Great Lakes Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement meaningful interventions to prevent pressure ulcers for one resident (R30) and complete consistent wound documentation for one resident (R29) of two residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer and inconsistent wound documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an ongoing infection prevention and control program, resulting in a lack of precautions for one resident (Resident #61) with an eye infection and the absence of line listings, infection control audits and surveillance for multiple months.

Inspectors wroteBased on interview and record review the facility failed to maintain ongoing review and implementation of the antibiotic stewardship program, resulting in the lack of monitoring of residents receiving antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for the initiation and dose changes of psychotropic medication for one resident (R4) of four residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate advanced directives for one resident (R30) of one resident reviewed for advanced directives, resulting in the resident being listed as a full code when their wishes were to be a Do not resuscitate (DNR).

Inspectors wroteBased on interview and record review the facility to input stop dates for as needed psychotropic medications for two residents (Resident #16 and Resident #27).

Inspectors wroteBased on interview and record review the facility failed to timely submit a Level 1 PASARR (Preadmission Screening and Resident Review) Screenings for one resident (Resident #31), resulting in Resident #31's PASARR not being completed within the annual timeframe or transmitted to OBRA (Omnibus Budget Reconciliation Act). Findings Include:On 1/13/2026 at 9:55 AM, a review was conducted of Resident #31's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included, Hypotension, Bipolar Disorder, Adjustment Disorder with mixed Anxiety and Depressed mood and Major Depressive Disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow care-planned interventions, update and/or revise the care-planned interventions and provide assistance for two residents (Resident #8, Resident #36) of two residents reviewed for accidents, resulting in unassisted Activities of Daily Living (ADL) care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice for urinary catheters and follow care planned interventions for two (Resident #60, 62) of two residents reviewed for urinary catheters, resulting in urinary catheter bags on the floor, no physician orders for urinary catheters with the likelihood of urinary catheter associated infections.

Inspectors wroteBased observation, interview and record review the facility to complete a comprehensive nutritional assessment and timely address weight loss for one resident (Resident #44) of one resident reviewed for nutrition. Findings Include:On 1/12/2025 at approximately 11:45 AM, Resident #44 was observed resting in bed. He stated he typically eats well at the facility but would like more food during meals. On 1/13/2025 at approximately 10:30 AM, a review was conducted of Resident #44's records and it indicated he admitted to the facility on [DATE] with diagnoses that included, Necrosis of left Femur, Acute and Chronic Respiratory Failure, Acute Embolism and Thrombosis and Osteoporosis. Further review of Resident #44's records indicated the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in a medication error rate of 6.67 percent with the likelihood of further medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in the likelihood of unwanted reactions such as hematoma, severe stomach pain and potentially dangerous, rapid increases in potassium levels in the blood.

Inspectors wroteBased on interview and record review the facility failed to administer an influenza vaccine for one resident (Resident #19) of five residents reviewed for immunizations.

Inspectors wroteThis Citation pertains to Intake Numbers MI00150106 and MI00150127. Based on observation, interview and record review, the facility failed to prevent a fall with injury for one resident (Resident #301), of three residents reviewed, by not following the care plan which required 2 staff for all Activities of Daily Living (ADL) care. Only one staff member was attending to Resident #301 when she partially rolled out of bed and sustained a fracture of the left clavicle, several fractured ribs, extensive bruising, and back and rib pain, all of which resulted in an extended hospitalization.

Inspectors wroteThis Citation pertains to Intake Number MI00150127. Based on observation, interview and record review, the facility failed give prompt treatment for several fractures related to a roll/fall out of bed for one resident (Resident #301).

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 11/18/2024 at 7:45 AM, initial tour was conducted in the kitchen in the presence of Dietary Manager F, the following expired/outdated items were found: Dry Storage Room: - 3-1-gallon containers of [NAME] Vinegar with expiration date of 7/9/2024 - Manager F stated the vinegar is good for a year after they receive it and the date received was 7/9/2023. Walk-in Cooler: [...]

