Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Maples Benzie County Medical Care during CMS and state inspections, most recent first.
Medication storage and labeling were not maintained in two med rooms and one med cart. Surveyors found an insulin pen without a discard date, an opened PPD vial without an opened date, and multiple PPD vials in the 100-hall med room with missing or inconsistent opened/expiration dates. An RN was also observed administering meds while the med cart was left unlocked and unattended. RN staff and the DON acknowledged the labeling and locking requirements, and the facility’s pharmacy guidance stated PPD is good for 30 days after opening.
Failure to provide privacy during medication administration: An RN exposed a resident’s abdomen and gave an insulin injection in the dining room while the resident was preparing for a meal with other residents present. In a separate incident, an RN interrupted another resident’s breakfast in the dining room to administer eye drops while several residents were present. Both residents had dementia and severe cognitive impairment, and the facility policy required privacy.
A facility failed to provide written transfer notifications to residents or their representatives and failed to document information sent to the receiving hospital for three residents transferred for hospital care. Records for one resident transferred to the ED and two other residents sent to the hospital did not show the required written notice or documentation of communication with the hospital, and an RN confirmed the missing transfer communication documentation.
Failure to Document and Monitor Changes in Condition: Two residents had changes in condition that were not adequately assessed or documented. One resident with DM, insulin use, and septicemia developed AMS with confusion, tachycardia, and later DKA, but the EMR lacked ongoing assessments, BG checks, and documentation of VS, behaviors, orientation, or other clinical findings. Another resident with dementia and pulmonary fibrosis had drowsiness, weakness, cough with blood-tinged sputum, low O2 sat, tachypnea, and abnormal lung sounds, but there was no follow-up note or documented reassessment after the initial nursing assessment.
Food handling and sanitation deficiencies were observed in the kitchen and satellite serving area. A Chef used a probe thermometer on uncooked turkey and initially only wiped it with an alcohol wipe before later washing, rinsing, and sanitizing it after questioning. A slicer had visible food debris under the cover, a staff member returned ice cream cups that had fallen on the floor back to storage, and another staff member donned gloves without washing hands first.
Three residents experienced falls resulting in serious injuries due to the facility's failure to identify and mitigate environmental hazards, ensure proper use of assistive devices, and implement care planned interventions. Incidents included a resident sustaining multiple leg fractures after slipping on a wet floor post-shower without safety equipment, another falling during a transfer due to an unlocked shower chair and lack of gait belt, and a third suffering fractures after a bed alarm was not activated as required by the care plan.
The facility failed to adhere to food safety standards, risking foodborne illness for 77 residents. A pureed salad was improperly stored at 48 F, above the safe holding temperature, and the thermometer used was not sanitized. Additionally, improper sanitization practices were observed with wiping cloths, as staff were not correctly trained to measure sanitizing solution concentration, leading to potential contamination.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to update and document care plan interventions. Despite having a tab alarm, the resident's care plan lacked additional interventions after falls, and there was no routine check for the alarm's placement and operation. Staff interviews revealed uncertainty about intervention implementation, and facility policies on fall risk assessment were not followed.
The facility failed to ensure sanitary storage of respiratory equipment for two residents, leading to a deficiency in care. A resident with COPD and Parkinson's had a nebulizer with condensation stored improperly, while another with hypoxemia and CHF had oxygen tubing not stored in a protective bag. Staff interviews confirmed non-compliance with facility policies on equipment storage.
A resident with dementia and a progressive tremor was not provided with adaptive dining equipment as prescribed, leading to difficulties in self-feeding. Observations showed the resident using standard cutlery, resulting in food spillage and frustration. Staff interviews confirmed the oversight, with adaptive utensils found unused in a kitchen drawer, contrary to the resident's care plan and facility policy.
