Below 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 Medilodge Of Gtc during CMS and state inspections, most recent first.
Failure to prevent and manage pressure injuries: Two residents developed worsening pressure wounds when pressure was not effectively relieved. One resident with significant mobility impairment remained seated in a WC for prolonged periods, while CNA documentation of repositioning did not match observations and the resident’s gluteal PI deteriorated from stage 3 to unstageable. Another resident with paraplegia developed an unstageable pressure injury to the foot after a malfunctioning sand bed left the foot resting against a hard plastic ridge for hours.
Soiled kitchen floors, drain lines, and the area under the hand sink were observed in the food service area, and the DD confirmed dietary staff were responsible for cleaning those areas. In addition, multiple meal carts and trays were observed with uncovered cake being transported down the hallway and into resident rooms, including trays where the meal was covered but the cake remained uncovered.
Medication storage was out of compliance in two med rooms and two med carts because loose pills, medication debris, and expired or improperly labeled items were found. Surveyors observed multiple loose tablets in the East Hall and North Hall carts, including several identified medications and one pill that could not be identified, along with insulin pens lacking expiration dates and an opened tuberculin vial in storage without an expiration date. Staff interviews confirmed the loose pills remained in the carts, and the DON and NHA acknowledged that loose pills, unclean carts, and expired medications were unacceptable.
Infection control breaches were observed during resident care and medication administration, along with improper PPE storage and a soiled utility room hopper. An LPN handled insulin and an antianxiety medication without proper barriers or gloves, and administered PEG tube medication without a gown despite an order for enhanced barriers. A CNA performed catheter care without changing gloves or using hand hygiene, while PPE was stored near a soiled hopper and exposed to possible overspray.
Failure to Obtain Timely Consent for Geri Chair Restraints: Two residents with severe cognitive impairment were observed using geri chairs that the facility labeled as restraints in the EMR. Both residents had monthly restraint elimination reviews documenting the geri chair use for positioning and comfort, but the DPOA consents were not signed until months after the chairs were put in place. The NHA stated the facility did not consider geri chairs to be restraints, despite the EMR documentation.
The facility failed to notify the State LTC Ombudsman of two residents’ discharges. One resident was discharged to an apartment and another was sent to the ED, but review of the Ombudsman documentation showed no notification for either discharge. The NHA stated notification was only required for emergent transfers, although the facility policy required the Social Services Director or designee to provide Ombudsman notice via monthly list.
Failure to monitor acute illness and notify the physician promptly for two residents led to delayed treatment and hospitalization. One resident had a critically low BP documented with no further monitoring or explanation for transfer, while another resident had a significant BP drop with no documented assessment, manual recheck, or timely provider notification before later hospitalization for hypotension, acute anemia, and GI bleed. The DON confirmed the EMR lacked documentation of the required follow-up and notification.
Smoking paraphernalia was left unsecured for a resident who smoked and had COPD, lung cancer, and an oxygen concentrator in his room. Staff observed a vape in his lap, lighters on an unused fireplace, and the resident keeping cigarettes and a lighter on his person and in his walker bag while going to the smoking area. The DON stated smoking items should be locked up, and the facility policy required smoking articles, including e-cigarettes, to be secured by staff and not kept in the resident's room or on the resident's person.
Failure to appropriately assess and timely address unintentional weight loss for a resident with vascular dementia, severe cognitive impairment, and muscle weakness. The resident’s weight steadily declined from 142 lbs to 124.4 lbs, and RD notes documented delayed recognition and intervention, including late documentation of weight loss and delayed changes to med pass 2.0 and weekly weights. The NHA, DON, and Regional RD confirmed the delay, and the DPOA stated he was not informed about the resident’s weight loss or the med pass 2.0 intervention.
Failure to act on pharmacy MRR recommendations for two residents. One resident with dementia, repeated falls, and PTSD had a pharmacist note about antipsychotic-related orthostatic hypotension and suggested BP checks, but there was no physician response and the change was not documented until later. Another resident with CHF had a pharmacist recommendation about lidocaine patch timing, but the MRR was not correctly entered into the EMR.
An LPN drew up the wrong insulin dose for a resident on sliding-scale insulin, preparing 14 units instead of the ordered 9 units after checking the resident’s blood glucose. The same LPN then administered the insulin and held the subcutaneous injection site for only four seconds, despite stating the expected hold time was ten seconds. Leadership confirmed nurses were expected to double check insulin doses and follow the five rights of medication administration.
A resident with cancer, dysphagia, and pneumonitis had a documented full code order, intact cognition, and had signed a CPR consent requesting resuscitation. One morning, a CNA found the resident unresponsive and not breathing and alerted an RN, who delayed going to the room, assessed for a pulse, concluded the resident was dead, and covered him with a sheet without initiating CPR or calling a code. The RN left to retrieve a stethoscope, administered medications to another resident, then returned and again failed to start CPR, later stating she did not know the resident’s code status and believed he was already dead. Another RN subsequently discovered the resident’s full code status, directed that CPR be started, and called a code blue and 911; when staff entered the room, the resident was pulseless and not breathing but did not exhibit clear signs of irreversible death. During the code, the first RN told staff to stop CPR, citing the DON, and also contacted an on-call provider who documented a change in code status to DNR based on nursing reports, despite state law and facility policy requiring the resident’s consent and specific signatures for a DNR. Multiple staff reported that too much time elapsed between finding the resident unresponsive and initiating CPR, and the facility’s CPR/BLS policy and AHA BLS algorithm, which required immediate CPR for a pulseless, non-breathing full code resident without obvious signs of irreversible death, were not followed.
