Great Lakes Healthcare Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure skin rashes were treated for 1 of 3 residents reviewed for non-pressure related skin conditions and medications were administered as ordered by the physician for 1 of 3 residents reviewed for pain. (Residents S and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the head of the bed was elevated to at least a 30 degree angle for a resident with an enteral feeding (tube feeding) that was infusing for 1 of 1 resident randomly observed for tube feeding. (Resident S)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure intravenous (IV) access sites were assessed and flushed regularly for 2 of 3 residents reviewed for IV therapy. (Residents J and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received medications as prescribed for 1 of 3 residents reviewed for pain and 1 of 3 residents reviewed for intravenous (IV) therapy. (Residents F and H)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to wear the correct personal protective equipment (PPE) for a resident in enhanced barrier precautions for 1 of 1 resident with a peg tube (a tube inserted directly into the stomach for nutrition) and an indwelling Foley (urinary) catheter. (Resident S)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADLS) received the care and assistance needed related to showers, greasy hair, dirty fingernails, and facial hair for 5 of 12 residents reviewed for ADLS. (Residents 96, H, C, 95, and 19)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with dry scaly skin were treated, treatments were completed, and abrasions were assessed and monitored for 7 of 7 residents reviewed for non-pressure related skin conditions, interventions were in place for a resident with diarrhea for 1 of 1 resident reviewed for diarrhea, and medications were held and administered with and without parameters for 4 of 5 residents reviewed for unnecessary medications. (Residents J, H, F, E, B, G , C, D, L, K, and M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure over the counter medications and creams were labeled correctly related to resident names and directions for use for 1 of 1 treatment cart and 1 of 3 medications carts observed. (The East Unit treatment and medication carts)

Inspectors wroteBased on record review and interview, the facility failed deliver snacks to the residents who wanted them for 1 of 1 bedbound resident reviewed for nutrition and 3 of 5 residents in the Resident Council meeting. (Residents L, 44, 86, 121)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was served under sanitary conditions related passing food and beverages that were uncovered down the hallway for 2 of 2 meals observed and for 1 of 3 units observed. (The lunch and breakfast meal and the East unit)

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment was clean and in good repair related to dirty floors, bed rails, tables, and enteral feeding poles, as well as torn privacy curtains and uncontained wash basins, urinals and plastic cylinders for 3 of 3 units. (The South, West, and East units).

Inspectors wroteBased on record review and interview, the facility failed to ensure a dependent resident received the alternate meal choice they requested for 1 of 1 resident reviewed for choices. (Resident L)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded related to the resident's use of oxygen for 1 of 26 resident records reviewed. (Resident M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to a CNA placing an enteral tube feeding on hold before a change in position for 1 of 3 residents reviewed for tube feeding. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure cardiopulmonary resuscitation (CPR) was not initiated as requested by the resident who had a signed Do Not Attempt Resuscitation (DNR) form for 1 of 1 resident reviewed for death. (Resident 119)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who had a pressure ulcer received the care and services to promote healing related to treatments not being completed as ordered by the physician and signed out on the treatment records for 3 of 6 residents reviewed for pressure ulcers. (Residents F, E, B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who was admitted with a limited range of motion received the necessary treatment and services to prevent decline related to application of an orthotic device by the Physical Therapy (PT) for 1 of 3 residents reviewed for range of motion. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with a urinary catheter received the necessary treatment and services related to not assessing urinary output as ordered for 2 of 3 residents reviewed for urinary catheters. (Residents D and 53)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a physician's order for intravenous (IV) fluids received the correct amount over a 24 hour period for 1 of 1 resident reviewed for hydration. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a bolus enteral feeding was administered correctly for 1 of 3 residents reviewed for Tube Feeding. (Resident K)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure supplemental oxygen was set at the correct flow rate for 1 of 2 residents reviewed for respiratory care. (Resident M)

Inspectors wroteBased on record review and interview, the facility failed to create and follow a care plan including specific interventions to address the mental health of a resident who recently lost their mother for 1 of 1 resident reviewed for Mood/Behavior. (Resident 77)

Inspectors wroteBased on record review and interview, the facility failed to ensure there was adequate monitoring of a resident's heart rate per the physician's orders prior to the administration of a blood pressure medication for 1 of 5 residents reviewed for unnecessary medications. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to post the State Long-Term Care Ombudsman's contact information. This had the potential to affect 112 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to identify a resident with continued significant weight loss and provide interventions/care planning for the weight loss for 1 of 3 residents reviewed for nutrition and weight loss. (Resident D)Finding Includes:Resident D's record was reviewed on 2/5/26 at 11:41 a.m. The diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus, and morbid obesity. A Significant Change Minimum Data Set assessment, dated 12/14/25, indicated a moderately impaired cognitive status, no behaviors, was able to feed herself after set up, was dependent for toileting, bathing, and transfers, and required maximum assistance with hygiene and bed mobility. The weight was 294 pounds and had no known significant weight loss or gain. She received a therapeutic diet and a hypoglycemic. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure timely laboratory (lab) services were provided as ordered, related to urinalysis (UA) testing (testing for a urinary tract infection), for 1 of 3 residents reviewed for lab testing. (Resident G)