A facility failed to maintain infection control during a dressing change for a resident with a stage II pressure injury. An LPN did not perform hand hygiene after removing gloves and before applying new ones, contrary to the facility's policy. The LPN was unaware of the requirement, and both the Clinical Care Coordinator and Nursing Home Administrator acknowledged the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, discard, and label medications in two medication rooms and one medication cart. On the 300-hall medication cart, surveyors found one insulin pen with an opened date but no discard date. In the 300-hall medication room, an opened tuberculin purified protein derivative (PPD) solution vial was observed without an opened date. During the same observation, RN N was seen administering medications to a resident in room [ROOM NUMBER] while her back was turned to the medication cart, and the cart remained unsecured and unlocked until 10:05 AM. The 300-hall housed 20 residents, 18 of whom had a diagnosis of dementia. In the 100-hall medication room, multiple PPD solutions were observed with labeling problems, including one opened vial with no opened date or expiration date and other vials with opened dates and expiration dates that were inconsistent or improperly marked. RN I stated she was not sure how long PPD solution was good for after opening and said multi-use vials needed to be dated when opened and have an expiration date. Review of the facility's pharmacy medication storage and stability guidance confirmed that PPD solution is good for up to 30 days after opening. The DON confirmed that multi-use vials needed to be dated when opened and discarded per pharmacy recommendations, and that medication carts are to remain locked unless attended by a nurse.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to provide a dignified dining experience based on the reasonable personal concept for two residents. Resident #47 was admitted with diagnoses including dementia, diabetes, and long-term use of insulin, and her most recent MDS indicated severely impaired cognitive skills for daily decision making. While she was in the dining room with 16 other residents preparing for the midday meal, an RN approached her, lifted her shirt, exposed her abdomen, and administered an injection in her stomach without providing privacy. Resident #33 was admitted with diagnoses including dementia, glaucoma, and macular degeneration, and her most recent MDS showed a BIMS score of 5, indicating severe cognitive impairment. While she was eating breakfast in the dining room with three other residents, an RN interrupted her in the middle of the meal and administered eye drops, with a total of 8 residents present in the dining room at the time. During interview, the DON stated residents are asked if they would like privacy if they are administered anything other than oral medications and may choose to have them administered in a common area, but also stated that for residents with cognitive impairments who are unable to make daily decisions, staff typically try to do medication administration in private. The facility policy titled Medication Administration included a requirement to provide privacy.
Failure to document transfer notifications and hospital communication
Penalty
Summary
The facility failed to provide written notifications of the reason for hospital transfers to residents or their resident representatives and failed to document information communicated to the receiving hospital for three residents reviewed for hospitalizations. Resident #3 was transferred to the hospital emergency department, but the electronic medical record did not include documentation that a written notification of transfer was provided to the resident or the resident representative, and it also did not include a progress note or other documentation showing what information was communicated to the receiving hospital at the time of transfer. Resident #49 was found lying on her right side in the bathroom with her feet toward the toilet and her head in the shower, and the report states that the transfer coordinator at the local hospital was called to anticipate arrival; however, the record did not include documentation of information communicated or provided to the receiving hospital. Resident #13 agreed to go to the ER and was transported by EMS with paperwork and a phone charger, and the transfer department at the local hospital was notified by ambulance, but the record likewise did not include documentation of information communicated or provided to the receiving hospital. The Clinical Coordinator RN confirmed there was no written communication for the reason for transfer for Resident #13 or Resident #49 and no specific communication documented for continuation of care needs for residents transferred out.
Failure to Document and Monitor Changes in Condition
Penalty
Summary
The facility failed to monitor and document clinical assessments for two residents who experienced changes in condition. For Resident #3, who had diabetes, received daily insulin, and had a diagnosis of septicemia, staff documented worsening confusion and disorientation over several days, along with tachycardia and suspected worsening infection. The record showed a progress note on 10/19/25 describing altered mental status, but there were no prior notes or assessments documenting the change over the preceding three days, and there was no documented ongoing assessment before the resident was sent to the ER on 10/20/25 for altered mental status. Resident #3’s record also lacked documentation of blood sugar checks during the altered mental status episode, despite the resident’s insulin-dependent diabetes and later hospital discharge diagnosis of diabetic ketoacidosis. The record did not include documented monitoring of temperature, pulse, respirations, behaviors, orientation, memory, judgment, speech, mood, or other symptoms while the resident was experiencing the change in condition. The DON and Clinical Coordinator RN reviewed the record and confirmed the absence of clinical documentation of the change of condition, and both agreed there should have been documented assessments. For Resident #15, who had dementia and pulmonary fibrosis and was severely impaired in daily decision-making, a nurse documented increased drowsiness, weakness, refusal to get out of bed, a productive cough with scant red blood in sputum, oxygen saturation of 91% on room air, respiratory rate of 24, and diminished lung sounds with faint coarse/crackles in the right lower lobe. The record contained no follow-up vital signs or progress note showing the resident’s condition after this assessment. During interview, the nurse stated the resident’s condition was monitored visually and that repeat vitals were probably taken but not entered, and acknowledged a follow-up note should have been entered. The ADON and DON both stated they would have expected follow-up documentation of the resident’s ongoing condition, and the DON stated the physician should have been notified and the communication followed up in the EMR.
