in their care due to the absence of Spanish-language care plans, communication boards, and adequately trained staff. Staff relied on informal translation methods, and family members reported ongoing communication barriers that affected the residents' ability to express their needs and preferences.
Two residents with moderate cognitive impairment and significant medical needs, whose primary language was Spanish, did not have care plans addressing their communication needs. Staff relied inconsistently on phone translation apps or Spanish-speaking staff, and communication boards were not available in the residents' rooms. The facility's interdisciplinary team did not create or implement appropriate communication care plans until prompted by surveyors, resulting in a lack of systematic support for these residents.
A resident with advanced cancer and significant care needs was left for an extended period covered in dried vomit and debris, as shown in photos and confirmed by interviews. Staff failed to provide timely hygiene care and did not consistently document care actions, resulting in the resident remaining in an undignified state.
Two residents experienced falls due to inadequate supervision and improper use of assistance devices. One resident fell from a mechanical lift due to a broken sling loop, resulting in a scalp hematoma and T12 compression fracture. Another resident's wheelchair tipped over in a transportation van due to improper securing, though no injuries were sustained. These incidents highlight failures in safety protocols and equipment inspection.
A resident was temporarily moved to a different room due to a Covid-19 outbreak, but her personal photographs and decor were not transferred with her, leaving her surrounded by unfamiliar items. The resident, who was moderately cognitively impaired, expressed a desire for her belongings to be moved. The facility's administrator was unaware of the potential risks of not having personal belongings, despite the facility's policy emphasizing residents' rights to keep and use personal property.
Expired medications were found in medication carts and a refrigerator, including pantoprazole sodium sachets, hydroxyzine vials, and intravenous medications. Staff interviews revealed lapses in checking for expired medications, despite training. The ADONs and DON acknowledged a breakdown in supervision, with expired medications overlooked by both staff and a pharmacist.
The facility failed to properly label, date, and store food items in the kitchen, leading to potential contamination. Observations revealed unlabeled and improperly stored food, including ground meat and pot roast, which had turned a dark color. Additionally, the steam table contained food particles and was not cleaned regularly. The Dietary Manager acknowledged these issues, and the facility's policies on food storage and equipment sanitization were not followed.
A resident with severe cognitive impairment and multiple health issues was found in a visibly dirty wheelchair on several occasions. Despite facility policies and staff expectations, the wheelchair was not cleaned, as confirmed by interviews with staff including an LVN, CNA, ADON, and DON. The facility's policy emphasized the importance of maintaining clean equipment to prevent hazards, yet this was not adhered to, placing the resident at risk of hygiene issues.
A resident with severe cognitive impairment and diabetes had a DTI on her buttocks that was not covered with a dressing, contrary to physician orders. The CNA noticed the missing dressing but failed to inform the nurse, and the LVN was unaware of the issue. The DON confirmed that staff were expected to report such issues, but no in-service training on wound care had been conducted. This failure to adhere to care protocols potentially placed the resident at risk of infection.
A facility failed to ensure proper disposal of sharps, placing residents at risk of exposure to contaminated sharps. An LVN was observed discarding a lancet and needle into a trash can instead of a sharps container after performing procedures on a resident. Interviews revealed awareness of the correct protocol, but it was not followed, and no recent training on sharps disposal had been conducted.
A resident with severe cognitive impairment and a Foley catheter was found with their catheter bag improperly positioned on the floor, contrary to the care plan and facility policy. Despite staff responsibilities to ensure proper catheter care, observations and interviews revealed lapses in adherence, placing the resident at risk for infection.
A resident did not receive the correct dosage of Depakote through a gastrostomy tube due to an LVN's failure to verify physician orders and check gastric residual volume. The LVN administered two capsules instead of one and did not check the residual volume, which is crucial for proper medication absorption. The facility's policies on medication administration were not followed, as confirmed by interviews with the LVN and DON.
The facility's admission policy failed to protect residents' personal property by requiring them to waive potential facility liability. This was highlighted by incidents where two residents reported missing money and credit cards. Despite the facility's awareness and offers of a trust fund and lock box, the policy of not assuming responsibility for personal belongings was not compliant with regulations.
A resident with non-Hodgkin's lymphoma required surgical wound care, during which an LVN failed to perform proper hand hygiene. The LVN did not wash hands before putting on gloves, after removing the old dressing, or after cleansing the wound, contrary to the facility's wound care policy. The DON confirmed the expectation for hand hygiene to prevent cross-contamination and infection.
