Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grayling Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
A facility failed to timely assess and monitor change in condition for two residents. One resident with CKD, BPH, and cognitive decline developed worsening confusion, hallucinations, poor intake, and dehydration while family repeatedly raised concern for a UTI; the UA was delayed, VS were not consistently obtained, and the resident was later hospitalized with septic shock due to UTI and died. Another resident with CHF, CKD, AFib, and DM had ordered BMP monitoring that was not completed as scheduled while receiving multiple diuretics and potassium, was transferred to the hospital with SOB, and later died after hospitalization. Interviews showed inconsistent urine-output documentation practices and lack of clear understanding of monitoring and notification expectations.
Improper Waste Disposal and Dumpster Area Maintenance: Both dumpsters were observed full of garbage, with lids unable to close due to the volume of waste. Fourteen bags of garbage and eight empty cardboard boxes were also found on the ground behind one dumpster, and facility email records showed the scheduled trash pickup did not occur.
Facility Premises Not Properly Maintained: The facility failed to maintain general repair of the premises. Surveyors observed the 3-bin sink drain line indirectly connected to the floor drain with a rubber adapter while fresh vegetables were washed in the third compartment, ice machine drain lines extending below the lip of the floor bowl drain, water damage above the maintenance hall entrance, peeling paint and dust/debris in the men's restroom, and a damaged rear exit door sweep allowing daylight under the door.
Psychotropic medications were ordered for four residents without a documented, specific diagnosis or clinical indication in the chart. The EMR showed orders for antidepressants, an antipsychotic, and Xanax, but the diagnosis fields were blank or the record otherwise lacked support for why the meds were being used. The NP said prescriptions were written with an active dx, while the DON said the dx was not entered into the EMR.
Care plan interventions were not updated to reflect a resident’s current mobility and dietary needs. The resident had a history of stroke, dysphagia, dysarthria, and TBI, and was observed using a manual wheelchair while the care plan still described independent electric wheelchair use. During a meal, the resident was totally dependent on staff for feeding, yet the tray card and care plan still listed adaptive utensils and other equipment that were no longer being used.
A resident with a history of stroke, dysphagia, TBI, and cognitive impairment was repeatedly observed seated with a severe left lateral neck lean while eating. During meals, the resident had wet coughing, throat clearing, and gurgled vocal quality, yet a feeding assistant, an LPN, and a CNA did not improve posture or provide compensatory swallowing cues. Speech therapy documentation recommended upright posture during meals to support safety and reduce aspiration risk, but those recommendations were not included in the care plan, physician orders, or tray card.
Failure to Follow Fall Mat Interventions: The facility failed to follow care planned fall interventions for two residents at risk for falls. One resident had a history of falls, mild cognitive impairment, and staff kept a fall mat on the floor all the time because the resident liked to self-transfer, even though the care plan said the mat was to be next to the bed when in use. Another resident had dementia, stroke-related deficits, severe cognitive impairment, and a fall history; staff also left the fall mat on the floor throughout the day despite the care plan and MD order directing that it be used only while the bed was in use and checked each shift for proper placement.
An LPN failed to don the required gown and gloves before providing PEG tube care to a resident on EBP. The nurse entered the room where EBP signage was posted, handled the PEG tube without gloves, and flushed the tube without wearing a gown. The LPN later stated she normally forgets to use EBP PPE when caring for the resident’s PEG tube.
A facility failed to obtain consent for a psychotropic medication for a resident with severe cognitive impairment. The resident's legal guardian was not informed or educated about the medication's risks and benefits before its initiation. The oversight was confirmed by the facility's social worker and NHA, acknowledging that a signed consent should have been obtained according to the facility's policy.
A resident with severe cognitive impairment was transferred to a hospital following a fall without receiving the required written notification. The Business Office Manager and Nursing Home Administrator were unaware of the notification requirement, leading to a failure in following the facility's transfer and discharge policy.
A facility failed to provide a physician order and implement a care plan for a resident with edema, resulting in inconsistent management of the condition. The resident, with a history of acute respiratory failure and other conditions, was observed with swollen, discolored legs. Despite the need for daily ACE wraps, there was no documented care plan or physician order, leading to a deficiency in care.
A resident with cognitive impairment and arthritis experienced a hot coffee spill, resulting in skin redness. Despite this, the facility did not complete an accident report or conduct a hot beverage assessment to determine the need for adaptive equipment. Staff interviews revealed that standard procedures were not followed, and the resident's difficulty in grasping items was not adequately addressed.
