Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Great Lakes Rehabilitation Center during CMS and state inspections, most recent first.
Pressure ulcer prevention and wound documentation failures: One resident admitted with a coccyx wound had inconsistent skin/wound assessments, limited documentation, and duplicate topical orders, while another resident with a moderate Braden risk score developed a facility-acquired unstageable heel pressure injury after staff noted boggy heels, delayed use of a PRAFO boot, refusal of heel offloading, and no documented heel-elevation interventions or skin prep order.
Food Service Sanitation and Hand Hygiene Deficiencies: Staff observed undated chicken noodle soup in the refrigerator, a visibly soiled mixer, microwave, and ice machine, and improper glove use during food prep when an employee donned gloves and changed gloves without washing hands. The CDM stated the mixer is cleaned after each use, the microwave after each meal, and the ice machine monthly, but there was no ice machine cleaning log.
Infection control oversight was incomplete, with missing line listings for several months, no 2025 hand hygiene, kitchen, or laundry audits, and incomplete staff infection control training. A resident with shingles in the left eye had no precautions in place, and the EMR contained no orders or care plan for enhanced barrier precautions.
Failure to maintain the antibiotic stewardship program resulted in a lack of monitoring of residents receiving antibiotics. The facility could not provide line listings or infection maps for several months, and the IC nurse confirmed those months were not completed. The nurse said antibiotic use was being tracked on paper but had not been entered into a line listing, and no infection maps were observed. The nurse also described using nurse notes, McGeer's criteria, and a 3-day monitoring process for suspected UTI, while physician risk-versus-benefit documentation was only generally consistent.
Failure to obtain informed consent for psychotropic meds: A resident with anxiety, dementia with behavioral disturbance, adjustment disorder, and depression who lacked decision-making capacity was receiving multiple psychotropics, including an antipsychotic, antidepressants, and an anxiolytic. Record review found no evidence the DPOA was aware of the med starts or dose changes, and the SW stated consent was only being obtained for antipsychotic meds while an updated Seroquel consent remained unsigned.
A resident who was capable of making her own decisions had conflicting code status documentation in the EMR, with a physician order for full code despite a signed form indicating no CPR, no mechanical ventilation, and hospitalization only. No advance directive care plan was present, and the SW acknowledged the mismatch between the order and the resident’s signed wishes.
Two residents had open-ended PRN psychotropic orders without stop dates. One resident with dementia and other medical diagnoses had PRN Prochlorperazine for nausea/vomiting, with no care plan mention or side-effect monitoring documented, despite a pharmacy review recommending discontinuation or a specific duration. Another resident with vascular dementia, psychotic disturbance, mood disturbance, and anxiety had PRN Ativan for anxiety and agitation; staff reported it was effective for severe behaviors, but the order remained open-ended even after pharmacy review noted the issue and hospice was referenced on the form.
PASARR Not Timely Submitted: A resident with bipolar disorder, adjustment disorder, and major depressive disorder had a Level 1 PASARR that was not transmitted to OBRA within the required timeframe. Survey review found the resident’s PASARR had not been submitted for over a year, and the facility had only completed the first step of the electronic process, leaving the form pending in the portal instead of being sent to OBRA.
Failure to Provide Planned Assistance and Supervision During ADLs: Two residents with impaired cognition and mobility needs were observed completing bathroom and transfer activities without the level of assistance directed in their care plans. One resident with dementia, prior fall history, and visual impairment was seen ambulating and transferring without using the walker or reaching the call light, while staff described the resident as independent. Another resident with cognitive decline and osteoporosis was observed toileting unassisted, unable to reach the call light, and refusing a gait belt, despite care plans requiring supervision or touching assistance and staff cueing.
Urinary catheter care was not followed for two residents with indwelling Foley catheters. One resident’s drainage bag was observed without a dignity cover and touching the floor, and the record showed no physician order for catheter care. Another resident’s catheter bag was dropped to the floor and then held above the bladder, with urine flowing back toward the resident, despite a care plan directing staff to keep the bag and tubing below bladder level and the facility policy requiring the bag to stay off the floor and covered.
Failure to complete a comprehensive nutritional assessment and address weight loss for a resident with multiple medical diagnoses, including necrosis of the L femur, respiratory failure, embolism/thrombosis, and osteoporosis. The resident reported eating well overall but wanting more food at meals, while records showed a significant weight decline from 201.2 lbs to 187.8 lbs and no additional documentation of interventions beyond a dietary note, Mini Nutritional Assessments, and a care plan identifying nutritional risk.