Incomplete Documentation of Bruising on Weekly Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 1 of 11 residents reviewed, specifically by not documenting bruising on a resident’s Weekly Wound Progress Report during the admission period. The resident was admitted for rehabilitation after a significant cerebral infarction and had diagnoses including cerebral infarction, acute cystitis, atherosclerotic heart disease, and benign prostatic hyperplasia. He was severely cognitively impaired, had short- and long-term memory problems, used a wheelchair, and was totally dependent on staff for toileting, bathing, and other personal hygiene tasks. His care plan noted anticoagulant therapy related to CVA, and provider orders included aspirin, clopidogrel, enoxaparin, and monitoring for bleeding-related adverse reactions. Facility shower sheets documented bruising on the resident’s arms on multiple occasions, including bilateral arm bruising and bruising on the left forearm. However, the Weekly Wound Progress Report did not contain documentation related to the bruising on the resident’s arms, and the provider’s wound care surgical notes also did not document the bruising. The Treatment Nurse stated the bruising was typical with anticoagulant therapy, age, and skin fragility and would not necessarily require documentation on the weekly skin assessment. The DON stated she reviewed the shower sheets daily, was aware of the discoloration and its possible causes, and did not feel it required further assessment or documentation.
Failure to Change Gloves and Perform Hand Hygiene During Wound and Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program during wound care for two residents. One resident had a stage 4 sacral pressure ulcer, was admitted with diagnoses including pressure ulcer of the sacral region, and had an order to cleanse the sacrum with normal saline, pat dry, apply calcium alginate, and cover with a dry dressing daily. A second resident had bilateral lower-extremity amputations, had surgical wounds, and had an order to cleanse the left AKA stump with normal saline, pat dry, apply Betadine, and leave open to air daily. During observation of wound care, the wound nurse performed hand hygiene and put on clean gloves, but after removing the soiled dressing from the first resident she did not remove the soiled gloves before continuing wound care with the same gloves. During care for the second resident, she did not sanitize her hands before putting on clean gloves after cleaning the sacral area and then proceeded to cleanse the left AKA stump surgical wound. When interviewed, the wound nurse stated she should put on gloves, cleanse, change gloves, and sanitize hands before putting on new gloves, and said changing gloves from dirty to clean procedures is important to prevent the wound from getting worse and infected. The facility also failed to ensure proper glove use during incontinent care for the first resident. During observation, the CNA performed incontinent care and did not change her gloves throughout the observation. In interview, the CNA stated she should wash hands and change gloves, keep hands clean, and not touch the resident with dirty gloves, and acknowledged she had received training on incontinent care. The LVN and DON both stated that gloves should be changed and hands sanitized when moving from dirty to clean tasks during wound care and incontinent care, and the facility policy stated handwashing should occur before and after caring for each resident, before and after applying gloves, and after contact with contaminated items.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of Resident #3’s needs and preferences when the resident’s call light was not kept within reach. Resident #3 was a [AGE]-year-old male admitted on [DATE] with diagnoses of muscle weakness and abnormalities of gait and mobility. His care plan, dated 04/23/26, identified an ADL self-care performance deficit related to decreased mobility and lack of coordination and directed staff to encourage him to use the bell to call for assistance. The same care plan also identified him as at risk for falls related to a history of falls at home, muscle weakness, and lack of coordination, with interventions to ensure the call light was within reach and to encourage its use as needed. The quarterly MDS assessment showed a BIMS score of 7, indicating severe cognitive impairment, and documented that the resident required substantial assistance with toileting, hygiene, dressing, bed mobility, and transfer. During observation on 06/18/26 at 10:55 a.m., the resident was in bed awake and his call light was observed on the floor, while the resident pointed to it hanging off the wall and did not give a verbal response. Staff interviews confirmed that the call bell should always be within reach, that all staff were responsible for ensuring it was in place, and that no other intervention had been implemented even though the resident was reported to throw the call bell away from himself. The facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Wound Care Provided Without Following Physician Order
Penalty
Summary
The facility failed to ensure that Resident #2 received wound care in accordance with the physician’s order and the facility’s wound cleaning protocol for the left above-the-knee amputation stump dressing change. Resident #2 was a [AGE]-year-old female admitted on [DATE] with diagnoses including acquired absence of the left leg below the knee and acquired absence of the right leg below the knee. Her MDS dated [DATE] indicated a BIMS score of 15 and that she had surgical wounds. The physician order dated 06/08/26 directed staff to cleanse the left AKA stump with normal saline, pat dry, apply Betadine, and leave open to air daily. During observation and interview on 06/18/2026, the wound nurse cleansed the left AKA stump with wound cleanser, applied Betadine solution, and covered the area with a 4-inch x 4-inch bordered gauze. When questioned, the wound nurse stated the bordered gauze was applied per the resident’s request even though it was not part of the wound care orders, and she stated she should have checked with the doctor first and obtained an order before implementing the request. The DON stated the procedure was to notify the physician of the resident request and obtain a one-time or PRN order before carrying out the treatment request, and that treatment without an order could result in the wound not healing.
