The Lodge of Saginaw Health and Wellness

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for clinical records. The facility failed to ensure facility staff documented bruising on Resident #1's Weekly Wound Progress Report during his admission from 04/04/26 - 06/23/26. This failure could place residents at risk for inaccurate assessments and monitoring.

Inspectors wroteBased observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #1and #2) of six residents reviewed for infection control. 1. The facility failed to ensure Wound Nurse J performed hand hygiene and changed her gloves during Resident #1 and #2's wound care on 06/18/26. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/18/2026. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3's rooms were in a position that was accessible to the resident on 06/18/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of six residents reviewed for wound care. The facility failed to follow the facility's wound cleaning protocol for Resident #2's left above the knee amputation stump dressing change on 06/18/26. This failure put Resident #2 at risk of not receiving necessary treatment and a worsening of their wound.

Inspectors wroteTag: F689 /4027S/S= D Surveyor Name(s): [NAME] NnadiImmediate Supervisor: Verlair AsheBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 6 residents (Resident #3 and #6) reviewed for accident prevention. The facility failed to ensure Resident #3's fall mat was placed alongside his bed while she was lying in the bed on 06/18/26. 2. The facility failed to ensure Resident #6's bed was in a low position for fall prevention per the care plan while he was lying in bed on 06/18/26. This failure could prevent the residents from having an environment that was free from hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #4 and Resident #5) of six residents reviewed for respiratory care. 1. The facility failed to ensure Resident #4 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 06/18/26. 2. The facility failed to ensure Resident #5 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and BiPAP mask was stored properly when not in use on 06/18/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 Residents (Resident #63 and Resident #5) of 23 residents reviewed for bowel and bladder incontinence.1. The facility failed to ensure Resident #63 was not left in soiled briefs, or being double briefed.2. The facility failed to ensure Resident #5 had physician's order for an indwelling catheter (device used to drain urine from bladder). This failure could place residents at risk of skin breakdown, infections and improper treatment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 32 residents (Residents #13 and #98) reviewed for pharmacy services. The facility failed to administer the morning medications on time resulting in Residents #13's hydrocodone scheduled for 2:00 PM not being administered and Resident #98's hydralazine not being administered at 2:00 PM on 12/15/25. This failure could cause residents to develop changes in their medical conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in 1 of 1 kitchen. The facility failed to ensure various foods stored in the kitchen freezer inside the walk-through fridge were sealed, dated and labeled and remove items opened past 7-day time frame. This failure could place all residents at risk for food contamination and food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training and care of the cognitively impaired for 2 (CNA G and CNA H) of 5 CNAs reviewed for annual training. The facility failed to provide CNA G and CNA H with 12 hours per year of annual training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #54) whose drug regimens were reviewed. The facility failed to clarify Resident #54's orders for KCL (potassium chloride, which is used to treat and prevent low blood potassium levels) and Clonidine (a medication used to treat hypertension) when the facility's Pharmacy Consultant made the recommendation for the change on 09/29/25 when the order was to give the medications by mouth. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including: The right to be fully informed in language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition. for 2 of 12 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to ensure the staff was adequately able to communicate with Residents #1 and #2 in their primary language, Spanish, for their care and service needs. This failure place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 12 residents (Residents #1 and #2) reviewed for care plans. The facility failed to ensure their IDT created a communication care plans for their Spanish speaking Residents #1 and #2. This failure could place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and protect and promote the rights of each resident for 1 of 9 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 did not remain covered in a substance, which appeared to be dried vomit and other detritus, for an extended period. This failure could place residents at risk of psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #1 and Resident #2) reviewed for accidents. 1. On 12/31/24, CNA F and CNA G failed to safely transfer Resident #1 during the use of the mechanical lift, which resulted in the resident sustaining a scalp hematoma and T12 compression fracture. 2. On 12/18/24 the Van Driver failed to properly restrain Resident #2's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis. The noncompliance was identified as PNC. The IJ began on 12/18/24 and ended on 01/20/25. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but were not limited to receiving treatment and supports for daily living for one (Resident #1) of six residents reviewed for environment. The facility failed to ensure Resident #1's personal photographs and décor were moved with her into the room she had to temporarily move into on 09/26/24, due to a Covid-19 (a severe acute respiratory syndrome) outbreak. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (1 nurses medication cart for 400 hall and medication aide cart for 400 and 200 halls) of 3 carts and 1 refrigerator in the medication room reviewed for pharmacy services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. 1. The facility failed to ensure food items stored in the refrigerator were properly labeled with the contents after being removed from the original packages and dated to reflect when the food items were opened. 2. The facility failed to ensure food items stored in the refrigerator were properly discarded based on expiration date. 3. The facility failed to store ground meat and pot roast were wrapped in plastic wrap away from the original packaging with liquids flowing onto the tray with other items and had turned to a dark/grey color. These failures could place all residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #30) of six residents reviewed for resident rights. The facility failed to ensure Resident #30's wheelchair was free of debris. This failure could place residents at risk of not having a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing based on the comprehensive assessment for 1 of 4 residents (Resident #22) reviewed for pressure ulcers. The facility failed to ensure the DTI on Resident #22's right and left buttocks across the sacrum was covered with a dressing. This failure could place residents at risk of pain and lead to systemic infections causing harm for residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 of 1 resident (Resident#87) reviewed for hazards. The facility failed to ensure LVN H discarded sharps in the sharp containers. This failure placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #75) of four residents reviewed for quality of care. The facility failed to ensure Resident #75's catheter bag was not on the floor. This deficient practice could place residents at risk for UTIs and other infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for 1 of 3 residents (Resident #87) reviewed for pharmacy services. 1. The facility failed to ensure LVN H administered Resident #87's Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg 1 capsule via gastrostomy tube, in the morning related to mood on 09/11/24 at 7:51 AM. 2. The facility failed to ensure LVN H checked the residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) before administering medication through gastrostomy on Resident #87. These failures could place residents at risk of medical complications.

Inspectors wroteBased on interview and record review the facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for 1 of 1 policy reviewed. The facility failed to not request or require residents or potential residents to waive potential facility liability for losses of personal property. This failure could place residents at risk of misappropriation of their personal property.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of 1 resident reviewed for infection control during wound care. LVN C failed to change gloves and perform hand hygiene while providing wound care to Resident #4. These failures could place residents at risk of infection, slow wound healing, and or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents goals and preferences for one (Resident #1) of three residents reviewed for intravenous medication administration. The facility failed to ensure Resident #1 received the proper care for her peripherally inserted central catheter (PICC) line when: 1. Multiple facility staff failed to discontinue the PICC line when ordered by her physician from 8/22/2023 through 8/26/23, and 2. Multiple facility staff failed to ensure the dressing to her PICC line was changed weekly as ordered and stated in the facility policy. These failures placed the residents with parenteral/IV fluids and lines at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs and plan of care; and ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, for 2 of 2 meals (breakfast) observed. The facility failed to serve the 08/16/23 and 08/17/23 breakfast meals on time according to the schedule. This failure could place all residents who consume food by mouth at risk for decreased meal satisfaction, decreased intake, loss of appetite, avoidable weight loss, side effects from medications given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food panty items were properly stored in plastic bags, labeled, and dated in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 2 (Resident #36 and Resident #137) of 5 residents reviewed for pharmacy services, in that: The facility failed to ensure Resident #36 prescribed eye drops and Resident #137's eye drops, magnesium tablets, Thera cream, and vitamins were stored in a secured place. This failure could place all residents on the 300 and 400 Halls at risk of drug diversion or misuse of medications.