Great Lakes Healthcare Center

In the surveyor’s words

From the most serious findings on record at Great Lakes Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 27, 2021

  Based on record review and interview, the facility failed to provide supervision to prevent an elopement of a cognitively and mentally impaired resident, who had a court appointed Guardianship, from signing himself out of the facility. The resident was out of the building for 5.5 hours before he was identified as missing. The Police were notified and a Silver Alert was issued. The whereabouts were unknown to the facility and the resident was found in a neighboring state at a hotel close to an airport 4.5 days later. The Hotel where the resident was found was 30-31 miles from the facility. The Guardianship papers were not at the facility at the time of the elopement, though the facility was aware of the Guardianships, for 1 of 3 residents reviewed for supervision. […]

• Actual harm, isolatedF692Dec 21, 2022

  Based on observation, record review, and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to not following the Registered Dietitian's (RD) recommendations timely which resulted in a significant weight loss for a resident who was NPO and only receiving an enteral feeding. The facility also failed to ensure food consumption was documented for residents with a history of weight loss for 5 of 7 residents reviewed for nutrition. (Residents 89, 24, N, 5, and 8) Findings include: 1. On 12/12/22 at 9:37 a.m., Resident 89 was observed sitting in a wheelchair in her room. At that time, there was an enteral tube feeding of Jevity infusing at 45 cubic centimeters (cc) per hour. On 12/16/22 at 5:30 a.m., the resident was observed in bed. […]

• Actual harm, isolatedF686Jul 27, 2021

  Based on observation, record review, and interview, the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing of pressure ulcers, related to treatments not completed as ordered by the Physician for 5 of 6 residents reviewed for pressure ulcers. One pressure wound had deteriorated due to increased drainage, redness, and inflammation for Resident C. (Residents C, E, G, J & K) Findings Include: 1) During an observation of Resident C, on 7/25/21 at 10:23 a.m. with RN 2 present, there were two foam dressings on the resident's inner left and right knees. The dressings were marked with the date of 7/22/21. Both dressings were saturated with dark colored drainage. […]

• No harm, potential for more than minimal, widespreadF812Feb 24, 2025

  Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty oven doors, dry storage bin, light fixtures, vents, and floors for 1 of 1 kitchen. Finding includes: During the Initial Kitchen Sanitation Tour on 2/17/25 at 9:09 a.m. with the Kitchen Manager, the following was observed: a. There was a dark, dripping substance along the bottom of the oven door. b. There was an accumulation of dirt on the edges of the ceiling light fixtures above the food preparation area. c. There was an accumulation of dirt on the vents in the ceiling above the food preparation area. d. There was a tan, sticky substance on the handle of the sugar storage bin. e. […]

• No harm, potential for more than minimal, widespreadF880Jan 19, 2022

  Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to staff not wearing PPE (personal protective equipment) inside TBP (Transmission Based Precautions) rooms, no signs on resident room doors indicating TBP or positive for COVID-19, no signs at the facility entrances indicating there were positive COVID-19 residents residing in the building, wearing gloves in the hallway, no hand hygiene before donning and after glove removal, transporting soiled PPE in the hallway, no visible signs of increased cleaning on high touched surfaces, not monitoring residents who were in TBP for COVID-19 and not monitoring, tracking and trending other infections… […]