Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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 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.
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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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.
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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 | — | 0 | 0 |
| Covenant Skilled Nursing And Rehabilitation At Wel | 2 mi | — | 3 | 0 |
| Great Lakes Rehabilitation Center | 2.4 mi | — | 24 | 0 |
| Healthsource Saginaw, Inc | 3 mi | — | 3 | 0 |
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