Failure to Timely Assess and Monitor Change in Condition
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure timely and comprehensive assessment, treatment, and documentation for change in condition for two residents. For one resident with a history that included CKD, anemia, BPH, and subdural hemorrhage, the record and interviews showed a decline in mental status from being alert and oriented to being confused, hallucinating, and increasingly weak with poor intake and dehydration. Family reported repeated concerns about a possible UTI and asked staff to test for one, but the UA was not obtained until later, and the record showed no UA order was present on the earlier date when symptoms were first documented. Nursing notes documented confusion, hallucinations, poor appetite, and decreased oral intake, while vital signs were not obtained daily or with the change in condition. The resident was later transferred to the hospital with altered mental status, low blood pressure, and no response to fluids and antibiotics, and the hospital diagnosed septic shock secondary to UTI, AKI superimposed on CKD, dehydration, and metabolic encephalopathy. The resident died in the hospital, and the death certificate listed septic shock due to UTI. For the second resident, who had CHF, atrial fibrillation, CKD, diabetes, and moderate cognitive impairment, the record showed an order for BMP monitoring every two weeks, but the required BMP was not completed on the scheduled date. The resident had been receiving diuretics and potassium supplementation, including Lasix, spironolactone, torsemide, metolazone, and potassium chloride, and had prior lab results showing abnormal sodium, BUN, and creatinine values. Family stated the facility did not catch the potassium level and believed the kidneys shut down because the resident’s potassium levels were not being monitored. The resident was transferred to the hospital for shortness of breath and later died after hospitalization. Interviews with nursing staff, the DON, the Administrator, and the provider showed inconsistent understanding of urinary output documentation, lack of a defined policy for output monitoring and change in condition, and uncertainty about when to notify the provider. Staff described documenting urine output as small, medium, or large without a shared definition or training, and the DON and Administrator stated they did not know what those terms meant for urine output. The provider and NP stated they would expect notification for decreased or absent urine output and hallucinations, and the NP stated the delay in care did not make sense. The record also showed inconsistent documentation of mental status, urine output, and vital signs across nursing and provider notes.
Improper Waste Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests. On 03/10/2026 at 2:05 PM, both dumpsters were observed full of garbage, and the volume of garbage prevented the lids from closing. Fourteen bags of garbage and eight empty cardboard boxes were also observed on the ground behind one of the full dumpsters. Record review of facility email communications with the garbage disposal company noted that pickup was scheduled for Friday, March 6, and the pickup never occurred.
Facility Premises Not Properly Maintained
Penalty
Summary
The facility failed to maintain general repair of the premises. On 03/10/2026, the drain line from the three-compartment sink was observed indirectly connected to the floor drain by means of a rubber adapter, and the Dietary Manager stated that fresh vegetables were washed in the third compartment of the three-bin sink, with the rubber adapter in place to prevent splashing onto the floor. On 03/11/2026, the drain lines from the ice machine were observed extending down below the lip of the floor bowl drain. Also on 03/10/2026, water damage was observed on the ceiling and wall above and to the left of the entrance to the maintenance hall leading to the kitchen, restrooms, and employee back door entrance; the Maintenance Director stated a service line leak had recently been repaired but the walls had not yet been repaired or repainted. The men's restroom wall had peeling paint on both sides of the sink, dust and debris buildup around the plumbing under the sink, and peeling paint in the toilet stall beside the toilet. On 03/11/2026, daylight was observed coming in from under the maintenance hall rear exit door, and the door sweep was damaged and missing across the bottom right half of the door.
Psychotropic Medications Lacked Documented Diagnoses
Penalty
Summary
The facility failed to ensure psychotropic medications were used to treat a specific, diagnosed, and documented condition for four residents reviewed for unnecessary medications. For Resident 46, the medical record showed orders for citalopram 20 mg daily and trazodone 25 mg at bedtime, but review of the physician orders, care plan, and diagnosis list did not identify a documented diagnosis or clinical indication supporting either medication. For Resident 19, the record showed orders for Wellbutrin XL 150 mg at bedtime and citalopram 40 mg daily, but the medical record did not identify a documented diagnosis or clinical indication supporting either medication. For Resident 8, the EMR showed active orders for Xanax 0.25 mg three times daily and Zyprexa 15 mg at bedtime, but the medication orders did not identify a specific diagnosed condition being treated, and the diagnosis field on the medication order report was blank. For Resident 49, the EMR showed active orders for quetiapine 25 mg daily and venlafaxine ER 37.5 mg plus 75 mg daily, but the medication orders did not identify a specific diagnosed condition being treated, and the diagnosis field was blank. The NP stated psychotropic prescriptions were written with an active diagnosis, and the DON stated the diagnosis was not entered into the EMR, although residents had care plans based on the psychotropic drug class. The facility policy stated residents are not to receive psychotropic medication unless necessary to treat a specific condition diagnosed and documented in the clinical record.