A cognitively intact male resident with cancer, dysphagia, and pneumonitis had a documented full-code status and had signed a CPR consent requesting resuscitation. When he was found unresponsive, staff initiated CPR after confirming his full-code status, but during the code an RN entered the room and instructed staff to stop, stating the code status had been changed to DNR based on direction from the DON. The DON later denied ordering CPR to stop and stated that a full code should be fully run, while the RN reported she had contacted an on-call provider who changed the code status to DNR due to suspected imminent death. A PA documented that nursing reported the resident had passed, CPR was started, and the code status was changed to DNR, and acknowledged changing the status based solely on nursing information, while an NP and the cited Michigan Do-Not-Resuscitate Procedure Act described that a valid DNR requires the declarant’s and physician’s signatures and two witnesses, which had not been obtained.
A resident with cancer, dysphagia, and pneumonitis was found unresponsive by a CNA, and an RN assessed the resident and later called a code blue, after which the resident was determined to be deceased. The IDT progress note describing the sequence of events was entered by the NHA, and a separate code blue report in the EMR listed the DON as the person preparing it, even though the DON was not on-site and did not document the event. The RN involved stated she had charted the incident but could not identify where in the EMR, and the DON suggested another staff member may have opened the assessment for the RN because the RN did not know how to do it, resulting in documentation not being entered under the correct staff member’s name and failing to meet professional standards for accurate medical records.
A facility failed to implement effective infection control and surveillance measures following a scabies diagnosis in a resident, resulting in the spread of scabies to multiple residents. Despite clinical recommendations and physician orders for treatment and contact precautions, the facility did not document the infection, initiate transmission-based precautions, or monitor other residents for symptoms, leading to several residents developing pruritic rashes and discomfort.
A resident with a new colostomy was discharged home without adequate preparation or support, despite being unable to independently manage colostomy care and requiring assistance with daily activities. The facility did not schedule necessary surgical follow-up or provide sufficient education, leading to repeated ER visits for complications including wound infection and colostomy management issues.
Two residents experienced lapses in care when staff failed to coordinate post-surgical follow-up and did not implement a bowel protocol as ordered. One resident did not have surgical staples removed or a follow-up appointment scheduled as required, while another went seven days without a bowel movement and did not receive prescribed interventions. Staff interviews and record reviews confirmed that established protocols were not followed.
Two residents were observed self-administering medications without proper assessments or documentation by the facility's interdisciplinary team. One resident was using a nebulizer without a documented assessment or care plan, while another had an outdated and incomplete assessment. The Director of Nursing acknowledged the lack of regular assessments, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple health conditions was diagnosed with influenza, but the facility failed to document and assess the resident's respiratory status and changes in condition. Staff did not follow protocols for documenting signs and symptoms, and the resident's need for supplemental oxygen was not communicated to the provider in a timely manner. The resident was eventually transferred to the emergency department for further evaluation.
A resident developed a stage 2 pressure injury that was inaccurately documented and not properly assessed by a physician. The facility failed to implement Enhanced Barrier Precautions (EBP) and complete wound treatments as ordered. Staff did not wear appropriate PPE during high-contact activities, and there was no physician's order or care plan for EBP. The Director of Nursing confirmed these deficiencies.
A resident with an indwelling catheter was observed with their urinary collection bag uncovered and on the floor, with the drainage tube touching the ground, posing a risk of infection. The facility's catheter care policy did not specify that bags should remain off the floor, and both the DON and an RN acknowledged the infection risk associated with this practice.
The facility failed to provide proper respiratory care for two residents. One resident received supplemental oxygen without a documented order or assessment, and another received oxygen at a higher rate than prescribed. The facility did not ensure completion of respiratory assessments or proper documentation and communication with providers.
The facility failed to provide adequate supervision during mealtimes for three residents, resulting in severe consequences, including the death of one resident. Despite clear care plans and medical recommendations, residents with a history of choking and dysphagia were left unattended, leading to choking incidents and hospitalization.