Medication administration errors exceeded the allowed rate when two residents were involved in unsafe or incorrect med administration practices. One nurse initially prepared Heparin with the wrong syringe/needle and route confusion before correcting it, and another nurse crushed an ER Potassium chloride tablet and gave it orally even though it should not have been crushed. The observed error rate was 6.67%, above the 5% threshold.
Medication administration errors occurred with two residents. An RN prepared a Heparin injection with the wrong syringe and needle and initially identified the route incorrectly before correcting the preparation and giving the dose subcutaneously. Another nurse crushed an extended-release Potassium chloride tablet and administered it orally; the nurse later acknowledged it should not have been crushed, and the pharmacist confirmed the ER form was not safe to crush.
A resident with HTN, dementia, AKI, and muscle weakness consented to the flu vaccine, but the EMR showed the vaccine was not given during the year reviewed. During an IC nurse interview, staff were unsure at first and then confirmed the vaccine had been missed.
A resident with complex medical conditions suffered a fall and multiple injuries due to the facility's failure to follow the care plan requiring two staff members for ADL care. Only one CNA was present, leading to the resident partially rolling out of bed and sustaining fractures and bruising. The incident was not documented on the day it occurred, and the resident was hospitalized the following day.
A resident with multiple medical conditions suffered fractures after a fall from bed, but the facility failed to provide prompt treatment. The resident, on blood thinners, experienced severe bruising and pain, which were not documented or assessed immediately. The incident was not properly recorded, leading to a delay in hospital transfer.
The facility's kitchen was found to have several expired and improperly labeled food items, increasing the risk of cross-contamination and foodborne illness. Additionally, the sanitization process for the three-compartment sink was inadequate, with the solution initially testing at 0 PPM, below the required 150 PPM. A technician later found a blockage in the tubing affecting the chemical mix. The facility's logs inaccurately recorded the PPM as consistently adequate prior to the inspection.
The facility failed to maintain comfortable temperatures for two residents, leading to distress for one resident who was too cold to eat or sleep. The common areas were also reported to be cold, discouraging residents from participating in activities. Maintenance issues with the heating system, including a Freon leak, were identified as the cause, but a permanent solution had not been implemented.
The facility failed to administer insulin timely for two residents with diabetes, as blood sugar checks were conducted well after meals, leading to delayed insulin administration. Additionally, the facility did not ensure proper documentation and coordination of hospice services for a resident, as hospice notes were not included in the resident's medical record.
Two residents in an LTC facility experienced unmet food preferences, leading to dissatisfaction. One resident, with multiple health issues, requested salads and fresh fruit, which were inconsistently provided. Another resident requested grits for breakfast, which were initially provided but then discontinued without consultation. The facility failed to document and honor these preferences, resulting in unmet needs and dissatisfaction.
The facility failed to complete required MDS Comprehensive Assessments for two residents, leading to potential misidentification of their needs. Both residents had admission and quarterly assessments, but lacked the necessary annual full assessments. The MDS Nurse acknowledged the oversight, noting a system error that prompted incorrect assessments.
The facility failed to update care plans for two residents, leading to unmet care needs. A resident with severe cognitive impairment had dry skin not documented in her care plan, while another resident's dietary preferences were not consistently met despite being communicated. This indicates a lack of communication and documentation in care planning.
A facility failed to maintain proper narcotic medication practices and storage, resulting in discrepancies in the narcotic log count for a resident. The medication cart review revealed mismatched counts, and the medication room had expired and improperly labeled items. The medication refrigerator was unlocked, and staff personal items cluttered the area.