Care Plan Not Updated for Mobility and Feeding Needs
Penalty
Summary
The facility failed to update and revise Resident #15’s mobility and dietary care plan interventions in a timely manner. R15 was admitted with diagnoses including cerebral infarction, dysphagia, dysarthria, traumatic brain injury, and cervicalgia, and his most recent MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. During observation, R15 was sitting in a manual wheelchair in his room, while an electric wheelchair was seen in the corner of the room. His guardian stated that he had not been able to use the electric wheelchair for a couple of years because of safety concerns and that a manual wheelchair had been introduced as a seating alternative, yet the care plan still reflected that he was able to transport himself independently via electric wheelchair and needed help positioning at the table as needed. The facility also did not timely revise R15’s eating and adaptive equipment interventions to match his current status. During breakfast, R15 was observed receiving total assistance from a CNA, who used standard cutlery and cups without lids to feed him. However, the tray card listed built-up angled-left utensils, cups with handles and lids, and other adaptive equipment. The CNA stated that R15 had not been able to feed himself for a while and no longer required adaptive utensils because he was totally reliant on staff for feeding assistance. The care plan still included interventions stating that he was independent after set-up and that adaptive equipment was to be used, despite the observed change in his functional status.
Failure to Maintain Upright Meal Positioning
Penalty
Summary
The facility failed to ensure functional positioning to carry out activities of daily living for one resident with a history of cerebral infarction, dysphagia, dysarthria, traumatic brain injury, and cervicalgia. The resident’s most recent MDS showed moderate cognitive impairment. During observation, the resident was repeatedly seen seated in a wheelchair with a significant left lateral neck lean, with the left ear contacting the left shoulder and the chin angled toward the left collarbone. A power wheelchair was present in the room, but the resident was using a manual wheelchair as a seating alternative because the power wheelchair was no longer considered safe. During meals, the resident continued to eat in the same excessive left lateral neck position. Surveyors observed wet coughing, throat clearing, gurgled or wet vocal quality, and visible facial redness during coughing episodes while the resident was eating lunch and breakfast. A feeding assistant, an LPN, and a CNA were observed providing meal assistance without improving the resident’s posture or providing compensatory swallowing cues. The resident stated that eating in the current position was “a problem” and that the positioning was sometimes painful. The resident’s speech evaluation and discharge summary both documented that posture affected function and that upright posture during meals was recommended to facilitate safety and efficiency and reduce aspiration risk, with good prognosis dependent on consistent staff follow-through. The resident’s plan of care, physician orders, and tray card did not contain the speech therapy recommendations. The DOR stated the resident had not been re-evaluated by speech therapy because the therapy department had not received reports of choking or coughing during meals, and OT documentation noted the customized wheelchair still left the resident with a significant lateral lean that impacted self-feeding. The DON acknowledged the quality of life and aspiration concerns related to the resident’s positioning.
Failure to Follow Fall Mat Interventions
Penalty
Summary
The facility failed to implement fall interventions as written in the care plans for two residents who were identified as being at risk for falls. Resident #19 was admitted with muscle weakness and a history of falls, and the 2/13/26 MDS showed a BIMS score of 10/15 with a fall in the look-back period. Observations on 3/9/26, 3/10/26, and 3/11/26 showed a fall mat on the floor in R19’s room while the bed was positioned against the wall, and staff interviews indicated the mat was kept on the floor all the time because the resident liked to self-transfer. However, the care plan stated the floor mat was to be next to the bed when in use, when the resident was in bed. Resident #49 was admitted with dementia, cerebral infarction, gait and mobility abnormalities, muscle weakness, need for assistance with personal care, and left-sided hemiplegia. The 10/10/25 MDS showed a BIMS score of 3 and a fall in the look-back period. Observations on 3/9/26, 3/10/26, and 3/11/26 showed a gray fall mat on the floor next to the bed, and on 3/11/26 the resident was observed attempting to mobilize the wheelchair onto the mat and having difficulty navigating the lip of the mat. The care plan and physician order both directed that the floor mat be next to the bed while the bed was in use and checked each shift for proper use and placement, but staff stated they believed the mat stayed down all day and did not verify the care plan when asked. The DON stated staff likely considered the mats low-profile and confirmed that orders and care planned interventions should be followed as written, including removing fall mats from the floor when the residents were not in bed.