Fall precautions not maintained for two residents
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards for two residents who were identified as being at risk for falls. For one resident with muscle weakness, gait and mobility abnormalities, and severe cognitive impairment, the care plan directed staff to keep the call light within reach, respond promptly to requests for assistance, and follow the fall protocol. During an observation, the resident was in bed while the fall mat was found leaning against the wall instead of being placed beside the bed. Staff interviewed afterward stated the mat should have been next to the bed and that it was everyone’s responsibility to keep it in place. For another resident with Parkinson’s disease, dementia, prior femur and rib fractures, muscle weakness, orthostatic hypotension, and a history of multiple falls, the care plan directed staff to follow the facility fall protocol. The record also showed recent falls with a bed change for safety and fall precautions. During an observation, the resident’s bed was not in the lowest position until a CNA was alerted and lowered it. Staff interviews stated that the bed should be kept in the lowest position and that the CNA and nurse were responsible for ensuring the fall precautions were in place. The facility’s fall clinical protocol stated that staff and the physician would identify interventions to prevent subsequent falls and that staff would follow up on falls with injury until the resident was stable. Interviews with the CNA, housekeeper, LVN, and DON all confirmed that the fall mat should have been in place for the first resident and that the bed should have been in the lowest position for the second resident. The observations showed that these fall-prevention measures were not in place at the time the residents were found in bed.
Improper Storage of Oxygen Tubing and BiPAP Mask
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who were receiving oxygen therapy and, for one resident, BiPAP therapy. Resident #4 was an older female with COPD and chronic respiratory failure with hypoxia, had a BIMS score of 08, and had a care plan and physician order for continuous oxygen at 3 liters via nasal cannula. Resident #5 was an older male with COPD, had a BIMS score of 11, and had care plan and physician orders for PRN oxygen at 2 liters via nasal cannula and noninvasive ventilation via BiPAP. During observation and interview, Resident #4 was found lying in bed with the oxygen tubing connected to the oxygen tank on the wheelchair draped across the wheelchair and not stored in a bag. Resident #4 stated she did not know how the oxygen tube should be stored. During a separate observation and interview, Resident #5 was sitting in his wheelchair with oxygen tubing connected to his oxygen machine laying on his nightstand and not stored in a bag. His BiPAP machine and breathing mask were also on the nightstand, and the breathing mask was not bagged. Resident #5 stated he used oxygen when he laid in bed and that no one had told him the oxygen tube and BiPAP mask should be in a bag. A CNA stated she had changed Resident #4 and left her in bed per request, and did not notice the exposed nasal cannula on the wheelchair. She stated the facility policy is that nasal cannulas and breathing masks should be bagged when not in use, and that nurses and CNAs are responsible for ensuring this because bagging prevents contamination. An LVN stated the oxygen tubes and BiPAP mask should be bagged for infection control and that staff are responsible for making sure this occurs. The DON stated that anytime the oxygen tube and BiPAP mask are not in use they should be placed in a bag to prevent bacterial contamination. The facility policy stated to keep oxygen cannula and tubing used PRN in a plastic bag when not in use or cover tubing with a poly tubing cover.