Inspectors wroteBased on record review and interview, the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 3 residents who were reviewed for ADLs. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty oven doors, dry storage bin, light fixtures, vents, and floors for 1 of 1 kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to pressure ulcers and medication use for 4 of 30 MDS assessments reviewed. (Residents 59, 86, D, and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to shaving, washing hair, providing showers, and providing nail care for 6 of 10 residents reviewed for ADLs. (Residents E, D, C, B, F, and L)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered and/or held per blood pressure parameters for 4 of 6 residents reviewed for unnecessary medications. The facility also failed to ensure pre and post respiratory assessments were completed for 1 of 2 residents reviewed for hospitalization, and areas of discoloration, peeling skin, and edema were assessed and monitored for 2 of 9 residents reviewed for skin conditions non-pressure related and 2 of 2 residents reviewed for edema. (Residents 59, M, 65, 87, F, 81, 75, and 24)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper medication storage related to insulin pens and multi-dose vials not labeled when opened or expired, and loose pills observed in the medication carts and medication rooms for 2 of 2 units (The [NAME] and East Units)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to medications touched with bare hands, disposal of a used lancet into the garbage can, glucometers not disinfected after use for 1 of 2 glucometers observed, and not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP). (Residents C, 20, 12, 146, and G )

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty resident equipment, floors, curtains, personal and hygiene items not contained, and a clock not working for 2 of 2 units. (East Unit and [NAME] Unit)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 3 residents reviewed for dignity. (Resident L)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had physician's orders to self-administer for 2 of 2 residents reviewed for self-administration of medication. (Residents 83 and G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodations of needs related to a resident's bed being long enough so his feet were not touching the foot board for 1 of 2 residents reviewed for positioning. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's family received the resident's medical record in a timely manner after the request was processed for 1 of 1 resident reviewed for medical records. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to the intent to borrow medications from another resident during medication pass for 1 of 6 residents and 1 of 5 nurses observed during medication pass. (Resident C and LPN 1)

Inspectors wroteBased on record review and interview, the facility failed to ensure treatments were completed as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 59)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents reviewed for mobility. (Resident L)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure smoking materials were secured for 1 of 1 resident reviewed for smoking. (Resident 56)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collection bag was kept off of the floor and documentation of urinary output was completed for 1 of 1 resident reviewed for urinary catheters. (Resident 73)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 2 residents reviewed for nutrition. (Residents 65 and 67)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure gastrostomy tube (a tube surgically inserted into the stomach that allows for the delivery of food and medication) water flushes and medications were instilled via gravity, and enteral feedings were started at the correct time for 2 of 2 residents reviewed for tube feeding. (Residents 147 and 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 4 residents reviewed for oxygen. (Resident 59)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's pain was controlled with over the counter medications for 1 of 5 residents reviewed for pain. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to monitor for signs and symptoms of an infection of a resident's perma cath (a long, flexible tube that's inserted into a vein in the neck or chest) used for dialysis for 1 of 2 residents reviewed for dialysis. (Resident M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 28 opportunities for errors during medication administration. This resulted in a medication error rate of 7.14% (Residents 12 and 147)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was free from a significant medication error related to the administration of a sliding scale insulin for 1 of 6 residents and 1 of 5 nurses observed during medication pass. (Resident 12 and LPN 2)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that every resident received specialized rehabilitative services as determined by their comprehensive plan of care to restore their highest practicable level of physical well-being for 1 of 1 resident reviewed for rehabilitative services. (Resident G)

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of medications given for 1 of 5 residents reviewed for unnecessary medications (Resident F) and percentage of tube feeding given for 1 of 2 residents reviewed for tube feeding. (Resident 75)

Inspectors wroteBased on record review and interview, the facility failed to accurately and thoroughly report an allegation of resident to resident abuse to the Indiana Department of health (IDOH), related to location of altercation, circumstances of the altercation, diagnoses of the residents, injury, and results of the investigation in the five day follow-up, for 1 of 2 abuse incidents reviewed. (Residents C and D)

Inspectors wroteBased on record review and interview, the facility failed to have a current smoking assessment completed for 1 of 3 residents reviewed who smoked independently. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to monitor a resident with a history of substance abuse for signs and symptoms of alcohol use and the resident had an altercation with another resident while intoxicated, for 1 of 2 residents reviewed for behaviors. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's record was complete and accurate related to an intrafacility transfer for 1 of 9 residents reviewed for medical record accuracy. (Resident J)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's privacy was respected, related to Employee 1 using her private cell phone to take a video of the cognitively impaired resident (Resident B), without the approval of the resident's Court Appointed Guardian for 1 of 1 residents reviewed for privacy.