Pressure ulcer prevention and wound documentation failures
Penalty
Summary
The facility failed to develop and implement meaningful interventions to prevent pressure ulcers for one resident and failed to complete consistent wound documentation for another resident, resulting in the development of an unstageable pressure ulcer and inconsistent wound records. One resident was admitted with diagnoses including progressive multiple sclerosis, bacteremia, hyperlipidemia, peripheral vascular disease, and quadriplegia, and was reported to have been admitted with a Stage 2 coccyx wound that later resolved and reopened. The wound nurse stated the resident preferred to remain in a chair most of the day and refused staff attempts to reposition her, and the only prevention measure identified was a low air loss mattress. Record review for this resident showed that skin and wound evaluations were not consistently completed and did not consistently include pictures, measurements, staging, further interventions, changes in treatment orders, or wound descriptions. The wound nurse stated the resident did not have weekly wound assessments from admission until the wound closed because she was working the floor and not able to perform her wound nurse duties. The resident also had two separate orders for the same topical treatment, one for breakdown and one for prevention, and the wound nurse stated she was not aware she had entered both orders. The resident’s wound was documented as having resolved and later reopened, with limited documentation available for the interval. A second resident, who was capable of making her own decisions and had diagnoses including hypertension, fractures with routine healing, falls, and chronic kidney disease, developed a facility-acquired unstageable pressure ulcer on the left heel after admission. On admission, the resident’s heels were documented as boggy, and the Braden Scale score was 14, indicating moderate risk for pressure injury. The resident was observed sitting in a wheelchair with a dressing on her left foot and stated that someone was supposed to change it but had not done so yet. Staff reported that she often refused to wear her PRAFO boot and refused heel elevation when in bed, and the wound care nurse stated the boot was not started until after the heel injury had already developed. The care plan for the second resident included general skin impairment interventions, but it did not contain additional pressure prevention interventions beyond the PRAFO boot added after the wound developed. The DON stated that wound prevention interventions should be in the tasks so aides can see them and document completion, but the record review showed no documentation for elevating the heels and no physician order for skin prep. The wound care nurse stated that heel elevation is standard of care and that skin prep should have been in place, while the CNA confirmed the Kardex did not indicate heel elevation for the resident.
Food Service Sanitation and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. During the initial kitchen tour, chicken noodle soup was observed inside the refrigerator without a date mark, and the Certified Dietary Manager stated she was not sure when it had been prepared before removing it from the refrigerator. At the same time, the mixer was visibly soiled with a yellow residue, the microwave had visible soil on the interior ceiling, and the interior walls of the ice machine had a chunky yellow residue. The Certified Dietary Manager stated the mixer is cleaned after each use, the microwave is cleaned after each meal, and maintenance is supposed to clean the ice machine monthly. During lunch observation, [NAME] D put on gloves without washing hands and proceeded to prepare food in the kitchen. [NAME] D later removed gloves and put on new gloves without washing hands and continued preparing lunch. When interviewed about handwashing procedures when using gloves, the Certified Dietary Manager stated that hands should be washed after taking off gloves. Maintenance E stated the ice machines are cleaned once a month, but there is no cleaning log for the ice machine. The facility policy states that all equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions, and equipment used daily, such as the microwave and stove, is to be cleaned daily at the end of the shift.
Infection Control Program Not Implemented and Precautions Missing for Resident With Eye Infection
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program. The Infection Control nurse stated she was behind on infection control tasks and reported that line listings were incomplete for August, September, October, November, and part of December 2025. When the last 6 months of line listings were requested, the facility provided only a partially completed December 2025 and January 2026 record, with no line listings available for August through November 2025. The Infection Control nurse also stated that infection control audits for hand hygiene, the kitchen, and the laundry had not been completed in 2025, and that about 30 staff members did not receive infection control or hand hygiene training because meetings could not be completed. The facility also failed to maintain precautions for a resident with shingles in the left eye. The Infection Control nurse stated the resident had received antibiotics from the eye provider and that she had initially placed the resident on enhanced barrier precautions and then contact precautions, but ultimately settled on enhanced barrier precautions. During the survey, the resident’s room was observed and no precautions were in place. Review of the electronic medical record showed no orders or care plans for enhanced barrier precautions for the resident.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to maintain ongoing review and implementation of its antibiotic stewardship program, resulting in a lack of monitoring of residents receiving antibiotics. During interview and record review, the facility provided line listings only for December 2025 and January 2026 when the last 6 months were requested. No line listings or infection maps were provided for August, September, October, or November 2025, and the Infection Control nurse confirmed those months were not completed for line listing. The nurse stated that antibiotic use was being tracked on paper but had not been put into a line listing, and no infection maps were observed. The Infection Control nurse also stated that when nurses suspect infection, they document it in a nurse's note, contact infection control, and determine whether McGeer's criteria are met. The nurse said that if a resident presents with one symptom of UTI, a three-day monitoring period is used, and if criteria are met on day two, a UA is sent. When asked about physician documentation of risk versus benefit for antibiotic use, the nurse stated that physicians are generally good about it, but she has to keep up on them at times. The facility policy required documentation of findings made during surveillance of antibiotic usage patterns, and the surveillance policy listed antibiotic review and pharmacy records among the data sources to be reviewed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the initiation and dose changes of psychotropic medication for one resident who had diagnoses including anxiety disorder, dementia with other behavioral disturbance, adjustment disorder, and depression and had been deemed incapable of making her own decisions. Record review showed the resident was receiving multiple psychotropic medications, including citalopram, lorazepam, Zoloft, and Seroquel, with orders dating from August through November 2025. The record review also showed no evidence that the durable power of attorney was aware of the medication initiation or dosage changes. During interview, the Social Worker stated that psych services and nursing obtain informed consent for medications, but also stated that informed consent was only being done for antipsychotic medications. The Social Worker acknowledged that an updated consent for Seroquel still needed to be signed and that the durable power of attorney had not been reached, despite attempts by phone and prior contact for hospice questions and care conference planning. Review of the facility policy titled Psychotropic Medication Use stated that prior to initiating, increasing the dose of, or switching antipsychotic medication, staff and the physician will review non-pharmacological alternatives, the indication and rationale, potential risks and benefits, and the resident's or representative's right to accept or decline treatment.