Incontinence Care and Foley Catheter Order Deficiencies
Penalty
Summary
The facility failed to ensure Resident #63, an older female with heart failure, dementia, cognitive communication deficit, severe cognitive impairment, and frequent bladder and bowel incontinence, received appropriate continence care. Her quarterly MDS reflected she required moderate assistance with toileting and was not on a toileting program. During observation, she was found in bed with a brown ring on the fitted sheet and an odor of urine about her. When staff later changed her, the fitted sheet, top sheet, and the bottom of her shirt were wet with urine, and she was wearing two briefs, with the inner brief soaked with urine. Staff interviews confirmed that double briefing was not allowed and that incontinent residents were to be checked every two hours, but the resident had remained soiled until staff intervened. The facility also failed to ensure Resident #5 had a physician order for an indwelling catheter. Resident #5’s MDS reflected cognitive impairment, dependence on staff for personal hygiene and toileting assistance, and use of an indwelling catheter. His care plan referenced Foley catheter use, enhanced barrier precautions, catheter care, and monitoring for urinary tract infection signs and symptoms. However, the December 2025 treatment administration record contained no treatment order for the catheter or catheter care, and the physician’s orders did not include an order for catheter use, the French size, or any care or treatment related to the catheter. A progress note documented that Resident #5 had a 16 French Foley catheter inserted on 12/02/2025, and staff interviews showed awareness that he required catheter checks for drainage, cleanliness, and signs of infection. The LVN who reviewed the chart could not locate a catheter order, and the ADON and DON stated the admitting nurse should have entered the order and the ADON should have reviewed it within 24 hours. The DON stated the orders were in the queue but had not been approved and needed to be activated, and that the omission placed the resident at risk of inadequate care to the Foley, monitoring, and infections.
Missed Scheduled Medication Doses
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when two residents did not receive scheduled medications as ordered. Resident #13, a female with chronic pain, rotator cuff pain, and Alzheimer’s disease, had physician orders for Hydrocodone-Acetaminophen 10-325 mg three times daily and an additional PRN hydrocodone order. Her December 2025 MAR showed that the scheduled 2:00 PM dose was not administered on 12/15/25. Resident #98, a male with high blood pressure, fractures of the left leg and right pelvis, and dementia, had an order for Hydralazine 50 mg three times daily. His December 2025 MAR showed that the 2:00 PM dose was not administered on 12/15/25. His vital signs on that date showed a blood pressure of 122/61, and he stated on interview that he was not aware he had missed the dose and denied headache. Staff interviews showed the morning medication pass for the 400 Hall was delayed because an agency medication aide did not report to work, and an agency nurse was pulled from the 200 Hall to cover medications for both halls. LVN-E stated she was still administering morning medications for the 400 Hall at 12:00 PM and began giving them around 11:30 AM after realizing they had not been given. ADON-D stated she was notified around 7:00 AM, later realized the 400 Hall had not been covered, and contacted physicians who said not to give afternoon medications, only morning and evening doses. The DON stated there was miscommunication about the agency nurse’s assignment and that other nurses in the building could have assisted, but she was not made aware until 11:45 AM. The facility’s Medication and Treatment Orders policy did not address medications being administered by the frequency ordered or the timeliness of medication administration.
Unsealed and Unlabeled Food Stored in Kitchen
Penalty
Summary
Food subject to spoilage and removed from its original container was found in the kitchen freezer inside the walk-through fridge not kept sealed, labeled, or dated. During observation and interview with the Dietary Manager, a container of red sauce, corn, gravy, and green beans were identified as leftovers but were not labeled with their contents or a disposal date. The fridge also contained open, exposed diced ham, sliced turkey, and link sausage in their original packaging without being sealed to air or marked with a disposal date. The freezer inside the walk-through fridge also contained two clear bags of unknown, unlabeled white balls that were not sealed and were open to air. The Dietary Manager stated she had been out of work for a week and had not completed her daily walk-through of the kitchen upon returning. She stated the cooks and all kitchen staff were responsible for properly labeling, dating, and removing items past the 7-day time frame. The Administrator later stated he was not aware the food had been found opened, unsealed, and missing labels or disposal dates, and acknowledged the Dietary Manager was responsible for ensuring food was kept in a safe manner to prevent foodborne illnesses.
Incomplete CNA Annual In-Service Training
Penalty
Summary
The facility failed to provide sufficient in-service training to ensure the continuing competence of nurse aides, including the required annual education in dementia care, abuse prevention, and care of cognitively impaired residents. Based on interview and record review, CNA G and CNA H did not have evidence of the required 12 hours of annual training. CNA G’s personnel record showed a hire date of 10/24/23, and CNA H’s personnel record showed a hire date of 02/28/23, but the annual training records reviewed did not show 12 hours of annual in-service training for either aide. During interview, the ADON stated that in-services were provided by the ADONs and DON together and said she was aware all CNAs had to have 12 hours annually, but she was not aware CNA G and CNA H were short on training hours. The DON stated that she and the ADONs provided monthly CNA in-services and that the company also used a computerized program to send aides certain in-services to complete, but she was not aware CNA G and CNA H did not have their 12 hours. The Regional Corporate RN stated the computerized system appeared to be corrupted because the complete 12 hours for CNA G and CNA H could not be found. The facility policy titled In-Service Training Program, Nurse Aide stated annual in-services are no less than 12 hours per employment year.
