23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Traverse City, MI
2-star overall rating with 1-star inspections with abuse icon flag with $148,763 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1000 Pavilions Circle, Traverse City, MI
(231) 932-3163
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
240
Certified beds
Average residents
179
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
1.29
Registered nurse staffing
LPN hours / resident day
0.38
Licensed practical nurse staffing
Aide hours / resident day
2.83
Nurse aide staffing
Weekend hours
4.11
Weekend nurse staffing
RN turnover
15%
Annual RN turnover
Total nurse turnover
22%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.0%
4.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.1%
1.5 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
4.1%
2.9 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.5%
0.9 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
19.6%
6.2 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
16.5%
0.1 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.7% |
13.9%
2.8 pts worse
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
11.7%
0.2 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
20.4%
3.8 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.6%
0.1 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
82.8%
9.4 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
11.5%
7.8 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.3%
1.5 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
79.5%
13.7 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
24.2%
1.3 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (9 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-23
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-07-23
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-23
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-11-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-10
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-10
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
Fire Safety
Have an externally vented heating system.
Corrected 2024-10-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-10-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-06
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-06
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-10-06
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-06
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-06
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-06
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-10-06
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-23
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-23
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-23
Health
Ensure 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.
Corrected 2025-07-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-23
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-23
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-06
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-23
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-23
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-23
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-23
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-07-23
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-10
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-18
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-02-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-03
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-02-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-03
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-03
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-05
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-05
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-10
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-10
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-10
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-10
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-10
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-10
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-10
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-10
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-10
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-29
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-06
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-06
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-06
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-06
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-06
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-06
Penalties and ownership
Fine · fine $119,415
Fine
Payment Denial · denial start 2025-07-12 · 25 days
25 day denial
Fine · fine $29,348
Fine
Payment Denial · denial start 2024-10-17 · 19 days
19 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
Traverse City, MI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Traverse City, MI
2-star overall rating with 1-star inspections with $69,430 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Traverse City, MI
4-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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