Grand Traverse Pavilions

Inspectors wroteThis pertains to intakes 2687925 and 2741873. Based on observation, interview, and record review the facility failed to ensure adequate supervision and/or implement appropriate interventions to prevent falls for three Residents (#1, #3, & #5) of three residents reviewed for falls, resulting in Resident #3 sustaining a right hip fracture which required hospitalization and surgical intervention.

Inspectors wroteThis citation pertains to intake 2726722. Based on interview and record review, the facility failed to treat one Resident (#2) with dignity and respect out of three residents reviewed for resident rights. This deficient practice resulted in Resident #2 experiencing emotional distress and feelings of intimidation.

Inspectors wroteThis citation pertains to intake 2734782Based on observation, interview, and record review, the facility failed to follow resident choices for one Resident (#7) of three residents reviewed. This deficient practice resulted in feelings of hopelessness and frustration.

Inspectors wroteThis deficient practice pertains to Intake 2641153. Based on interview and record review, the facility failed to effectively monitor, report, and respond to a change in condition for one Resident (#1) of three residents reviewed for quality of care. This deficient practice resulted in Resident #1 receiving delayed medical treatment leading to hospitalization and subsequent death.

Inspectors wroteThis deficient practice pertains to Intake 2641153. Based on interview and record review, the facility failed to provide the necessary oxygen therapy as prescribed by a physician for one Resident (#1) of three Residents reviewed for respiratory services.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development and progression of two stage 4 pressure ulcers for one resident (Resident #68) out of five residents reviewed for pressure ulcer development. This deficient practice resulted in Resident #68 experiencing severe pain during dressing changes and subsequently required wound debridement and antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management as prescribed by the physician for one Resident (#431) of two residents reviewed for pain. This deficient practice resulted in unrelieved pain and required Resident #431 to be subsequently transfer to the emergency department (ED).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet the needs of three sampled Residents (R9, R169 and R430), and eight Residents in a confidential group interview within the facility population of 181 Residents. This deficient practice resulted in actual and potential avoidable episodes of incontinence, frustration and helplessness with call lights going unanswered and needs not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation has two deficient practice statements. DPS A Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteOn 6/11/25, the following observations were made of the dining rooms: Elm Dining Hall: At 12:25 p.m., 25 Residents were observed sitting in the dining room without drinks. Three staff members were observed at 12:30 p.m. when the meal cart was delivered attempting to pass out meals to residents. Dogwood Dining Hall: At 12:20 p.m., six residents were observed in the dining room without drinks. At 12:30 p.m., 10 residents were observed in the dining hall without drinks. The meal cart was delivered at 12:44 p.m. with one staff member assisting residents with their meals. Cherry Dining Hall: At 12:40 p.m., six residents were observed in the dining room without drinks. At 12:45 p.m. nine residents were observed in the dining room without drinks. At 12:50 p.m., 14 residents were observed in the dining room without drinks. [...]

Inspectors wroteBased on interview and record review the facility failed to make prompt efforts to resolve grievances for three Residents (C3, C7, & #66) of nine residents reviewed for the facility's grievance and resolution process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely secured and stored in three of six medication carts reviewed for medication storage and properly dispose of medications in one of six medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent resident to resident physical abuse resulting in harm from the reasonable person perspective, for three Residents (R149, R155, and R158) of three residents reviewed for abuse prevention.

Inspectors wroteBased on interview and record review, the facility failed to provide applicable bed hold policy information and/or written transfer notifications to two Residents (#154 and #68) of four residents reviewed for transfer and discharge process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plan interventions for one Resident (R155) of five residents reviewed for behavior care planning.

Inspectors wroteBased on interview and record review, the facility failed to administer medication per physician order for one resident (Resident #2) of 35 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly supervise one Resident (#121) of two residents reviewed for Activities of Daily Living during (ADL) care. This deficient practice resulted in a fall with injury. Resident #121 (R121) On 6/10/25 at 12:24 p.m., R121 was observed sitting in the main dining hall waiting for her meal tray. R121 was noted to have a large purple bruise under her left eye and a dark red/purple bruise under her left nostril. An attempted interview was conducted with R121 who was not able to respond appropriately. Review of R121's Progress Notes read, in part, 6/6/25: (R121) is being seen today to follow up on a witnessed fall that occurred this morning at 6:06 a.m. in the member's room while CNA (Certified Nursing Aide) was dressing her for the day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the sanitary storage and cleaning of respiratory equipment for two Residents (#430 and #433) of two residents reviewed for respiratory services.

Inspectors wroteBased on interview and record review, the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and develop individualized care plan interventions to mitigate trauma triggers for one Resident (#79) of one resident reviewed for trauma-informed care.