Food Handling and Sanitation Deficiencies
Penalty
Summary
Food was not prepared and handled in accordance with professional standards in the kitchen and satellite serving kitchen. During a kitchen tour, a fresh turkey still in its wrap was observed on a prep table, and the Chef stated it had been thawed in advance and was being prepared for a later meal. The Chef used a probe thermometer to check the turkey’s internal temperature, then wiped the probe with an alcohol wipe and replaced the cap before washing, rinsing, and sanitizing it after being questioned about proper cleaning of the thermometer after contact with uncooked poultry. A slicer was also observed covered with plastic on a prep table, and when the cover was removed, food debris was seen on the underside of the blade and casing. In the walk-in freezer, a staff member picked up single-serve plastic cups of ice cream that had fallen onto the floor and placed them back into the cardboard box on the shelf. In a satellite serving kitchen, a staff member entered the prep area from the dining room and put on gloves without first washing hands. The report cites these events as failures to follow food-contact surface sanitation, discard of contaminated food, and handwashing requirements.
Failure to Prevent Accidents Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
The facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions, resulting in falls and injuries for three residents. One resident with moderate cognitive impairment and a history of independent ambulation sustained multiple lower leg fractures requiring surgical intervention after slipping on a wet floor while exiting the bathroom post-shower. The resident was barefoot, without a gait belt or non-skid footwear, and the CNA assisting her did not attempt to use a shower chair or other safety devices, assuming the resident would refuse them based on prior behavior. The incident occurred as the resident lost her balance on the floor transition, which was wet from the shower, and fell backward, resulting in an open fracture confirmed by emergency services. Another resident with severe cognitive impairment and mobility issues fell in the shower while being assisted by a CNA. The resident attempted to transfer from a wheelchair to a shower chair, but the shower chair was not properly locked, the floor was wet, and the resident was barefoot without a gait belt. The CNA admitted to forgetting to lock the wheels and not placing a towel on the ground, and the water was running at the time of the fall, making the floor slippery. The care plan for this resident required contact guard assistance with a gait belt and walker for transfers, but these interventions were not implemented at the time of the incident. A third resident with Alzheimer's disease and a history of repeated falls was found on the floor with a right femur fracture and lumbar compression fracture. The care plan included the use of a bed alarm to alert staff when the resident was getting out of bed, but the alarm was not turned on at the time of the fall. Staff interviews confirmed that the bed alarm was in place but not activated, likely due to oversight by the night shift CNA. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices, but these measures were not consistently implemented, leading to actual harm.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 77 residents. During an observation in the Oak dining room, a stainless steel pan containing pureed salad was found to have a temperature of 48 F, above the maximum holding temperature of 41 F. The Food Service Worker (FSW) I initially reported a temperature of 39 F after improperly measuring it by placing the thermometer probe at the bottom of the pan. Upon correction, the temperature was confirmed to be 48 F. FSW I admitted to not sanitizing the thermometer probe before use and was unaware of the correct method for measuring food temperature. No corrective action was taken to address the food's temperature. Further observations in the Pine unit revealed improper sanitization practices. Wiping cloths were stored in a red bucket near the food preparation area, and FSW J demonstrated incorrect use of QT 40 test strips to measure the concentration of quaternary ammonium in the sanitizing solution. FSW J was not instructed to hold the strip still in the solution for the required ten seconds, leading to an inaccurate reading of more than 400 PPM. This indicates a lack of proper training and adherence to the FDA Food Code, which requires equipment food-contact surfaces and utensils to be cleaned whenever contamination may have occurred.
