A list of the most recent deficiencies for Great Lakes Rehab 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-05 | 2024-01-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-05 | 2024-01-08 | 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 | 2023-12-05 | 2024-01-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2024-01-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-05 | 2024-01-08 | N |
| 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 | 2023-12-05 | 2024-01-08 | N |
| Post nurse staffing information every day. | Health | 2023-12-05 | 2024-01-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-05 | 2024-01-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-05 | 2024-01-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-05 | 2024-01-08 | 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 | 2023-12-05 | 2024-01-08 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-12-05 | 2024-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-05 | 2024-01-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-05 | 2024-01-08 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-05 | 2024-01-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-04 | 2024-01-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-04 | 2024-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-04 | 2024-01-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-04 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-11-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-19 | 2022-11-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-19 | 2022-11-25 | 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 | 2022-09-19 | 2022-11-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-19 | 2022-11-25 | 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 | 2022-09-19 | 2022-11-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-19 | 2022-11-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-19 | 2022-11-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-09-19 | 2022-11-25 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-19 | 2022-11-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-19 | 2022-11-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-19 | 2022-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-19 | 2022-11-25 | 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 | 2022-09-19 | 2022-11-25 | N |
| Provide or obtain dental services for each resident. | Health | 2022-09-19 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2022-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-11-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-13 | 2022-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-01 | 2021-11-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-10-01 | 2021-11-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-01 | 2021-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-01 | 2021-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-11-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-10-01 | 2021-11-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-01 | 2021-11-19 | 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 | 2021-10-01 | 2021-11-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-04 | 2021-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-04 | 2021-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-04 | 2021-11-19 | 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 | 2021-05-27 | 2021-07-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-27 | 2021-07-23 | Y |