Inspectors wroteBased on record review and interview, the facility failed to act upon a suicidal ideation of a cognitive impaired resident in a timely manner, related to the resident's statement of wanting to kill herself on 7/10/24 and Social Service and the Administrator not notified until 7/23/24, for 1 of 1 dementia resident reviewed with suicidal ideation. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to promptly notify the resident's Power of Attorney (POA) of the onset of new non-pressure skin areas and a transfer to the hospital. The facility also failed to promptly notify the resident's physician of abnormal labs for 1 of 3 residents reviewed for non-pressure sores and 1 of 3 residents reviewed for a change in condition. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to initiate neurological checks after an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a history of falls was wearing the proper footwear to prevent further falls and/or injury for 1 of 3 residents reviewed for falls. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper PPE (personal protective equipment) prior to providing care to a resident on enhanced barrier precautions (EBP) and hand hygiene not completed after direct resident care, for 2 of 5 residents observed for infection control practices. (Residents C and G) This had the potential to affect the residents on 2 of 3 Units (East and West) and residents who required treatment for pressure wounds.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet residents' needs related to a call light not placed within reach for 2 of 7 residents observed for call light placement. (Residents G and K)

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's Responsible Party in writing of an intrafacility transfer related to changing rooms due to a COVID-19 outbreak for 3 of 3 residents reviewed for infection control. (Residents D, M, N)

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and homelike environment, related to stained, dirty, and tattered bed linens for 3 of 6 residents reviewed for a homelike environment. (Residents D, C, and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure a recapitulation of the resident's stay was documented on the discharge summary provided to the resident at the time of discharge for 3 of 3 residents reviewed for discharge. (Residents B, E, and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who were dependent and/or required assistance with activities of daily living (ADL's) received assistance with their meals, for 2 of 6 residents reviewed for ADL's. (Residents L and C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to dressings not present as ordered by the Physician, for 1 of 3 residents reviewed for pressure ulcers. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' with pressure ulcers received the necessary treatment and services to promote healing, related to dressings not present, treatments not completed as ordered, and preventative interventions not completed correctly, for 3 of 3 residents reviewed for pressure ulcers. (Residents C, B, and D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was labeled correctly, insulin bottles were not expired, and expired medication were discarded timely for 2 of 3 medication carts and 1 of 2 medication rooms. (South and [NAME] Unit medication Carts, and the East Unit medication room)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to improper use of personal protective equipment (PPE) prior to entering and leaving a COVID-19 room, cleaning of reusable equipment, hand hygiene after direct resident contact and glove removal, and the storage of wash basins and tooth brushes for random observations of infection control. (Residents 264, 213, 63, and 12)

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen area, as well as the residents' environment, was clean and in good repair related to an accumulation of rust, dirty baseboards, dirty floors, stained curtains, discolored floor tile, and urine odors in 1 of 1 kitchen areas and on 1 of 3 units. (The Main Kitchen and [NAME] Unit)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 3 of 4 residents reviewed for self-administration of medication. (Residents 43, 52, and 15)

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of a change in condition for 1 of 1 residents reviewed for notification of change. (Resident 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had privacy during a physical exam by the Nurse Practitioner (NP) for 1 of 1 residents reviewed for privacy. (Resident 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to nail care and the removal of facial hair for 3 of 8 residents reviewed for ADL's. (Residents 12, 47, and 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 4 residents reviewed for skin conditions non-pressure related. (Resident 96)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 213)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's urostomy was documented and monitored for 1 of 2 residents reviewed for catheters. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enteral tube feeding was infusing at the correct flow rate through a peg tube (a tube inserted directly into the stomach for nutrition) for 1 of 2 residents reviewed for tube feeding. (Resident 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was on and set at the correct flow rate, and nebulizer treatments were completed in a timely manner for 2 of 3 residents reviewed for respiratory care and 1 of 1 nebulizer treatments observed. (Residents 63 and 312)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a meal was served at an appetizing temperature related to the temperature of the hot foods served for a breakfast meal for 1 of 3 Units (East), which has the potential to affect the 30 residents who resided on the Unit.

Inspectors wroteBased on observation and interview, the facility failed to ensure an employee completed proper hand hygiene after coughing and blowing their nose for 1 staff member on 1 of 3 units (East Unit) during a random observation for infection control, which had the potential to affect the 30 residents on the unit. (LPN 5)

Inspectors wroteBased on observation, record review, and interview the facility failed to care for a PICC (peripherally inserted central catheter) line in accordance with professional standards of practice, related to not obtaining line flush orders, lack of aseptic technique with care of the line, and dressing changes, for 1 of 3 residents reviewed for PICC line care. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents reviewed during 5 medication pass observations. 3 errors in medications were observed during 33 opportunities for errors in medication administration. This resulted in a medication error rate of 9.09%. (Residents L & M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide residents with diets as care-planned, ordered, and per preferences, for 3 of 3 residents reviewed for nutritional services. (Residents J, K, and L)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's record was accurately documented, related to documenting a medication was administered when the medication had been omitted, for 1 of 3 residents reviewed for documentation of medications. (Resident D)

Inspectors wroteBased on observation and interviews, the facility failed to ensure the facility was a sanitary and comfortable environment for the residents, related to cigarette smoking where the residents are taken in and out of the building by the Ambulance (Ambulance Bay), which had the potential to affect any of the 101 residents who reside in the facility if they are transferred by Ambulance.