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TheVardellReport
Great Lakes Rehabilitation Center
Skilled nursing facility and nursing facility
4180 Tittabawassee Road
Saginaw, MI 48604
Report
← Great Lakes Rehabilitation Center, free profile
Life by Vardell Presents
The Vardell Report.Great Lakes Rehabilitation Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Saginaw, MI
- Record Period
- 2023–2026
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from December 2023 to January 2026, state surveyors documented 39 findings at Great Lakes Rehabilitation Center; 39 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 5
- 2023–2026, standard and complaint
- Findings
- 39
- Deficiencies cited by state inspectors
- Corrected
- 39
- Of 39 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 16 | 1 |
| 2024 | 1 | 7 | 0 |
| 2025 | 1 | 2 | 1 |
| 2026 | 1 | 14 | 1 |
What the Record Shows
- 39 of 39 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $21,244, its payment not published.
- 2 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, January 14, 2026, recorded 14 findings (most serious: Level G).
What to Ask About
- Quality of Care, Cited in Three Inspections
- Accident Hazards and Supervision, Cited in Three Inspections
- Kitchen and Food Safety, Cited in Three Inspections
- Pre-Admission Screening, Cited in Two Inspections
- Care Plan Timing and Review, Cited in Two Inspections
- Nutrition and Hydration, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
Report at a Glance
- Facility
- Great Lakes Rehabilitation Center
- Address
- 4180 Tittabawassee Road, Saginaw, MI 48604
- CMS Certification Number
- 235442
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 55
- Ownership
- For profit - Individual
- Record Window
- December 5, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
14 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Feb 12, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 12, 2026
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 12, 2026
- F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Feb 12, 2026
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jan 1, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 17, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 17, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
7 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 3, 2025
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Feb 3, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 3, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 3, 2025
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Feb 3, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 3, 2025
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 3, 2025
Enforcement Action
Civil money penalty, $21,244 imposed February 18, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 21, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jan 12, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
15 findings
- F732Post nurse staffing information every day.Level FNo actual harm, potential for moreCorrected Jan 8, 2024
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level FNo actual harm, potential for moreCorrected Jan 8, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 8, 2024
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Jan 8, 2024
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel ENo actual harm, potential for moreCorrected Jan 8, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Jan 8, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in December 2023, November 2024 and February 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F684 across all 5 inspections, oldest to newest - 2
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in December 2023, February 2025 and January 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F689 across all 5 inspections, oldest to newest - 3
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in December 2023, November 2024 and January 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F812 across all 5 inspections, oldest to newest - 4
Pre-Admission Screening, Cited in Two Inspections
Inspectors cited F645 in December 2023 and January 2026. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F645 across all 5 inspections, oldest to newest - 5
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in December 2023 and November 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F657 across all 5 inspections, oldest to newest - 6
Nutrition and Hydration, Cited in Two Inspections
Inspectors cited F692 in December 2023 and January 2026. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F692 across all 5 inspections, oldest to newest - 7
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in December 2023 and January 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F759 across all 5 inspections, oldest to newest - 8
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in December 2023 and January 2026. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F760 across all 5 inspections, oldest to newest - 9
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in December 2023 and November 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242526F761 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level E.
- 02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level G.
- 03
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
- 04
Was the required pre-admission screening done for every resident, and how is it tracked?
Pre-Admission Screening: cited in two inspections, most seriously at level E.
- 05
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level D.
- 06
How are weight and fluid intake tracked, and what happens when a resident starts losing weight?
Nutrition and Hydration: cited in two inspections, most seriously at level D.
- 07
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level D.
- 08
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 09
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
- 10
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 11
What led to the 2025 fine, and has it been paid?
A $21,244 civil money penalty was imposed February 18, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Michigan state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Dec 5, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Nov 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Feb 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Jan 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 235442
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowDecember 5, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before December 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.