Inspectors wroteBased on interview and record review, the facility failed to ensure availability of prescribed medications for one Resident (#431) of six residents reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRR's) were addressed by the attending physician and maintained in the clinical record for two Residents (#45 & #79) of five residents reviewed for MRR.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive dining equipment for two Residents (#80 and #111) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating.

Inspectors wroteBased on interview and record review, the facility failed to ensure an eligible resident was provided a pneumococcal vaccine as recommended by the Centers for Disease Control and Prevention (CDC) for 1 Resident (#54) of 5 residents reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure eligible residents were provided a COVID-19 vaccine as recommended by the Centers for Disease Control and Prevention (CDC) for 2 Residents (#54 & #433) of 5 residents reviewed for immunizations.

Inspectors wroteMI00150655 Based on interview and record review the facility failed to assess bowel function for one Resident (R1) of three residents reviewed for bowel care/complaints of constipation. This deficient practice resulted in the potential for missed signs and symptoms of constipation and resulted in hospitalization.

Inspectors wroteThis citation pertains to Intake MI00150291. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and neglect by facility staff for three Residents (#1, #2, #3) of five residents reviewed for abuse, neglect, and exploitation.

Inspectors wroteThis deficiency pertains to Intake MI00148163. Based on interview and record review, the facility failed to provide advanced written notice prior to a room change for one Resident (#2) of six residents reviewed for room changes.

Inspectors wroteThis citation pertains to intakes MI00149104 and MI00149112. Based on interview and record review, the facility failed to protect the resident's right to be free from mental and verbal abuse by facility staff for one Resident (#1) of four residents reviewed for abuse, resulting in feelings of fear, humiliation, and the potential for psychosocial harm.

Inspectors wroteThis deficiency pertains to Intake MI00148163. Based on interview and record review, the facility failed to develop, implement, and operationalize policies and procedures to ensure the appropriate placement on a secured unit for one Resident (#2) of six residents reviewed for involuntary seclusion.

Inspectors wroteThis citation pertains to intakes MI00149113, MI00149014 and MI00148163. Based on interview and record review, the facility failed to report allegations of abuse to the State Agency (SA) within the appropriate time frame for one Resident (#1) of four residents reviewed for abuse, resulting in the potential for continued abuse.

Inspectors wroteThis citation pertains to intake MI00149014. Based on interview and record review, the facility failed to ensure a thorough investigation of an allegation of verbal abuse for one Resident (#6) of four residents reviewed for abuse, resulting in the potential for unidentified and continued abuse.

Inspectors wroteThis deficiency pertains to Intake MI00147134. Based on interview and record review, the facility failed to provide timely notification to the physician for one Resident (#4) of three residents reviewed for a change in condition. This deficient practice resulted in a delay in medical treatment and subsequent death for Resident #4.

Inspectors wroteThis deficiency pertains to Intake MI00147235. Based on interview and record review, the facility failed to ensure timely laboratory services were provided per physician's orders for one Resident #1 (R1) of 3 residents reviewed for laboratory services. This deficient practice resulted in extreme elevation of blood glucose levels requiring R1 to be hospitalized .

Inspectors wroteThis deficiency pertains to Intake MI00147235. Based on interview and record review, the facility failed to ensure a resident representative was informed about medication changes for one Resident (#1) of 3 residents reviewed for medication review.

Inspectors wroteThis citation pertains to intake MI00145621. This citation has two parts: A and B. A. Based on interview and record review, the facility failed to ensure appropriate, timely assessments and physician/provider notification for a change in condition for one Resident (#173) of three residents reviewed for death, resulting in actual harm when R173 became unresponsive and ultimately expiring in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 164 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of adverse events to correct quality deficiencies and maintain sustained compliance. This deficient had the potential to affect all 164 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident and/or Resident Representative in writing, the reason for transfer of four Residents (R1, R56, R149, R621) of five residents reviewed for facility initiated transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the facility bed hold policy for two Residents and/or Resident Representatives (#621 and #149) of five residents reviewed for notice of bed hold policy.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for the use of psychotropic medications for one Resident (#136) of five residents reviewed for unnecessary medications, resulting in the potential for unnecessary use of mood-altering drugs and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply orthopedic braces per physician orders for two Residents (#104 and #155) out of five Residents reviewed for range of motion, positioning, and mobility. This deficient practice resulted in the potential for a reduction in range of motion and/or complications following cervical [neck] surgery.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate interventions to prevent unsafe wandering and elopement for three Residents (R132, R156, & R221) of three residents reviewed for elopement. This deficient practice resulted in continued unsafe supervision and an elopement from the locked memory care unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice for one Resident (#83) out of two residents reviewed for respiratory care. This deficient practice resulted in the potential for hypoxia (oxygen deficiency), respiratory complications, and the potential for re-hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician and maintained in the clinical records for two Residents (R61 and R91) of five residents reviewed for MRR.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of targeted behaviors and use of non-pharmacological interventions prior to administration of as needed anti-anxiety medication for one Resident (#136) of five residents reviewed for unnecessary medications, resulting in the potential for over-medication and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely dental services were provided for three Residents (R49, R61, and R56) of three residents reviewed for dental services.