Pharmacy Recommendation Not Followed for Oral Medication Orders
Penalty
Summary
The facility failed to ensure that pharmacy consultant drug regimen irregularities were acted upon for one resident whose medications were reviewed. Resident #54 was a readmitted male with a BIMS score of 10, diagnoses including hypertension, stroke, and anxiety disorder, and he received 51% or more of his calories through tube feeding. His orders listed NPO status, clonidine 0.1 mg by mouth every 8 hours as needed for HBP, and potassium chloride liquid 20 mEq by mouth daily for low potassium, while the December 2025 MAR showed potassium chloride was administered each day and clonidine was not given. The pharmacy consultant’s Quality Assurance-Nursing Recommendations, dated 09/29/25, noted that the resident received medications via PEG tube and that the orders for KCL and clonidine PRN read to give by mouth, with a request to clarify; the follow-through column was checked. During interviews, the ADON stated the resident used a g-tube and could not have anything by mouth, including medications, and said she and the other ADON were responsible for reviewing pharmacy recommendations and making needed changes. The DON stated the ADONs were responsible for follow-up on pharmacy recommendations and that she trusted them to complete them accurately.
Failure to Provide Language-Appropriate Communication for Spanish-Speaking Residents
Penalty
Summary
The facility failed to ensure that two residents, both of whom primarily spoke Spanish and had moderate cognitive impairment, were fully informed of and able to participate in their care and treatment in a language they could understand. Both residents had complex medical conditions and required substantial assistance with activities of daily living. Record reviews showed that their care plans were not available in Spanish, and there were no communication boards, binders, or devices at their bedsides to facilitate communication in their preferred language. Interviews and observations revealed that staff often relied on ad hoc translation by Spanish-speaking staff members or used phone apps, but there was no consistent or systematic approach to ensuring effective communication. Several staff members, including the ADON, MDS RN, and DON, acknowledged that communication boards were not present in residents' rooms and that staff had not received training on communicating with non-English speaking residents. Family members of both residents expressed concerns about the lack of Spanish-speaking staff and the residents' inability to communicate their needs, including pain and care preferences, to the staff. The facility's own policies and posted resident rights stated that residents have the right to communicate in their native language to receive treatment, care, and services. Despite this, the facility did not provide adequate resources or training to ensure that Spanish-speaking residents could effectively communicate with staff about their care, leading to unmet needs and a lack of participation in their own treatment decisions.
Failure to Develop and Implement Person-Centered Care Plans for Non-English Speaking Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents whose primary language was Spanish. Both residents had moderate cognitive impairment and significant medical and functional needs, including assistance with activities of daily living, mobility impairments, incontinence, and multiple chronic medical conditions. Despite these needs and the residents' inability to communicate in English, their care plans did not include communication strategies or materials in Spanish, nor were there communication boards or devices available in their rooms to facilitate understanding between staff and residents. Observations and interviews revealed that staff members, including CNAs and RNs, did not speak Spanish and relied on phone translation apps or Spanish-speaking staff when available. However, there was no consistent or systematic approach to ensuring effective communication with Spanish-speaking residents. Communication boards were only available at the nurses' station and therapy room, not in the residents' rooms, and staff were not uniformly trained on how to use translation tools or communication aids. Several staff members confirmed the absence of communication binders or boards in the rooms of non-English speaking residents, and some were unaware of the need for such resources. The facility's own care plan policy requires the interdisciplinary team (IDT) to develop care plans based on comprehensive assessments, including the resident's preferences and needs. However, interviews with the DON, MDS coordinator, and other staff indicated that care plans addressing language and communication needs for Spanish-speaking residents were not created until prompted by surveyor inquiries. The lack of timely and appropriate care planning for communication placed these residents at risk of having unmet needs due to language barriers.
