Saginaw Senior Care and Rehabilitation Center, LLC

In the surveyor’s words

From the most serious findings on record at Saginaw Senior Care and Rehabilitation Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 21, 2022

  This Citation pertains to Intake Numbers MI 426 and MI 587. Based on interview and record review the facility is placed in Immediate Jeopardy for its 1) Failure to transfer one resident (Resident #1) to the hospital for emergency medical treatment after the resident called 911 twice asking for help and assistance and its 2) Failure to provide adequate assessment and monitoring for Resident #1, of four residents reviewed for abuse and neglect. On [DATE] Resident #1, who was cognitively intact and her own responsible party, returned to the facility from [CONDITION(S)] at approximately 4:30 PM and did not receive her medication in a timely manner. Resident #1 called 911 around 9:00 PM with complaints of not feeling well and not receiving her medication and care. […]

• Actual harm, isolatedF686Oct 9, 2024

  Based on observation, interview and record review the facility failed to prevent the development of and worsening of pressure ulcers for 3 residents (Resident #15, Resident #25, Resident #33) of five residents reviewed for pressure ulcers resulting in the development of facility-acquired pressure ulcers, including a Stage 3 pressure ulcer, and the worsening of pressure ulcers. Findings include: Resident #25 (R25): R25 is [AGE] years old and admitted to the facility on [DATE] with diagnosis that include encephalopathy, cerebral infarction and pressure ulcer of unspecified buttock, unspecified stage. […]

• Actual harm, isolatedF684Jul 15, 2024

  This Citation has two Deficient Practice Statements. Deficient Practice Statement 1: This Citation Pertains to Intake Numbers MI00137515 and MI00141236. Based on interview and record review, the facility failed to ensure that timely and appropriate care was provided, per professional standards of practice and Health Care Provider orders, for one resident (Resident #802) of three residents reviewed for assessment and monitoring, resulting in a lack of accurate infection control surveillance, Resident #802 not receiving medications as ordered for Covid-19, a lack of comprehensive assessment, documentation, and a timely response to an acute change in condition, and death. […]

• Actual harm, isolatedF684Oct 19, 2023

  Based on interview, record review, the facility failed to ensure quality of care for nursing assessment for two residents (Resident #17, Resident #62), resulting in infections for Resident's #17 peritoneal catheter site and Resident #62 being sent to the hospital for septic shock requiring antibiotic therapy and prolonged illness. Findings include: Record review of the facility provided 'Assessment, Nursing, Policy Number: NRS-114 and dated 07/01/2008, revealed that the purpose of the policy was to ensure adequate assessment of resident care needs in order to develop and comprehensive plan of care. Assuring the goals are directed at attaining the highest practical level of wellness based on residents' choices. […]

• Actual harm, isolatedF684Apr 21, 2022

  This Citation pertains to Intake Number MI 426. Based on interview and record review, the facility 1) Failed to ensure assessment, monitoring and notification to the physician in a timely manner for a resident experiencing a change in condition, and 2) Failed to monitor orthostatic blood pressures as ordered by the Physician, for one resident (Resident #1) of three residents reviewed for care needs, resulting in Resident #1 calling family and 911 expressing she was going to die, expressing low blood pressure, frustration, fear and a the lack of staff response. […]