Inaccurate Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure accurate advance directives for one resident, R30, who was admitted with diagnoses including hypertension, fractures with routine healing, falls, and chronic kidney disease and was deemed capable of making her own decisions. Record review showed that the electronic medical record contained a signed physician order for full code, dated [DATE] at 15:40 PM, while a separate signed code status document scanned into the EMR showed that R30 elected no CPR, no mechanical ventilation, and yes to hospitalization. There was no care plan present for advance directives. During interview, the Social Worker stated that code status care plans are completed by social services and that nurses complete the orders and paperwork on admission, and acknowledged that R30 should have had a DNR order and a matching care plan based on the signed code status document.
Open-Ended PRN Psychotropic Orders Without Stop Dates
Penalty
Summary
The facility failed to enter stop dates for as-needed psychotropic medications for two residents. One resident admitted with diagnoses including gastroenteritis and colitis, metabolic encephalopathy, dementia, hypertension, depression, diabetes, and acute kidney failure had an order for Prochlorperazine 10 mg by mouth every 6 hours as needed for nausea/vomiting, ordered without an end date. The resident’s care plan did not mention use of the medication or monitoring for adverse side effects. A pharmacy review on 12/2/25 recommended discontinuing the PRN use of Prochlorperazine or reordering it for a specific number of days, and the form was handwritten with “Hospice” and signed by a facility practitioner on 12/8/25, but the order remained open-ended. Social Work A stated she was not aware the resident had a current antipsychotic order for nausea/vomiting or that it was entered as PRN and open ended. A second resident admitted with diagnoses including clavicle fracture, acute kidney failure, vascular dementia, hypertension, psychotic disturbance, mood disturbance, and anxiety had an order for Ativan 0.5 mg by mouth every 6 hours as needed for anxiety and agitation, also without an end date. Social Work A reported the resident had behaviors including crawling out of bed, eating feces, and screaming/yelling, and that Ativan appeared effective in decreasing those behaviors. She stated she knew the PRN Ativan order did not have a stop date and had emailed the DON after an audit found it, but at the time of the discussion the order was still PRN and open ended. A pharmacy review recommended discontinuing the PRN use of Lorazepam or reordering it for a specific number of days, and the response indicated to continue PRN use because the benefit outweighed the risks, with “Hospice” handwritten on the form and signed by a facility practitioner on 12/7/25. The facility policy stated psychotropic medications are not prescribed or administered on a PRN basis unless necessary to treat a diagnosed specific condition documented in the clinical record, or the prescriber believes it is appropriate to extend the PRN order beyond 14 days.
PASARR Not Timely Submitted
Penalty
Summary
The facility failed to timely submit a Level 1 PASARR screening for one resident with diagnoses including hypotension, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder. Review of the resident’s record showed the last OBRA PASARR correspondence in the chart was dated 6/25/2024, indicating the resident did not meet criteria for a Level II evaluation by the local community mental health authority, and the PASARR had not been submitted for more than a year. During the survey, the facility provided a completed DCH-3877 that was signed as completed and submitted to OBRA on 9/19/2025, but OBRA’s response letter was not received until 1/13/2026. The OBRA representative reported the facility had submitted fewer than 15 PASARRs in the last year and stated that the facility appeared to be creating the forms in the system but not pressing the submit button to transmit them to OBRA. The Administrator later stated the facility had not had access to the OBRA system after the prior DON resigned and that staff had only completed Step 1 of the two-step process, leaving PASARRs pending in the portal rather than transmitted.
