Deficiency Records for Great Lakes Healthcare Center
Updated as of October 01, 2022
This is not the most recent data for Great Lakes Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Great Lakes Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-12 | 2022-08-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-12 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-07-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-09 | 2022-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-09 | 2022-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-09 | 2022-07-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-09 | 2022-07-01 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-09 | 2022-07-01 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-06-09 | 2022-07-01 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-05-11 | 2022-06-13 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-05-11 | 2022-06-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-11 | 2022-06-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-11 | 2022-06-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-01 | 2022-03-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-19 | 2022-02-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-19 | 2022-02-12 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-01-19 | 2022-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-19 | 2022-02-12 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-19 | 2022-02-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-19 | 2022-02-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-18 | 2021-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-04 | 2021-11-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-04 | 2021-11-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide appropriate foot care. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-04 | 2021-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-04 | 2021-11-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-04 | 2021-11-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-04 | 2021-11-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-04 | 2021-11-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-04 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-04 | 2021-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-04 | 2021-11-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-04 | 2021-11-08 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-10-26 | 2021-10-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-26 | 2021-10-27 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-07-27 | 2021-08-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-27 | 2021-08-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-27 | 2021-08-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-27 | 2021-08-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-27 | 2021-08-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-27 | 2021-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-27 | 2021-07-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-29 | 2021-07-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-29 | 2021-07-20 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-02-26 | 2021-03-28 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-26 | 2021-03-28 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-26 | 2021-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-19 | 2020-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-11 | 2020-10-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-09-11 | 2020-10-11 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-09-11 | 2020-10-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-11 | 2020-10-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-09-11 | 2020-10-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2020-09-11 | 2020-10-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-09-11 | 2020-10-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-09-11 | 2020-10-11 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-09-11 | 2020-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-09-11 | 2020-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-11 | 2020-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-11 | 2020-10-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-11 | 2020-10-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-09-11 | 2020-10-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-26 | 2019-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-11-26 | 2019-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2019-12-14 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-06-17 | 2019-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-29 | 2019-06-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-29 | 2019-06-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-29 | 2019-06-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-29 | 2019-05-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-29 | 2019-05-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-29 | 2019-05-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-23 | 2018-06-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-04-23 | 2018-06-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-04-23 | 2018-06-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-08 | 2018-05-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-03-08 | 2018-05-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-08 | 2018-04-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-08 | 2018-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-08 | 2018-04-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide activities to meet all resident's needs. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-08 | 2018-04-07 | N |
| Post nurse staffing information every day. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-08 | 2018-04-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-08 | 2018-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-08 | 2018-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-08 | 2018-04-07 | N |
