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 The Lodge Of Saginaw Health And Wellness during CMS and state inspections, most recent first.
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.
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.
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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) |
|---|---|---|---|---|
| Marine Creek Nursing And Rehabilitation | 3.5 mi | — | 17 | 0 |
| Fort Worth Wellness & Rehabilitation | 4.7 mi | — | 0 | 0 |
| River Oaks Health And Rehabilitation Center | 4.9 mi | — | 13 | 0 |
| Lake Lodge Nursing & Rehabilitation | 5.3 mi | — | 11 | 0 |
| The Harrison At Heritage | 6.5 mi | — | 11 | 0 |
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