The resident at Great Lakes Healthcare Center suffers from hemiplegia, which paralyzed one side of his body following his stroke. He also has Parkinson's disease and depends on staff for basic care like toileting and hygiene.
When he used his call light to alert staff that he needed to be changed, "the staff would say they would come back to do it, but they did not," the resident told inspectors on September 29. "He indicated he had been left for hours in a dirty brief."
The facility's own care plan required staff to check the resident for incontinence every two hours. But nursing records obtained by inspectors revealed massive gaps in documented care throughout September.
Staff failed to document any incontinence care during 16 evening shifts that month. Night shift records were missing for 13 different dates. Even day shift workers, who typically provide the most thorough care, failed to document incontinence checks on four separate days.
The resident told inspectors that staff did not check him "at least once per shift to see if he needed incontinence care," contradicting the facility's written protocols.
His medical assessment from July showed he was "frequently incontinent of bowel and bladder" and required "maximal assistance" with all daily activities. Despite his cognitive clarity for decision-making, his physical disabilities left him entirely dependent on staff response to his call light.
The documentation gaps spanned nearly the entire month. Evening shift records were blank on September 5, 7, 10, 17, 20, 21, 22, 23, 24, 26, 27, and 28. Night shift documentation was missing for September 6, 7, 9, 10, 12, 17, 18, 19, 20, 21, 22, 23, and 24.
When confronted with the missing records, the facility's Director of Nursing acknowledged that "incontinence care should be performed and documented each shift." She told inspectors "she did not know why there were dates/shifts with blanks."
The inspection occurred following complaints filed with state health officials. Two separate intake complaints, numbered 2606842 and 2614759, triggered the federal review that uncovered the care failures.
Federal regulations require nursing homes to provide necessary care and assistance for residents who cannot perform activities of daily living independently. The facility's own care plan, revised in August 2024 and marked as current, specifically outlined the two-hour incontinence check requirement.
The resident's quarterly assessment painted a picture of significant vulnerability. While mentally sharp enough to make daily decisions, his stroke-related paralysis and Parkinson's disease left him physically helpless. His frequent incontinence meant regular staff attention was not just policy but medical necessity.
Missing documentation often signals missing care in nursing home settings. When staff fail to record required checks, residents like this stroke patient may sit in waste for extended periods, increasing risks of skin breakdown, infections, and dignity violations.
The inspection found the documentation failures affected "few" residents, but for the paralyzed man who spoke with investigators, the impact was deeply personal. Unable to change himself or walk to a bathroom, he depended entirely on staff promises that went unfulfilled.
His account to inspectors was straightforward: staff would acknowledge his need for help, promise to return, then leave him waiting. Hours would pass before anyone came back to provide the basic hygiene care his condition required.
The facility received a citation for failing to provide adequate care and assistance with activities of daily living. Inspectors classified the violation as causing "minimal harm or potential for actual harm," though the resident's own description suggested the psychological impact of sitting helpless in waste extended beyond minimal.
Federal inspectors completed their review on September 30, documenting a clear pattern of care failures that left a vulnerable stroke patient without the basic dignity of clean clothing and proper hygiene assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Great Lakes Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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