Resident Left in Soiled Condition Due to Inadequate Hygiene Care and Documentation
Penalty
Summary
A deficiency occurred when a male resident with multiple complex medical conditions, including advanced cancer, malnutrition, dysphagia, and cognitive communication deficits, was left for an extended period covered in a substance that appeared to be dried vomit and other detritus. The resident required substantial to maximal assistance with self-care activities, as documented in his Minimum Data Set (MDS). On the day in question, the resident experienced episodes of vomiting, which were documented by nursing staff, and was administered medication for nausea. However, photographic evidence provided by a complainant showed the resident lying in bed shirtless, with dried brown substances visible on his chest, stomach, chin, facial hair, and hands, as well as a vomit bag with a significant amount of brown substance next to him. Interviews with staff revealed inconsistencies in the provision and documentation of personal hygiene care. The Certified Nursing Assistant (CNA) assigned to the resident stated she entered the resident's room multiple times to clean vomit but did not document each instance, citing a lack of a place to chart. The Activities of Daily Living (ADL) log only reflected two instances of personal hygiene care for the resident on the day in question. Other staff members, including the Director of Nursing (DON) and another CNA, stated that if a resident was observed to be dirty or covered in vomit, they would expect immediate cleaning. The DON acknowledged there was no way to determine how long the resident was left in this condition and estimated it would take 1-2 hours for vomit to dry. The facility's documentation and policy review indicated that all care actions, including hygiene assistance, should be recorded each time they are performed. However, the Administrator confirmed that charting was done by exception and could not specify an acceptable timeframe for how long a resident could remain soiled before being cleaned. The facility was unable to provide a copy of its Resident Rights policy during the survey. The failure to ensure timely and adequate hygiene care for the resident, as well as proper documentation, resulted in the resident remaining in a soiled and undignified state for an extended period, as evidenced by both photographic documentation and interviews.
Inadequate Supervision and Equipment Use Lead to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and the use of proper assistance devices to prevent accidents for two residents. In the first incident, two CNAs were involved in the improper transfer of a resident using a mechanical lift. The resident, who had severe cognitive impairment and was dependent on staff for all functional abilities, fell from the lift due to a broken sling loop. The CNAs used a sling with known damage, and during the transfer, the right side sling strap loop broke, causing the resident to fall and sustain a scalp hematoma and a T12 compression fracture. In the second incident, a van driver failed to properly secure a resident's wheelchair in the facility's transportation van. The resident, who had moderate cognitive impairment and required a wheelchair for mobility, was being transported to a dialysis appointment when the wheelchair tipped over. The van driver heard a loud popping noise and saw the resident and wheelchair moving, but was unable to prevent the fall. The resident ended up on the floor of the van with the wheelchair on top of his feet, although he did not sustain any injuries. Both incidents highlight a lack of adherence to safety protocols and proper equipment inspection. The CNAs involved in the first incident did not ensure the sling was in good condition before use, and the van driver did not secure the wheelchair properly, leading to the resident's fall. These failures in supervision and equipment use placed the residents at risk of injury.
Failure to Maintain Homelike Environment During Room Change
Penalty
Summary
The facility failed to ensure that a resident's right to a safe, clean, comfortable, and homelike environment was maintained during a temporary room change due to a Covid-19 outbreak. The resident, who was moderately cognitively impaired and had a history of cerebral infarction, hemiplegia, hemiparesis, cognitive deficits, and anxiety disorder, was moved to a different room after her previous roommate tested positive for Covid-19. However, her personal photographs and decor were not moved with her, leaving her surrounded by unfamiliar personal items. The resident expressed her desire to have her personal belongings moved to her temporary room until the outbreak subsided. The facility's administrator was under the impression that most of the resident's personal belongings had been moved with her, but acknowledged that he was not aware of the potential risks posed by the absence of personal belongings. The facility's policy on resident rights emphasizes the importance of residents being able to keep and use personal property, which was not upheld in this instance.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, specifically in the management of expired medications, which were found in various locations including medication carts and a refrigerator. During an observation, expired medications such as pantoprazole sodium sachets, hydroxyzine vials, and intravenous medications like ampicillin-sulbactam, piperacillin/tazobactam, and meropenem were discovered. These expired medications were not removed and destroyed as required, posing a risk of administering ineffective drugs to residents. Interviews with staff revealed lapses in the responsibility of checking for expired medications. A medication aide admitted to not recalling the last time she checked her cart for expired medications, despite acknowledging the importance of doing so to prevent adverse reactions and ensure effective therapy. Similarly, a nurse on the 400 Hall admitted to not checking her cart during her shift and was aware that expired medications should have been removed. Both staff members had received training on medication management but failed to adhere to the protocols. Further interviews with the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON) highlighted a breakdown in the chain of command and supervision. The ADONs were responsible for checking the refrigerator and ensuring expired medications were removed, but they failed to do so effectively. The DON acknowledged the oversight and indicated that the pharmacist also missed the expired medications during a previous check. The facility's policy required checking expiration dates before administering medications, but this was not consistently followed, leading to the deficiency.
