Great Lakes Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 14, 2026

  Based 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. Findings include: Resident #29: On 1/13/2026 at 11:40 AM, an interview was conducted with Wound Nurse G regarding Resident #29's wound she admitted with. The nurse reported the resident was admitted from home with a Stage 2 coccyx wound and they are now monitoring the area. She explained the resident prefers being in her chair most of the day and refuses staff attempts to reposition her. […]

• Actual harm, isolatedF689Feb 18, 2025

  This 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 . […]

• Actual harm, isolatedF689Dec 21, 2023

  This 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. […]

• No harm, potential for more than minimal, widespreadF812Jan 14, 2026

  Based 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.Findings include: On 01/12/2026 at 9:20am-9:40am during the initial kitchen tour with Certified Dietary Manager C observed chicken noodle soup inside refrigerator without datemarking. During this observation, CDM C was asked when the chicken noodle soup was prepared and stated she wasn't sure and removed the chicken noodle soup from the fridge. On 01/12/2026 at 9:20am-9:40am observed the mixer visibly soiled with a yellow residue. During this observation CDM C was asked how often the mixer is cleaned and stated it's cleaned after each use. […]

• No harm, potential for more than minimal, widespreadF880Jan 14, 2026

  Based 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. Findings include: On 01/13/2026 at 11:43 AM An interview was conducted with the Infection Control (IC) nurse B to set up a time to go over the infection control program. IC nurse B stated that she was behind on infection control tasks, she stated that she had some of the line listings for January 2026 completed, some of December 2025 completed and currently she is working on August 2025. […]