Failure to Use Required PPE During PEG Tube Care
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices when an LPN did not properly don required PPE before providing care to a resident with Enhanced Barrier Precautions. Resident #32 was admitted on 3/1/25, and the resident’s orders indicated EBP with targeted gown and glove use because of a PEG tube. During observation on 3/11/26 at approximately 9:52 AM, the LPN entered the resident’s room where signage indicated EBP and required gown and gloves before care. The LPN lifted the resident’s PEG tube without gloves to place a towel under it before flushing, then troubleshot the blocked PEG tube and flushed 350 mL of water through the tube without donning a gown as required by the posted signage. During an interview immediately after the treatment, the LPN stated that until taking the ADON position on 3/10/26, she had been the primary day shift nurse who performed PEG tube flushes for the resident. When asked whether she typically wore EBP PPE before flushing the PEG tube, the LPN stated she normally forgets when it comes to the resident’s PEG tube. The facility’s policy stated that PPE for EBP is necessary during high-contact resident care activities, including device care or use such as feeding tubes.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for a psychotropic medication prior to its initiation for a resident. The resident, who was admitted with diagnoses including cerebral infarction and cognitive communication deficit, had a severe cognitive impairment as indicated by a BIMS score of 3. A pharmacy order for Venlafaxine, a psychotropic medication, was initiated without obtaining consent from the resident's legal guardian. The guardian confirmed that she had not signed a consent form nor was she educated on the risks and benefits of the medication. The facility's social worker and nursing home administrator acknowledged the oversight, confirming that a signed consent should have been obtained as per the facility's policy on psychotropic medication use.
Failure to Notify Resident of Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding a transfer to a hospital following a fall. The resident, who had severe cognitive impairment as indicated by a BIMS score of 7, was hospitalized for one day. The Business Office Manager, responsible for completing transfer paperwork, confirmed that no transfer notification was completed because she was unaware of the requirement. Additionally, the Nursing Home Administrator verified that the transfer notification process was not conducted as she was unfamiliar with the requirement. The facility's policy on transfer and discharge, reviewed in January 2025, mandates that proper written notice be provided to the resident, including details such as the date of notice, reason for the move, and contact information for the ombudsman. This policy was not followed in the case of the resident's transfer.
Failure to Implement Care Plan for Edema Management
Penalty
Summary
The facility failed to provide a physician order, care plan, and implement interventions for a resident with edema, leading to a deficiency in care. The resident, who was cognitively intact, had a history of acute respiratory failure, type 2 diabetes, kidney failure, and muscle weakness. Observations over several days revealed the resident's lower legs were swollen and deep purple in color, indicating significant edema. Despite the resident's condition, there was no consistent application of ACE wraps to manage the swelling, and no physician order or care plan interventions were documented to address this issue. Interviews with the resident and staff, including an LPN and the Director of Nursing, confirmed the lack of a physician order and care plan interventions for wrapping the resident's legs. The LPN acknowledged wrapping the resident's leg without a physician order, and the Director of Nursing confirmed that the resident's legs should be wrapped daily to manage the edema. The absence of a documented care plan and physician order for this intervention resulted in a deficiency, as it potentially increased the resident's pain, swelling, and risk of skin ulcers.
Failure to Assess and Supervise Resident After Hot Liquid Spill
Penalty
Summary
The facility failed to ensure appropriate assessment, interventions, and supervision were in place after a hot liquid spill involving Resident #48, who has a history of stroke, dementia, and osteoarthritis in both hands. The resident, with a BIMS score indicating moderate cognitive impairment, was observed multiple times consuming hot coffee from a mug without a lid, despite having previously spilled hot coffee on his abdomen, resulting in skin redness. The incident was not followed by an accident and incident report, nor was a hot beverage assessment conducted to determine if adaptive equipment, such as a lid, was necessary to prevent future spills and potential burns. Interviews with facility staff, including RN G and the Director of Nursing, revealed that standard procedures following a hot beverage spill, such as completing an accident report and conducting a hot beverage assessment, were not followed. The Director of Rehabilitation confirmed that the resident's arthritic hands contributed to difficulty in grasping items, which was not adequately addressed in the resident's care plan. The Nursing Home Administrator acknowledged that a follow-up assessment was not completed, as the incident was considered a one-off, and no documentation from interdisciplinary team meetings regarding the incident was provided to the surveyor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grayling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munson Healthcare Crawford Continuing Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Mission Point Nursing & Physical Rehabilitation Of | 11.7 mi | ★★★★★ | 9 | 0 |
| Kalkaska Memorial Health Center | 24.1 mi | ★★★★★ | 4 | 1 |
| King Nursing & Rehabilitation Community | 24.4 mi | ★★★★★ | 1 | 0 |
| Munson Healthcare Otsego Memorial Hospital Ltcu | 26.4 mi | ★★★★★ | 11 | 0 |
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