Inspectors wroteThe facility failed to ensure comfortable room temperatures for two residents (Resident #24, Resident #110) from a census of 52 residents, resulting in Resident #110 becoming upset and disgruntled because he was too cold to eat and sleep. FACILITY Environment Resident #110: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #110 was admitted to the facility on [DATE] with diagnoses: Kidney disease, heart disease, pneumonia, COPD, and a history of falls with a fracture. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status/BIMS score of 11/15 and needed some assistance with all care. On [DATE] at 10:53 AM, Resident #110 was observed lying in bed, watching TV. He was awake, alert and talkative. The resident pointed at the heat register in the room; it read 68 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review the facility 1) Failed to check blood sugars and administer insulin per physicians' orders for two residents (Resident #30, Resident #158) of two residents reviewed for timely medication administration and 2) Failed to ensure coordination and integration of hospice services for one resident (Resident #51) of one resident reviewed for hospice. Findings Include: Resident #30: During Resident Council on 11/19/2024 at 10:30 AM, Resident #30 shared many times her blood sugar is being checked after she had already completed breakfast. She continued the nurse typically has an excuse as to why it was not checked prior to meal service. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food preferences were identified and followed for 2 residents (#8 and #109) of 2 residents reviewed for food or choices, resulting in both Resident #8 and #109 becoming upset, and discouraged that they did not receive the food that they had requested. Findings Include: Resident #109: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #109 was admitted to the facility on [DATE] with diagnoses: Cirrhosis of the Liver with ascites, vitamin/mineral deficiency, dehydration, history of falls, left hip pain, hypertension, COPD, depression, Panic disorder, GERD and arthritis. The MDS assessment dated [DATE] indicated Resident #109 had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Minimum Data Set/MDS Comprehensive Assessment for 2 residents (#35 and #45) of 15 residents reviewed for Comprehensive Assessments, resulting in the potential for the misidentification of resident needs, treatments and services for Resident #35 and Resident #45. Findings Include: FACILITY Resident Assessment Resident #35: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Dementia, heart disease, diabetes, kidney disease, depression and hypothyroidism. On 11/18/2024 at 10:27 AM, during a review of the MDS assessments for Resident #35 identified an admission assessment on 10/31/2023 and 4 quarterly assessments dated: 1/31/2024, 5/2/2024, 8/2/2024 and 11/2/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for 2 residents (Resident #10, Resident #109), of 15 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #10: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #10 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, history of falls with right leg fracture, respiratory failure, history of a stroke and heart disease. The MDS assessment dated [DATE] indicated the resident had severe cognitive impairment with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) Appropriate narcotic medication practices including, prevention of discrepancies in the narcotic log count for one resident (Resident #49) from the 300 hall medication cart of 2 carts reviewed for narcotics administration, and 2) Storage and handling of medications for one medication room of one reviewed and one of two medication carts reviewed, in accordance with acceptable pharmaceutical standards of practice, resulting in the potential for inappropriate access to narcotic medications, residents not receiving medications as ordered and a lack of therapeutic benefits of medication. Findings Include: FACILITY Medication Storage and Labeling On 11/19/2024 at 1:59 PM, the 300 hall medication cart was reviewed with Nurse M. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00139872. Based on interview and record review, the facility failed to ensure a timely transfer to acute care for evaluation after a fall with a head injury (swollen under left eye, indicating head injury) for one resident (Resident #101), who received a blood thinner (Xarelto 10 mg) and a low-dose aspirin (ASA 81 mg) daily, and who had a history of falls upon admission and of not using the call light, resulting in a slow brain bleed, hospitalization and death. Findings Include: Resident #101: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a prominent location for public viewing the actual hours worked by categories of nursing staffing and the census for each day resulting in the public and the 49 residents of the facility being unaware of the nursing staff available to care for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sufficient dietary staff to provide dietary services consistently for residents consuming foods from the kitchen, resulting in low dietary staffing, meals being served in Styrofoam containers with plastic utensils, and complaints of cold food.