Failure to Provide Planned Assistance and Supervision During ADLs
Penalty
Summary
The facility failed to follow care-planned interventions, update and/or revise care-planned interventions, and provide assistance for two residents who were reviewed for accidents, resulting in unassisted ADL care. Resident #8 had diagnoses including a prior fall, dementia, stroke, and visual impairment, with moderately impaired cognition. The care plan directed extensive assist with ambulation using a 2-wheeled walker and gait belt, limited assistance for toileting and transfers, prompt response to requests for assistance, and a safe environment with the call light within reach. However, the resident was observed walking from the bathroom to the bed without using the walker, with the wheelchair and walker positioned away from the resident and the call light draped over an overbed table out of reach. Staff later described the resident as independent, and CNA K stated the resident did not always use the call light and was checked on but did not always ask for help. Resident #8 was also observed later in the room and closet moving independently, including standing, walking back to the closet, turning off the light, and returning to the wheelchair. The resident again stated they were independent and did not often use the walker. The record review showed the most recent comprehensive assessment required setup or clean-up assistance for walking 10 feet, chair/bed-to-chair transfer, and toilet transfer, which did not match the observed unassisted mobility and transfers. The care plan also identified increased fall risk related to forgetting to use the walker and not using the call light, yet the call light remained out of reach during observations. Resident #36 had diagnoses including age-related cognitive decline, altered mental status, and osteoporosis, with moderately impaired cognition. The care plan required supervision or touching assistance for chair/bed-to-chair transfer and toilet transfer, and also directed staff to anticipate and meet needs, cue, reorient, and supervise as needed. Despite this, the resident was observed in the bathroom standing at the toilet, not holding the handrail, using both hands to pull down a robe trapped in the incontinent brief, and stating they did it themselves when asked if they needed help. The resident could not reach the call light, and staff later found no gait belt in the room. When staff entered, the resident refused the gait belt, and CNA K stated the resident did not put the light on and only did so when having a bowel movement and wanting to be cleaned. The resident’s brief was soiled with urine and bowel movement, and Nurse Q assisted with perineal care and standing. During exit conference, the Administrator stated they could not do one-on-one supervision and questioned the concern about lack of supervision.
Urinary Catheter Care Not Followed
Penalty
Summary
The facility failed to follow standards of practice for urinary catheters and did not follow care planned interventions for two residents with indwelling urinary catheters. Resident #60, who had diagnoses including chronic kidney disease, retention of urine, and anxiety disorder and was noted to have intact cognition, was observed with a urinary catheter hooked to the bed without a dignity bag, and later the drainage bag was seen touching the floor in the dining room. A CNA also adjusted the catheter bag and tubing under the resident’s wheelchair with gloved hands. The resident’s electronic record showed no physician order to care for the urinary catheter, although the admit/readmit screener documented a 16 Fr catheter with a 10 cc balloon. Resident #62, who had diagnoses including pneumonia, pressure ulcer, and multiple sclerosis and was also noted to have intact cognition, was observed with a urinary catheter drainage bag hooked under the wheelchair with amber urine in the bag and tubing. During transfer from the wheelchair to the bed, the drainage bag was dropped to the floor, then lifted above the level of the bladder, and urine was observed draining back toward the resident. The bag was then reattached to the bed frame and urine drained back through the tube into the drainage bag. The resident’s care plan directed staff to keep the catheter bag and tubing below the level of the bladder, and the facility policy stated the tubing and drainage bag should be kept off the floor, covered with a privacy/dignity covering, and positioned lower than the bladder at all times.