Inspectors wroteBased on observation, interview and record review the facility failed to follow to evaluate and treat one resident (R119) of two residents reviewed for therapy services. This deficient practice caused R119 to be uncomfortable each day when she sat in her wheelchair.

Inspectors wroteBased on interview and record review, the facility failed to ensure collaboration and communication between the facility and hospice provider for one Resident (R137) of one resident reviewed for hospice services. This deficient practice resulted in gaps in communication for coordination of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) maintain sanitary equipment, 2) date mark potentially hazardous food, 3) and monitor cooler temperatures, resulting in the potential for contamination of equipment and potential for conditions for foodborne illness, affecting all 138 residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in 12 (Resident #80, #431, #44, #12, #36, #125, #84, #98, #16, #20, #97, and #72) of 13 residents reviewed for dignity related to dining experience, call light wait times, and staff assistance of resident needs, resulting in the likelihood of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's accommodation of needs were met for 5 (Resident #81, # 68, #381,#34 and #96) out of 6 residents reviewed for accommodation of needs resulting in resident's inability to call for staff assistance with the potential for unmet care needs and a resident not receiving incontinence care products.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was consistently provided with personal hygiene related to facial hair and overall cleanliness with daily ADL care for 5 of 5 residents (Resident #7, #381, #72, #33 and #67) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem.

Inspectors wroteBased on observation and interview, the facility failed to provide food in a palatable and appetizing temperature for 4 residents (Resident #80, #74, #36, and #84) of 4 reviewed for food palatability resulting in dissatisfaction with meal service with the potential for decreased food acceptance and nutritional decline.

Inspectors wroteIn an observation on 9/11/23 at 1:16 PM., noted 2 sit to stand lifts (lift that assist residents to stand and transfer) parked on the 400 unit near room [ROOM NUMBER]. The bases (where residents plant their feet) of the lifts were noted to be soiled with dust, debris and food crumbs. There were no sanitizing wipes near or attached to the lifts. In an observation on 9/11/23 at 3:09 PM., noted 2 sit to stands parked on the 400 unit near room [ROOM NUMBER]. The bases of the lifts were noted to be soiled with dust, debris and food crumbs. A dark brown dried smeared substance was noted on the knee area of one of the lifts. There were no sanitizing wipes near or attached to the lifts. In an observation 09/12/23 at 3:00 PM., noted 2 sit to stands parked on the 400 unit near room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to perform a resident assessment and obtain a physician order for the self administration of medication for 1 of 1 resident (Resident #81), reviewed for self administration of medication, resulting in the potential for the mismanagement of medication and adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and immediately report to the State Agency an allegation of staff to resident abuse for 1 residents (Resident #95) of 6 residents residents reviewed for abuse, resulting in the potential for allegations of abuse to go unreported, undetected and the potential for further abuse to continue and go unrecognized.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure and thoroughly investigate and protect residents after an allegation of staff to resident physical abuse was made by Resident #95, resulting in the alleged perpetrator not being immediately removed from direct resident care, and an allegation of physical abuse not being investigated, and the potential for future mistreatment and/or abuse to go undetected and investigated to protect a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 3 of 3 residents (Resident #12, #86, and #33) reviewed for care planning, resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to revise an individualized care plan to reflect current therapy recommendations for 1 (Resident #297) of 25 residents reviewed for care plan revision, resulting in the potential for staff to provide care that was not consistent with the needs of the resident.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly assess and monitory a resident after a fall in 1 (Resident #297) of 5 residents reviewed for accidents and injuries, resulting in the potential for unnoticed and untreated head injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and ensure the resident safety 1 of 5 residents (Resident #96) reviewed for accidents and hazards, resulting in the potential for falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a leg strap (a device that goes around a leg to comfortably secure a urinary drainage bag in place) was in place for 1 resident (R98) in 1 resident reviewed for urinary catheter care, resulting in pain and injury.

Inspectors wroteBased on interview and record review the facility failed to ensure pain management interventions were implemented for 1 of 24 resident, (Resident #72) reviewed for pain, resulting in Resident #72's complaint of pain and inadequate pain management.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 2 residents (Resident #95, #381) of 2 residents reviewed for medical records, resulting in the potential for facility staff and providers not having all of the pertinent information to care for residents and track the history of abuse allegations.