Saginaw Senior Care and Rehabilitation Center, LLC

Name: Saginaw Senior Care and Rehabilitation Center, LLC
Address: 4322 Mackinaw Road, Saginaw, MI, 48603, US
Telephone: 9897928729

4322 Mackinaw Road, Saginaw, MI 48603 · Saginaw County · 71 certified beds · avg 69 residents/day · certified since Aug 31, 1973

Part of chain: NEXCARE HEALTH SYSTEMS (20 facilities, chain avg rating 3.8★)

3/5

Health inspection rating (on-site)

Serious findings on record

$68,083

Fines, last 3 years

4.12

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 9, 2024 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 7, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 15, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 14, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Oct 19, 2023 · F-0684

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 14, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (29)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Dec 4, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 4, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 6, 2025	D · Potential for harm, one-off	The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint
Oct 9, 2024	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Oct 9, 2024	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Oct 9, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Oct 9, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 15, 2024	▲ G · Actual harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 1, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 1, 2024	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint
Mar 1, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 19, 2023	▲ G · Actual harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 19, 2023	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 19, 2023	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (11 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2023	7	1	G ▲
2024	15	2	G ▲
2025	7	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $68,083.

Date	Type	Amount / length
Oct 9, 2024	Fine	$51,282
Jul 15, 2024	Fine	$16,801

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Michigan avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.12	4.32	3.95	top 48% in Michigan; top 35% in the U.S.
Registered Nurse hours	0.72	0.84	0.69	bottom 46% in Michigan; top 34% in the U.S.
Weekend total nurse staffing	3.61	3.79	3.50	top 49% in Michigan; top 37% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.34	0.49	0.48	bottom 35% in Michigan; bottom 40% in the U.S.
Total nursing staff turnover (%)	47.3	44.1	45.8	bottom 38% in Michigan; bottom 44% in the U.S.
RN turnover (%)	50.0	39.2	42.9	bottom 32% in Michigan; bottom 39% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.61, RN 0.63, weekend 3.16. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Nexcare Holdings, LLC	Organization	5% or Greater Direct Ownership Interest	100%	11/01/2013
Massoll, Fred	Individual	W-2 Managing Employee	NOT APPLICABLE	11/23/2020
Nexcare Health Systems, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	01/01/2009
Perry, Michael	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2015
Sangster, Todd	Individual	Corporate Officer	NOT APPLICABLE	11/04/2013

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Adira Nursing and Rehabilitation	0.7 mi	Saginaw, MI	★★☆☆☆	2/5
Hoyt Nursing & Rehab Centre	1.9 mi	Saginaw, MI	★★★☆☆	3/5
Covenant Skilled Nursing and Rehabilitation at Wel	2.0 mi	Saginaw, MI	★★★★☆	3/5
Great Lakes Rehabilitation Center	2.4 mi	Saginaw, MI	★★☆☆☆	2/5
Healthsource Saginaw, INC	3.0 mi	Saginaw, MI	★★★☆☆	2/5
Optalis Health and Rehabilitation at St. Francis	3.3 mi	Saginaw, MI	★★☆☆☆	1/5
Avista Nursing and Rehabilitation	6.7 mi	Saginaw, MI	★★★☆☆	3/5
Caretel Inns of Tri-Cities	7.4 mi	Bay City, MI	★☆☆☆☆	1/5
Carriage House Nursing and Rehabilitation	11.1 mi	Bay City, MI	★★☆☆☆	2/5
Bay Shores Senior Care and Rehab Center	11.4 mi	Bay City, MI	★★★★☆	3/5

Compare this facility with the 3 closest →

All facilities in Saginaw →

Facility data as of CMS processing date 2026-08-01. CCN 235113.

The Care File

Visit checklist — Saginaw Senior Care and Rehabilitation Center, LLC

4322 Mackinaw Road, Saginaw, MI 48603 · 9897928729

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $68,083

Most serious findings on record:

▲ Oct 9, 2024 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
▲ Jul 15, 2024 (F-0684, Actual harm, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
▲ Oct 19, 2023 (F-0684, Actual harm, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 235113 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)