Inspectors wroteOn 12/4/23 at 10:18 AM, encrusted food debris was observed on the digital probe thermometer. At this time, the thermometer was in it's sheath and food debris was observed in the sheath. CDM C proceeded to instruct staff to clean the thermometer and sheath. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/4/23 at 10:20 AM, a container of raw hamburger patties were observed to be dated 11/28 to 12/3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Second Quarter 2023 third party payroll services submitted Payroll-Based Journal (PBJ) data timely, resulting in the second quarter (April/May/June) 2023 payroll submission to trigger by CMS for staffing concerns with the likelihood to affect all residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to timely complete a mental health evaluation for one resident (Resident #26) reviewed and eight unsampled residents, reviewed for screening of mental and intellectual disabilities, after surpassing the 30-day exemption period, resulting in the likelihood for missed specialized behavior health services from the local Community Mental Health Organization.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain Resident #23's dignity and thoroughly investigate a customer service complaint, resulting in Resident #23 reporting offensive statements made to her by CNA (Certified Nursing Assistant) N with inadequate facility follow-up and feelings of frustration, unimportance, and betrayal. Findings Include: Resident #23: During initial tour on [DATE], Resident #23 was observed resting in their reclining chair. She was in good spirits and spoke about her overall physical progress since admitting to the facility. Resident #23 reported about 1.5 months ago she pressed her call light and it took about 40 minutes for a CNA to respond. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement/update interventions of offering and documenting bedtime snacks for two residents (Resident #31, Resident #32) with noted weight loss, resulting in Resident #31 to experience weight loss and Resident #32 to have a decline in weight and not receive any bedtime snacks between meals with a diagnosis of diabetes.

Inspectors wroteBased on observation, interview and record review the facility failed to 1. Ensure medication administration for Resident #252; 2. Effectively assess, monitor, and implement timely interventions for hearing loss and wax build up for Resident #4; and 3. Assess and monitor ICD (Implantable cardioverter-defibrillator) after implantation and monitor usage of [NAME] Heart Transmitter for Resident #38, resulting in, Resident #252's blood pressure and intravenous antibiotics not being administered, Resident #4 ears being severely wax compacted and causing hearing loss without timely facility interventions and inability to monitor Resident #38's cardiac status as they failed to recognize his ICD implantation and usage of [NAME] Heart Transmitter. Findings Include: Resident #4: [...]

Inspectors wroteObservation, interview and record review, the facility failed to monitor weight fluctuations and offer cueing with meals for two resident (Residents #31, Resident #32), resulting in weight loss and likelihood for further weight loss and a decline in overall health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that water flush tubing was utilized within a 24 hour period and maintain the head of bed (HOB) at 45 degrees per care plan for one resident (Resident #9), resulting in decreased elevation of the HOB and old water flush tubing with the likelihood of aspiration and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmacy services that included acquisition and provision of medications as ordered by a physician were provided to two residents (Resident #19, Resident #24) reviewed for pharmacy services, resulting in multiple missed doses of ordered medications and likelihood for prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications timely for one resident (Residents #24), resulting in missed medication administrations resulting in 3 errors during medication administration reviews with a medication error rate of 10%.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a significant medication error for one resident (Resident #4), resulting in Resident #4 receiving an additional 43 doses of Debrox (ear wax removal treatment) when the practitioner prescribed for five days. Findings Include: Resident #4: On 12/2/2023 during initial tour, Resident #4 was observed taking a nap in her wheelchair and was not able to be aroused. Her hearing aides were observed charging on the dresser. During Resident Council on 12/4/2023 at 11:30 AM, Resident #4 expressed frustration with being unable to hear what was being said and was going to leave the meeting. This writer was able position themselves next to the resident and repeat the questions to ensure inclusion and that her concerns were voiced. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 3 out of 4 medication carts contained medications with no labels of resident names and/or the date that medications were opened in the 100/200/400 Hall Medication Carts and the facility failed to label back up stock insulin in a multi-dose bottle, resulting in the likelihood of cross contamination and ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to care plan and provide documented collaborated visits with Hospice Service for one resident (Resident #7), resulting in the likelihood of unmet needs and confusion as to what services hospice provided.