Healthsource Saginaw, Inc

In the surveyor’s words

From the most serious findings on record at Healthsource Saginaw, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 15, 2023

  This Citation will have three Deficient Practice Statements (DPS). DPS #1 and DPS #2 pertain to two separate elopements resulting in two Immediate Jeopardies (IJ). Deficient Practice Statement #1 This Citation pertains to Intake Number MI00136527 Based on interview and record review the facility failed to respond to audible alarms and instead silenced the alarms, without verifying the source and ensuring that all residents were accounted for, resulting in one resident (Resident #110) eloping from the facility and crawling alongside the perimeter of the facility over grass, pavement and rocks on his hands and knees with the potential for serious harm and/or injury of two residents reviewed for wandering/elopement. […]

• Actual harm, isolatedF689Jan 14, 2025

  This Citation pertains to Intake Number MI00149011. Based on observation, interview and record review, the facility failed to supervise and prevent a fall for one resident (Resident #1) with a history of anticoagulants and falls, of 3 sampled residents, resulting in the lack of meaningful interventions to prevent repeated falls and the lack of ongoing supervision of a resident, who was a known fall risk, resulting in Resident #1 sustaining a fall from wheelchair and suffering a subdural hematoma with hospitalization and death. Findings include: Record review of the facility Assessment: Nursing' policy, dated 6/2021, revealed all residents will receive nursing care based on a documented assessment of individual needs/problems. […]

• Actual harm, isolatedF686Aug 12, 2024

  Based on observation, interview and record review, the facility failed to prevent two residents (Resident's #415 and Resident #75) from developing pressure ulcers, resulting in discomfort/pain, the likelihood for infection, delayed healing, antibiotic usage, and weekly wound care. Findings Include: Resident #415: Review of the Face Sheet, Wound Documentation dated 6/6/24 through 8/6/24, and care plans dated 1/23, revealed Resident #415 was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE], alert and his own person and required staff assistance with Activities of Daily Living/ADL's. The resident's diagnosis included, dementia, stroke, muscle weakness, anorexia, malnutrition, chronic pain, chronic kidney disease, and heart failure. […]

• Actual harm, isolatedF600Mar 27, 2024

  This Citation pertains to Intake Numbers MI00143243 and MI00143245. Based on interview and record review the facility failed to complete a comprehensive fall investigation and notification to a physician of X-ray results for one resident (Resident #602), resulting in; 1. Resident #602 falling on 02/26/2024, X-rays being completed on 02/27/2024 with the resident sustaining a nasal bone fracture, left side of maxilla (bone that forms upper jaw) fracture with recommendation for CT (computed tomography) scan; 2. Facility's failure to notify physician of x-ray results and recommendations.; 3. […]

• Actual harm, isolatedF684Aug 24, 2023

  This Citation Pertains to Intake Number MI00138983. Based on observation, interview and record review, the facility failed to institute and operationalize comprehensive monitoring, documentation, assessment, and interventions for three residents (Resident #20, Resident #44, and Resident #313) of three residents reviewed, resulting in a lack of timely assessment, documentation, and treatment of an injury of unknown origin for Resident #20, edema for Resident #44, and Resident #313 experiencing a displaced tibia (large bone in lower leg) fracture, lack of investigation, delayed care, unnecessary pain using the reasonable person concept, and the likelihood for decline in overall health status. […]