Failure to Complete Comprehensive Nutritional Assessment and Address Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment and did not timely address weight loss for Resident #44, who was admitted with diagnoses including necrosis of the left femur, acute and chronic respiratory failure, acute embolism and thrombosis, and osteoporosis. On 1/12/2025, the resident was observed resting in bed and stated he typically ate well at the facility but wanted more food during meals. Record review showed weights of 201.2 lbs on 10/2/2025 and 187.8 lbs on 12/17/2025, reflecting a 6.66% loss over two months, and a 6.1% loss from the admission weight of 200 lbs on 6/25/2025 to 187.8 lbs on 12/17/2025. The record contained a nutrition/dietary note from 6/21/2025 stating the resident was on a regular diet, had good intake at dinner, was edentulous, rarely wore dentures, and had Ensure Plus at bedside. The chart did not contain other notes addressing the documented weight loss or interventions to prevent further loss. Nutritional assessments in the record were Mini Nutritional Assessments rather than a comprehensive nutritional assessment, and the care plan identified a nutritional problem or potential nutritional problem with a goal to maintain adequate nutritional status and an RD evaluation for diet change recommendations as needed. During interview, the resident stated the facility had never weighed him and that he was not worried about his weight, and he also stated he did not typically eat breakfast and would most likely not consume it.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to administer medications per standards of practice for two residents during medication administration observations, resulting in a medication error rate of 6.67 percent. For one resident, a nurse prepared a Heparin injection using a 3 cc syringe with a 1-inch needle and initially identified the medication as IM before correcting to subcutaneous. Outside the resident’s room, the nurse questioned the required needle size and the physician’s order, then clarified the order in the electronic medical record and obtained a smaller syringe and appropriate needle before administering the Heparin subcutaneously. The resident’s record showed an order for Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML, inject 1 ml subcutaneously. For another resident, a nurse gathered morning medications and crushed Potassium chloride 30 milliequivalent before administering it orally. The nurse stated the resident had recently been sent to the emergency room and was being checked for a change in condition. When later questioned, the nurse acknowledged the Potassium should not have been crushed because it was extended release and stated the physician had not been called about the crushed administration. The pharmacist later stated the Potassium chloride ER should not be crushed and could be switched to liquid. The facility policy stated medications shall be administered safely and as prescribed, and the medication administrator must check the label three times to verify the right resident, medication, dosage, time, and route.
Medication Administration Errors with Heparin and Potassium Chloride
Penalty
Summary
The facility failed to administer medications according to standards of practice for two residents during medication administration observations. For one resident, Nurse P prepared a Heparin injection using a 3 cc syringe with a 1-inch needle and initially identified the medication as IM before correcting to subcutaneous. Outside the resident’s room, Nurse P questioned the required needle size and the physician’s order, then reviewed the electronic medical record, obtained a smaller syringe and appropriate needle from Nurse Manager B, redrew the Heparin, and administered it with the correct size needle. The resident’s record showed an order for Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML, 1 ml subcutaneously. For another resident, Nurse F gathered morning medications and crushed Potassium chloride 30 mEq before giving it orally. When later questioned, Nurse F acknowledged the medication was extended release and stated they had not called the physician to report that it had been crushed. The pharmacist later stated the Potassium chloride ER should not be crushed and could be switched to liquid. The facility policy required medications to be administered safely and as prescribed, with the label checked three times for the right resident, medication, dosage, time, and route.
Missed Influenza Vaccination
Penalty
Summary
The facility failed to administer an influenza vaccine for one resident, Resident #19, out of five residents reviewed for immunizations. Resident #19 was [AGE] years old and had diagnoses including hypertension, dementia, acute kidney failure, and muscle weakness. The resident was admitted most recently on 03/25/2025. Record review on 01/13/2026 showed that Resident #19 received an influenza vaccine on 01/30/2024 and had a scanned influenza immunization consent dated 01/07/2025 indicating consent to receive the influenza vaccine, but the EMR showed the resident did not receive the influenza vaccine in 2025. During an interview on 01/13/2025, the Infection Control nurse was unsure whether the resident had received the vaccine, checked the record, and then stated that the vaccine had not been given and was just missed.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to prevent a fall with injury for a resident by not adhering to the care plan, which required two staff members for all Activities of Daily Living (ADL) care. During an incident, only one staff member was present when the resident partially rolled out of bed, resulting in a fracture of the left clavicle, several fractured ribs, extensive bruising, and subsequent hospitalization. The care plan clearly stated that the resident required extensive assistance from two staff members for bed mobility, dressing, and toileting due to her medical conditions, including hemiparesis and limited mobility. The resident, who had a history of medically complex conditions such as anemia, hypertension, renal insufficiency, diabetes, and cerebrovascular accident, was found with significant bruising and pain following the incident. Observations revealed bruising on the left upper shoulder and hip area, and the resident reported pain during movement and while sleeping. The facility's records indicated that there was no documentation of the incident on the day it occurred, and the resident was not assessed until the following day when she was sent to the hospital. Interviews with staff revealed that the Certified Nurse Assistant (CNA) involved in the incident was alone in the room and attempted to catch the resident as she rolled from the bed. The CNA did not request assistance, despite the care plan's requirement for two staff members. The Director of Nursing (DON) acknowledged that staff education related to changes in elevation was initiated only after the incident. The facility's failure to follow the care plan and ensure adequate supervision directly contributed to the resident's fall and injuries.