Failure to Implement Revised Fall Interventions
Penalty
Summary
The facility failed to implement revised care plan interventions for a resident who experienced multiple falls. The resident, identified as having severe cognitive impairment due to conditions such as cerebral infarction, aphasia, and dementia, was observed with a tab alarm device intended to alert caregivers if the resident attempted to rise without assistance. Despite this, the resident experienced several falls, including an unwitnessed fall from a wheelchair resulting in facial trauma and a witnessed fall in the TV room while reaching for items. The resident's care plan, initially created in May, did not include additional interventions following falls in June, September, and October. The care plan lacked documentation of post-fall evaluations and fall risk assessments for incidents in June and September. Furthermore, there was no documentation on the Kardex or care plan to routinely check the placement and operation of the resident's tab alarm, which was a critical intervention for fall prevention. Interviews with facility staff, including a CNA and the DON, revealed uncertainty about when the tab alarm was added as an intervention and highlighted a lack of documentation and communication regarding the resident's fall interventions. The facility's policies on fall risk assessment and post-fall assessment were not adhered to, as evidenced by the absence of updated care plan interventions and the lack of a documented post-fall checklist. This deficiency in implementing and documenting fall prevention measures resulted in the potential for additional falls and subsequent injury to the resident.
Deficiency in Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of respiratory equipment for two residents, leading to a deficiency in respiratory care services. Resident #20, who has chronic obstructive pulmonary disease (COPD) and Parkinson's Disease, was observed with an assembled nebulizer stored on top of a dresser with condensation in the nebulizer cup over multiple days. This indicates that the nebulizer equipment was not properly cleaned and stored according to facility protocols, which require rinsing and drying the equipment before storing it in a designated case or bag. Resident #19, diagnosed with hypoxemia and congestive heart failure, was observed with oxygen tubing hanging on the back of their wheelchair and resting on their bed without a protective storage bag. Interviews with facility staff, including an LPN and a Clinical Care Coordinator, confirmed that the respiratory equipment was not stored according to the facility's policies, which require oxygen tubing and nasal cannulas to be stored in a bag when not in use. The staff acknowledged the need for additional education to meet these storage expectations.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment for a resident with a progressive tremor, resulting in increased difficulty with independent eating. The resident, who has dementia, muscle weakness, and activity limitations, was observed using standard stainless-steel cutlery instead of the prescribed built-up and curved utensils. This led to difficulties in self-feeding, as evidenced by food spilling onto the resident's chest and the resident resorting to eating with their hands due to frustration. Interviews with staff revealed a lack of adherence to the resident's plan of care, which specified the use of adaptive utensils. A Certified Nursing Assistant confirmed that the resident was supposed to receive adaptive utensils with every meal but was unsure if they were provided during breakfast. Another staff member retrieved the adaptive utensils from a kitchen drawer, indicating they were not placed on the resident's meal tray. The Director of Nursing verified that residents should receive adaptive equipment as per their care plan, aligning with the facility's policy on adaptive eating devices.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with an in-house acquired stage II pressure injury. During an observation, an LPN did not perform hand hygiene after removing gloves following the removal of an old dressing and before applying new gloves to cleanse and apply a new dressing. The LPN acknowledged the oversight and indicated a lack of awareness regarding the necessity of hand hygiene between these steps. The facility's hand hygiene policy, reviewed in the presence of the Nursing Home Administrator, clearly states that hand hygiene should be performed before and after handling clean or soiled dressings and after removing gloves. The policy emphasizes that the use of gloves does not replace the need for hand hygiene. The Clinical Care Coordinator and the Nursing Home Administrator both acknowledged the deficiency in hand hygiene practices as per the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paul Oliver Memorial Hospital Ltcu | 2.1 mi | ★★★★★ | 0 | 0 |
| Maple Valley Nursing Home | 21.3 mi | ★★★★★ | 1 | 0 |
| Manistee County Medical Care Facility | 26.7 mi | ★★★★★ | 11 | 0 |
| Grand Traverse Pavilions | 28.8 mi | ★★★★★ | 6 | 0 |
| The Villa At Traverse Point | 28.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maples Benzie County Medical Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.