Improper Food Storage and Cleaning Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in its kitchen, which could lead to food contamination and foodborne illness. During an observation of the refrigerator, it was found that food items such as green beans, ground meat, and pot roast were not labeled or dated after being removed from their original packaging. The ground meat and pot roast were improperly stored, wrapped in plastic wrap, and had turned a dark/grey color, with liquids from the meat pooling on the tray. The Dietary Manager acknowledged these issues, stating that the expectation was for cooks to label and date items, and that a daily walkthrough was conducted to remove items after seven days and clean the refrigerator. Additionally, the facility failed to maintain cleanliness in the kitchen's steam table. Observations revealed food particles, including green beans, diced carrots, and elbow macaroni noodles, in the water of the steam table. The Dietary Manager and a staff member responsible for the steam table confirmed that it was cleaned only twice a week, and the staff member was unsure how long the food particles had been present. The Dietary Manager stated that the steam table should be cleaned after each use to prevent cross-contamination. The facility's policies on food storage and equipment sanitization were not followed, contributing to these deficiencies. The policies required labeling, dating, and sealing of refrigerated foods, using leftovers within 72 hours, and storing raw meats on the bottom shelf. The sanitization policy outlined procedures for cleaning equipment, including removing food particles and sanitizing surfaces. The Administrator confirmed that the Dietary Manager was responsible for ensuring compliance with these guidelines to prevent food contamination and illness.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, specifically regarding the cleanliness of the resident's wheelchair. The resident, a male with severe cognitive impairment and multiple health issues including Parkinson's disease and osteoarthritis, was observed on multiple occasions sitting in a wheelchair that was visibly dirty with debris. Despite the facility's policy and staff expectations for maintaining clean equipment, the resident's wheelchair was not cleaned, which was acknowledged by both nursing and housekeeping staff during interviews. Interviews with staff, including an LVN, CNA, ADON, and DON, revealed a lack of adherence to the facility's procedures for maintaining clean wheelchairs. The LVN and CNA admitted to not noticing or addressing the cleanliness of the wheelchair, while the ADON and DON stated that it was the responsibility of the nursing staff to ensure wheelchairs were clean. The facility's policy on hazardous areas and equipment emphasized the importance of maintaining clean and properly functioning equipment to prevent potential hazards, yet this was not followed, placing the resident at risk of hygiene issues and potential infection.
Failure to Maintain Dressing on Resident's Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. The resident, a female with severe cognitive impairment and a history of diabetes, had a deep tissue injury (DTI) on her right and left buttocks across the sacrum. Despite having a physician's order to clean the wound and apply a hydrocolloid bandage three times a week, the resident was observed without a dressing on the wound. This oversight was noted during an observation with an LVN, who was unaware that the dressing was missing. The resident's care plan included monitoring and documenting the wound's condition, but these measures were not effectively implemented. Interviews with staff revealed lapses in communication and adherence to care protocols. A CNA admitted to noticing the absence of the dressing during incontinence care but failed to notify the nurse, citing forgetfulness. The LVN responsible for the resident's wound care stated that she had applied a dressing the previous day and expected staff to monitor the dressing every shift. However, she had not conducted any training for the staff due to being newly hired. The DON confirmed that staff were expected to follow orders and notify nurses if a dressing came off, but acknowledged that no in-service training on wound care had been completed. The facility's policy required staff to report any issues with dressings to the nurse, but this protocol was not followed, potentially placing the resident at risk of infection.