Failure to Provide Prompt Treatment for Resident's Fractures
Penalty
Summary
The facility failed to provide prompt treatment for a resident who suffered multiple fractures after a fall or drop from bed. The resident, an elderly female with a history of medically complex conditions including anemia, hypertension, renal insufficiency, diabetes, and more, was found to have acute left rib and clavicle fractures. Despite the resident's complaints of back pain and being dropped, there was a delay in documenting and addressing her injuries, which were only noted after she was sent to the hospital. The incident occurred when a CNA was changing the resident and she rolled out of bed, hitting her shoulder and head on a chair. The CNA attempted to catch her but was unsuccessful in preventing the fall. The resident was on Eliquis, a blood thinner, which increased the risk of severe bruising and bleeding. Despite the severity of the situation, there was a lack of immediate documentation and assessment of the resident's condition on the day of the incident. Interviews and record reviews revealed that the facility's staff did not adequately document the incident or the resident's condition in a timely manner. The resident's bruising and pain were not properly assessed or documented until the following day, leading to a delay in her being sent to the hospital. The facility's policies on charting and documentation were not followed, contributing to the deficiency in care provided to the resident.
Sanitary Deficiencies in Kitchen and Inadequate Sanitization Process
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During an initial tour of the kitchen, several expired and outdated food items were found in the dry storage room, walk-in cooler, and walk-in freezer. These items included vinegar, pureed toast, brownies, Parmesan cheese, pecans, marinara sauce, turkey, sliced carrots, mixed veggies, cornbread, gluten-free pizza, waffles, pie crusts, breakfast sandwiches, peanuts, hash browns, almonds, walnuts, bananas, pork crumble, spaghetti sauce, sweet and sour sauce, and Swedish meatballs. Many of these items were either expired or lacked proper labeling with open and use-by dates, contrary to the facility's policy that requires all leftovers to be labeled, covered, and dated when stored. Additionally, the facility's sanitization process was found to be inadequate. The solution for the three-compartment sink, which is premixed through a mechanism installed by a contracted service provider, was tested and found to be at 0 PPM, indicating it was not effective. Upon rerunning the solution, it barely reached the required 150 PPM. A technician later discovered a plug in the tubing where the chemicals mix, which was preventing the correct amount of chemicals from mixing. The facility's log indicated that the PPM was consistently recorded as 200 PPM prior to the inspection, raising questions about the accuracy of the log entries. The facility's policy requires the Quaternary Sanitizer to be at a minimum of 150 PPM, which was not met during the inspection.
Facility Fails to Maintain Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, resulting in discomfort and distress. Resident #110, who has a history of kidney disease, heart disease, pneumonia, COPD, and falls with a fracture, was observed to be very cold in his room, with the temperature reading 68 degrees Fahrenheit. Despite his repeated complaints over three days, the issue was not addressed promptly, and he was only offered an extra blanket, which he refused. Maintenance staff acknowledged the problem and noted that other rooms had similar issues, requiring some residents to be moved for repairs. Resident #24 and other residents reported that the common areas, including the theater, hallways, library, and activity areas, were cold, causing them to avoid participating in activities. During a Resident Council meeting, all nine residents in attendance expressed concerns about the cold temperatures in these areas. Staff members also confirmed that residents had complained about the cold and that they themselves wore jackets or fleeces during their shifts due to the low temperatures. The Maintenance Director explained that the facility's heating system had a leak in the line, causing Freon to leak and the system to malfunction. This issue led to fluctuating temperatures, with the building being cooler in winter and warmer in summer. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit, but the current system issues prevented this. The Director mentioned a potential solution involving an additive to locate and seal the leak, but this had not yet been implemented.
