Cycle 1
Health 2025-06-12 · Fire 2025-06-12
23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Traverse City, MI
Grand Traverse Pavilions
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
Facility snapshot
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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.29
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.45
CMS adjusted RN staffing hours
Adjusted total hours
5.05
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,471
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9972
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.29% · Performance 22.93% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.79
Baseline 5.44% · Performance 7.30% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Total nurse turnover
10
Baseline 36.31% · Performance 23.16% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.88
Baseline 4.54 hours · Performance 4.75 hours · Measure score 5.88 · Achievement 5.88 · Improvement 1.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 8.3% · Lower 95% interval 7.07% |
| Discharge to community | 59.04% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 244 · Observed rate 56.97% · Lower 95% interval 54.06% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.35% |
95.27%
3.1 pts better
|
Numerator 238 · Denominator 242 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 242 |
| Discharge self-care score | 49.41% |
53.69%
4.3 pts worse
|
Numerator 84 · Denominator 170 |
| Discharge mobility score | 60.59% |
50.94%
9.7 pts better
|
Numerator 103 · Denominator 170 |
| Pressure ulcers or injuries, new or worsened | 2.48% |
2.29%
0.2 pts worse
|
Numerator 6 · Denominator 242 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 6.4% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 3.26% |
8.2%
4.9 pts worse
|
Numerator 13 · Denominator 399 |
| Staff flu vaccination coverage | 93.03% |
42%
51 pts better
|
Numerator 387 · Denominator 416 |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 100 · Denominator 170 |
| Transfer of health information to provider | 99.45% |
95.95%
3.5 pts better
|
Numerator 182 · Denominator 183 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 41.44% |
25.2%
16.2 pts better
|
Numerator 46 · Denominator 111 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 99.3% · Q4 100.0% · 4Q avg 99.8% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 4.3% · Q2 4.9% · Q3 4.9% · Q4 4.3% · 4Q avg 4.6% · Used in QM five-star |
| 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 · Q1 4.4% · Q2 8.4% · Q3 8.3% · Q4 6.8% · 4Q avg 7.0% |
| 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 · Q1 5.7% · Q2 7.3% · Q3 4.2% · Q4 0.9% · 4Q avg 4.6% |
| 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 · Q1 12.8% · Q2 11.3% · Q3 13.3% · Q4 16.5% · 4Q avg 13.4% |
| 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 · Q1 18.2% · Q2 16.8% · Q3 14.0% · Q4 16.2% · 4Q avg 16.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 25.9% · Q2 15.9% · Q3 15.0% · Q4 9.9% · 4Q avg 16.7% · Used in QM five-star |
| 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 · Q1 16.1% · Q2 10.5% · Q3 9.7% · Q4 9.6% · 4Q avg 11.5% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 1.4% · Q3 1.9% · Q4 0.6% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 21.2% · Q2 31.5% · Q3 22.4% · Q4 21.3% · 4Q avg 24.2% |
| 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 · Q1 6.7% · Q2 5.1% · Q3 4.5% · Q4 6.3% · 4Q avg 5.7% · Used in QM five-star |
| 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 · Q1 86.8% · Q2 93.0% · Q3 93.8% · Q4 94.3% · 4Q avg 92.2% |
| 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 · Adjusted 19.3% · Observed 20.2% · Expected 11.7% · Used in QM five-star |
| 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 · Q1 0.7% · Q2 2.6% · Q3 4.6% · Q4 2.9% · 4Q avg 2.8% · Used in QM five-star |
| 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 · 4Q avg 93.2% |
| 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 · Adjusted 22.9% · Observed 23.8% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-09-14 · Fire 2023-09-14
16 health 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 citations
F · Potential for more than minimal harm
2025-06-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-23
F · Potential for more than minimal harm
2025-06-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-23
F · Potential for more than minimal harm
2025-06-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-12
K321 · Smoke Deficiencies
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
E · Potential for more than minimal harm
2025-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-11-28
E · Potential for more than minimal harm
2025-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-23
F · Potential for more than minimal harm
2024-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K321 · Smoke Deficiencies
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
E · Potential for more than minimal harm
2024-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-09-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
K222 · Egress Deficiencies
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
E · Potential for more than minimal harm
2023-09-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-10-06
Inspection history
Recent health citations
G · Actual harm
2025-10-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-03
D · Potential for more than minimal harm
2025-10-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-03
G · Actual harm
2025-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-23
G · Actual harm
2025-06-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-23
F · Potential for more than minimal harm
2025-06-12
F725 · Nursing and Physician Services Deficiencies
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
F · Potential for more than minimal harm
2025-06-12
F812 · Nutrition and Dietary Deficiencies
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
F · Potential for more than minimal harm
2025-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-12
F585 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2025-06-12
F761 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
D · Potential for more than minimal harm
2025-06-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-06-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-06-12
F756 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-06-12
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-12
F887 · Infection Control Deficiencies
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
D · Potential for more than minimal harm
2025-03-11
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-02-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
D · Potential for more than minimal harm
2025-01-09
F559 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-01-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
D · Potential for more than minimal harm
2025-01-09
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-03
G · Actual harm
2024-10-16
F580 · Resident Rights Deficiencies
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
G · Actual harm
2024-10-16
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-05
G · Actual harm
2024-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-19
F812 · Nutrition and Dietary Deficiencies
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
F · Potential for more than minimal harm
2024-09-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-19
F623 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F625 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F688 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-19
F756 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-09-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-19
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-19
F849 · Administration Deficiencies
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
F · Potential for more than minimal harm
2023-09-14
F812 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2023-09-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-09-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-09-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-14
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-09-14
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-09-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-14
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2023-09-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-09-14
F842 · Resident Assessment and Care Planning Deficiencies
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
What sits behind the stars
$119,415
2025-06-12
Fine
Fine · fine $119,415
Fine
$0
2025-06-12
Payment Denial
Payment Denial · denial start 2025-07-12 · 25 days
25 day denial
$29,348
2024-09-19
Fine
Fine · fine $29,348
Fine
$0
2024-09-19
Payment Denial
Payment Denial · denial start 2024-10-17 · 19 days
19 day denial
Ownership
County Of Grand Traverse
5% Or Greater Direct Ownership Interest · Organization
Ball, Emily
Operational/Managerial Control · Individual
Coleman, Rose
Corporate Officer · Individual
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