Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 3 | 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 | — | 0 | 0 |
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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 August 2026) and official state health department websites.