Deficiencies in Timely Insulin Administration and Hospice Coordination
Penalty
Summary
The facility failed to adhere to physician orders for timely blood sugar checks and insulin administration for two residents with diabetes. Resident #30 reported that her blood sugar was often checked after she had already eaten breakfast, which was confirmed by a review of her medical records. The records showed that her blood sugar was frequently checked well after meal service, with timeframes varying from 45 minutes to two hours post-meal. This delay in checking blood sugar levels led to the administration of insulin outside the ordered timeframes, as evidenced by the Medication Audit Report. Similarly, Resident #158 experienced delays in blood sugar checks and insulin administration. The medical records indicated that Resident #158's blood sugar was also checked well after meal service, with similar delays in insulin administration. The Unit Manager was unable to provide a reason for these delays, and there was no documentation in the progress notes to explain the late administration of insulin. Additionally, the facility failed to ensure proper coordination and integration of hospice services for Resident #51. Although the resident was admitted to hospice services, there was no documentation of hospice care or visits in the resident's electronic medical record. The Unit Managers were unaware of the location of hospice documentation, and it was later found that hospice notes were sent to the Social Worker's office instead of being included in the resident's medical record. This lack of documentation was contrary to the facility's contract with the hospice service, which required communication and documentation of the hospice plan of care.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of two residents, leading to dissatisfaction and distress. Resident #109, who was admitted with multiple diagnoses including cirrhosis of the liver and depression, expressed a desire for salads and fresh fruit with meals. Despite having full cognitive abilities, the resident's preferences were not consistently met, as evidenced by the absence of these items on his meal tickets and trays. The Certified Dietary Manager acknowledged the oversight and noted that the resident had received salads inconsistently, and the dietary notes did not reflect the resident's requests. Resident #8, who had a history of acute pancreatitis and anxiety, requested grits for breakfast, which were initially provided but then discontinued without consultation. The dietary staff assumed the resident no longer wanted grits because they were returned uneaten, but this decision was made without direct communication with the resident. The facility's policy on food preferences, which emphasizes assessing and communicating individual preferences, was not adhered to in this case. Both residents experienced a lack of communication and follow-through regarding their dietary preferences, resulting in unmet needs and dissatisfaction. The facility's failure to document and honor these preferences, as well as the lack of timely updates to dietary notes, contributed to the deficiency. The administrator acknowledged challenges within the dietary department, indicating systemic issues in managing resident food preferences.
Failure to Complete Required MDS Comprehensive Assessments
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Comprehensive Assessment for two residents, resulting in the potential for misidentification of their needs, treatments, and services. Resident #35 was admitted with diagnoses including dementia, heart disease, diabetes, kidney disease, depression, and hypothyroidism. The MDS assessments for Resident #35 showed an admission assessment and four quarterly assessments, but no annual full assessment was completed as required. Similarly, Resident #45 had an admission assessment and four quarterly assessments without the necessary annual full assessment. The MDS Nurse, responsible for completing all MDS assessments, acknowledged the oversight during an interview. She noted that the computer system incorrectly cued her to complete four quarterly assessments instead of the required three quarterlies and an annual assessment. This issue had occurred previously, and the MDS Nurse was unsure why the system was prompting the wrong assessments. The facility's policy mandates conducting and submitting resident assessments in accordance with federal and state timeframes, which was not adhered to in these cases.
Failure to Update Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing care needs of two residents. Resident #10, who was admitted with severe cognitive impairment and multiple health issues, was observed with very dry and scaly patches on her face. However, her care plan, which included interventions for skin care, did not mention this specific condition. The Wound Nurse and Unit Manager were unaware of the dry skin condition, indicating a lack of communication and documentation in the resident's care plan. Resident #109, who had full cognitive abilities and was on a therapeutic diet, expressed dissatisfaction with the food provided, specifically the lack of fresh fruit and salads. Despite having communicated his preferences to the dietary staff, his care plan did not reflect these preferences, and his meal ticket lacked this information. The Certified Dietary Manager acknowledged the resident's requests but had not consistently ensured that his dietary preferences were met, highlighting a gap in the care planning process.
Medication Storage and Narcotic Log Discrepancies
Penalty
Summary
The facility failed to ensure proper narcotic medication practices and storage, leading to discrepancies in the narcotic log count for a resident. During a review of the 300 hall medication cart, it was found that the narcotic log for Norco did not match the actual count in the cassette. The log indicated 17 tablets, but only 16 were present. Additionally, another narcotic log for the same resident showed a discrepancy where the count dropped from 5 to 3 without explanation, suggesting two tablets were removed without proper documentation. Nurse M confirmed that she did not make the correction on the log, and Nurse Manager G was informed of the issue. The medication room and carts were also found to have several storage and labeling issues. Expired medications and improperly labeled items were observed, including Cerave moisture cream, Medihoney, and Biofreeze bottles without resident names. The medication refrigerator, which contained narcotics, was unlocked, and the Lorazepam was not double locked as required. Additionally, staff personal items and food were found in the medication room, contributing to a cluttered environment. Expired items such as a fiber laxative and laboratory test tubes were also noted, along with liquor bottles for residents no longer at the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saginaw Senior Care And Rehabilitation Center, Llc | 2.4 mi | ★★★★★ | 8 | 0 |
| Covenant Skilled Nursing And Rehabilitation At Wel | 2.6 mi | ★★★★★ | 15 | 0 |
| Adira Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 13 | 0 |
| Healthsource Saginaw, Inc | 3.1 mi | ★★★★★ | 3 | 0 |
| Hoyt Nursing & Rehab Centre | 3.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.