Cycle 1
Health 2025-02-14 · Fire 2025-02-14
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Saginaw, MI
Covenant Skilled Nursing and Rehabilitation at Wel
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5939 Shattuck Road, Saginaw, MI
(989) 583-8110
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-07-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.55
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.84
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.62
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,590
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0027
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.14% · Performance 26.10% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.02
Baseline 4.59% · Performance 6.93% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Total nurse turnover
6.52
Baseline 88.37% · Performance 43.75% · Measure score 6.52 · Achievement 4.88 · Improvement 6.52
Adjusted total nurse staffing
10
Performance 6.03 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 9.7% · Lower 95% interval 7.96% |
| Discharge to community | 66.26% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 252 · Observed rate 62.3% · Lower 95% interval 59.82% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.21% |
95.27%
1.9 pts better
|
Numerator 174 · Denominator 179 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 179 |
| Discharge self-care score | 59.23% |
53.69%
5.5 pts better
|
Numerator 77 · Denominator 130 |
| Discharge mobility score | 64.62% |
50.94%
13.7 pts better
|
Numerator 84 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 3.35% |
2.29%
1.1 pts worse
|
Numerator 6 · Denominator 179 · Adjusted rate 3.73% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 6.13% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 3.28% |
8.2%
4.9 pts worse
|
Numerator 2 · Denominator 61 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.23% |
56.45%
2.8 pts better
|
Numerator 77 · Denominator 130 |
| Transfer of health information to provider | 99.23% |
95.95%
3.3 pts better
|
Numerator 129 · Denominator 130 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 22.99% |
25.2%
2.2 pts worse
|
Numerator 20 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
82.8%
11.5 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 95.1% · Q3 92.9% · Q4 91.5% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
11.5%
0.8 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 10.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.3%
1.2 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
79.5%
15.7 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
24.2%
3.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 28.0% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
5 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-02-14 · Fire 2023-02-14
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-02-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-02-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-27
F · Potential for more than minimal harm
2023-02-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-02-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-26
D · Potential for more than minimal harm
2024-09-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-02-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-02-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-14
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-08
Penalties and ownership
What sits behind the stars
Ownership
Covenant Healthcare System
5% Or Greater Indirect Ownership Interest · Organization
Covenant Medical Center, Inc.
5% Or Greater Direct Ownership Interest · Organization
Lutheran Homes Of Michigan, Inc
5% Or Greater Indirect Ownership Interest · Organization
Wellspring Tcc LLC
5% Or Greater Direct Ownership Interest · Organization
Birchmeier, Kevin
Corporate Director · Individual
Birchmeier, Kevin
Corporate Officer · Individual
Conzelmann, Noelle
Operational/Managerial Control · Individual
Gehm, David
Corporate Director · Individual
Kalbfleisch, Timothy
Corporate Director · Individual
Kalbfleisch, Timothy
Corporate Officer · Individual
Lutheran Homes Of Michigan, Inc
Operational/Managerial Control · Organization
Tompa, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Healthsource Saginaw, Inc
Saginaw, MI
2-star overall rating with 2-star inspections with $269,858 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Saginaw Senior Care and Rehabilitation Center, LLC
Saginaw, MI
4-star overall rating with 3-star inspections with $68,083 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Optalis Health and Rehabilitation at St. Francis
Saginaw, MI
3-star overall rating with 2-star inspections with $162,520 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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