Improper Disposal of Sharps Poses Risk in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not ensuring proper disposal of sharps, which placed residents at risk of exposure to contaminated sharps and potential bloodborne pathogens. During an observation, LVN H was seen discarding a lancet and a needle into a trash can instead of a designated sharps container after performing a blood sugar check and administering insulin to a resident. This action was contrary to the facility's policy, which requires immediate disposal of contaminated sharps into designated containers that are closable, puncture-resistant, leakproof, and properly labeled. Interviews with LVN H, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) revealed that there was an awareness of the correct protocol for sharps disposal, but it was not followed. LVN H admitted to wrapping sharps in gloves and discarding them in the trash, acknowledging the risk of staff being stuck and potential infection spread. Both the ADON and DON expressed that their expectation was for all sharps to be discarded in sharps containers and recognized the risk of injury from improper disposal. However, it was noted that there had been no recent training on sharps disposal for the staff.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in maintaining the proper positioning of the catheter bag to prevent urinary tract infections. The resident, who had severe cognitive impairment and was dependent on staff for toileting, had a Foley catheter due to a stage 4 pressure ulcer. Observations revealed that the catheter bag was found leaning on the floor, which was not in compliance with the care plan that required the bag to be positioned below the bladder and off the floor. This improper positioning was observed on multiple occasions, indicating a lapse in the staff's adherence to the care plan. Interviews with the staff, including a CNA, LVN, ADON, and DON, revealed a lack of consistent monitoring and adherence to the facility's catheter care policy. The CNA responsible for the resident's care stated that she had not observed any issues with the catheter bag touching the floor, despite evidence to the contrary. The LVN acknowledged that CNAs were responsible for ensuring the catheter bags were not on the floor, and the ADON and DON confirmed that all nursing staff were responsible for securing the catheter bags properly. The facility's policy emphasized the importance of keeping catheter tubing and drainage bags off the floor to prevent infections, yet this was not consistently followed, placing the resident at risk for infection.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of medication through a gastrostomy tube. On a particular morning, a Licensed Vocational Nurse (LVN) did not administer the correct dosage of Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg as per the physician's orders. The LVN administered two capsules instead of one, as the order had been changed earlier in the month. This discrepancy was due to the LVN not checking the physician's orders before administering the medication, relying instead on the blister pack instructions. Additionally, the LVN did not check the gastric residual volume before administering the medication through the gastrostomy tube, which is a critical step in ensuring the medication is absorbed properly. The facility's policy requires checking the residual volume to ensure it is not above a certain threshold, which could indicate that the resident's stomach is not processing food or medication effectively. The LVN admitted to forgetting this step, which could lead to the resident not receiving the therapeutic dose of the medication. Interviews with the LVN and the Director of Nursing (DON) revealed that the facility's expectations and policies were not followed. The DON emphasized the importance of adhering to the seven rights of medication administration and verifying orders before administration. The failure to follow these protocols could result in adverse effects such as overdose or underdose, and the medication not being effective due to improper absorption.
Facility's Admission Policy Fails to Protect Residents' Personal Property
Penalty
Summary
The facility failed to implement an admissions policy that did not require residents to waive potential facility liability for the loss of personal property. This deficiency was identified through interviews and record reviews, revealing that the facility's policy included a statement that the community assumes no liability for the security of personal items retained by residents or kept in their rooms. This policy was part of the resident's admission packet and was signed by the resident or responsible party. The deficiency was highlighted by incidents involving two residents who reported missing personal property. One resident, an elderly female with intact cognition, reported missing a significant amount of cash and credit cards shortly after her admission. Despite the involvement of the police and the facility's administration, the missing items were not recovered, and the resident's account of the incident varied. Another resident, also with intact cognition, reported $20 missing from her room. The facility offered a trust fund and lock box to secure personal items, but the resident declined these options. Interviews with the facility's social worker and administrator confirmed awareness of the missing items and the facility's policy of not assuming responsibility for personal belongings. The administrator acknowledged that residents were encouraged not to keep valuables and that the facility would replace items if staff were found responsible for their loss. However, the facility's policy of not assuming liability for personal items was not compliant with regulations, as it effectively required residents to waive potential facility liability.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program during wound care for a resident diagnosed with non-Hodgkin's lymphoma. The resident required surgical wound care, and the Licensed Vocational Nurse (LVN) responsible for the care did not adhere to proper hand hygiene protocols. During the procedure, the LVN did not perform hand hygiene before putting on gloves, after removing the old dressing, or after cleansing the wound. This lapse in protocol was observed during a wound care session, where the LVN changed gloves without washing hands, potentially leading to contamination of the wound. Interviews with the LVN and the Director of Nursing (DON) revealed a lack of adherence to the facility's wound care policy, which mandates hand hygiene after removing gloves and before touching the wound. The DON confirmed that the LVN was expected to perform hand hygiene at specific points during the wound care process to prevent cross-contamination and infection. Despite previous training and skills assessments, the LVN did not follow the established procedures, as outlined in the facility's policy revised in October 2010.
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.
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What surveyors actually found near you
We read the 864 citations issued within 25 miles in the last 12 months — including the 28 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marine Creek Nursing & Rehabilitation | 3.5 mi | ★★★★★ | 18 | 0 |
| Fort Worth Wellness & Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
| River Oaks Health And Rehabilitation Center | 4.9 mi | ★★★★★ | 17 | 2 |
| Lake Lodge Nursing & Rehabilitation | 5.3 mi | ★★★★★ | 11 | 0 |
| The Harrison At Heritage | 6.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.