A resident did not receive her prescribed Nifedipine for four days, leading to increased anxiety, chest pain, and fatigue. The facility failed to follow its policy on medication administration and errors, resulting in delayed communication with the pharmacy and physician, and inadequate documentation.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent pressure injuries and promote healing for two residents with wounds. One resident had diagnoses including Parkinson’s disease, central cord syndrome, left-sided hemiparesis, and polyneuropathy, and required substantial to maximal assistance with bed mobility and transfers. He was cognitively intact and did not exhibit rejection of care behaviors during the assessment period. He had a left gluteal pressure injury that was documented as a stage 3 wound and later worsened to an unstageable wound with slough covering most of the wound bed, rolled edges, and fragile surrounding tissue. Observations and interviews showed the resident remained seated in his wheelchair for extended periods without effective offloading of pressure from his buttocks. He was observed sitting in his wheelchair for four hours between survey observations, and later for more than five hours total. Although CNA documentation indicated turning and repositioning at regular intervals, the resident’s statements and surveyor observations did not match that documentation. The CNA stated the resident was lifted during catheter care every four hours and then placed back in the wheelchair, and confirmed she did not reposition him every two hours as documented. The DON stated that lifting the resident to stand during catheter care and placing him back in the chair did not constitute turning and repositioning or provide enough offloading for tissue recovery. The resident’s wound record showed the left gluteal wound had previously been documented as MASD and later as an unstageable pressure ulcer, with no new interventions added to the care plan after the wound progressed. The wound evaluation on 2/18/2026 showed improvement with granulation tissue, but the evaluation on 2/25/2026 showed deterioration, increased wound size, and nearly complete slough coverage. The facility policy required pressure redistribution, including repositioning and offloading, and the NPIAP guidance cited in the report stated that extended periods of sitting without redistributing pressure can lead to tissue damage. A second resident, admitted with paraplegia and aftercare following skin and subcutaneous tissue surgery, had undergone left ischial pressure wound reconstruction and was using a sand bed. A physician order required staff to monitor that his feet were not resting against the inner ridge of the sand bed and to use a pillow or other device if needed. On 2/17/2026, staff documented a new unstageable pressure injury on the right lateral foot after noting that part of the sand bed’s air flow was not working properly and the resident’s foot was leaning against the deflated hard plastic air ring. The unit manager later stated the air flow had likely been compromised overnight and the resident’s foot had been in contact with the inner edge of the sand bed for approximately 12 hours before the injury was discovered.
Soiled Kitchen Areas and Uncovered Food During Meal Delivery
Penalty
Summary
The facility failed to maintain best practices in the food service area. On 3/2/2026 at 11:20 AM, the floor, sewage drain lines, and floor drain under the three-compartment sink were observed soiled with dirt and food debris. At 11:22 AM, the drain line coming from the 2-compartment vegetable wash sink was also observed soiled. At 12:04 PM, the floor under the hand sink was observed soiled. When asked at 12:05 PM who was responsible for cleaning the kitchen floors and equipment, the Dietary Director confirmed that dietary staff were responsible for those tasks, not maintenance staff. Food was also observed being stored and transported without protection from contamination. At 12:08 PM, 12 room trays were observed on the Hall B North delivery speed rack with uncovered cake. During meal pass at 12:26 PM, CNA K removed a lunch tray from the speed rack; the meal was covered with a protective lid, but the cake was uncovered, and the tray was taken into the resident's room. During lunch observations, a cart used to transport meal trays to residents eating in rooms was placed in the south hallway and contained 12 uncovered chocolate cakes. Staff were observed transporting the uncovered cakes from the cart down the hallway to resident rooms. Additional carts were later observed with 11 and then 8 uncovered chocolate cakes.
Medication Storage Lapses With Loose and Expired Medications
Penalty
Summary
Medication storage was found out of compliance in two medication rooms and two medication carts because medications were not securely stored and expired or improperly labeled items were present. On the East Hall medication cart, surveyors found 14 loose medications in the second and third drawers along with a moderate amount of medication debris and paper backings, including Lamotrigine 200 mg, Klor-Con M20 20 mEq, Haloperidol 10 mg half tabs, Levetiracetam ER 500 mg, Losartan Potassium 50 mg, an unidentified white round pill, Metoprolol Succinate ER 25 mg, Amlodipine Besylate 5 mg, Apixaban 5 mg, Olanzapine 2.5 mg, and Metoclopramide Hydrochloride 5 mg. Three insulin pens were also found dated after opening but without an expiration date. On the North Hall medication cart, surveyors found 3 loose medications in the second and third drawers with medication debris and paper backings, including Carbidopa/Levodopa 25/100 mg, Amlodipine 2.5 mg, and Levetiracetam 500 mg. In the East Hall medication storage room, an opened vial of tuberculin purified protein derivative 1 ml with an opened date of 1/13/26 was present without an expiration date written. During interview, an LPN stated the loose pills were likely due to tightly packed pill cards and said the carts were cleaned by night shift, while an RN stated the unit manager had recently looked in the cart and that the loose pills were still present. The DON and NHA acknowledged that loose pills, unclean medication carts, and expired medications were unacceptable, and no definitive documentation was provided showing when the carts or storage areas were last cleaned or audited.
Infection Control Breaches During Resident Care and PPE Storage
Penalty
Summary
The facility failed to provide sanitary catheter care, sanitary medication administration, enhanced barrier precautions during high-contact care, sanitary handling of facility equipment, and sanitary storage of PPE. On 3/3/2026, the soiled utility room hopper at the B Side Nurses Station was observed with grime buildup, and PPE items including opened and closed boxes of gloves, face shields, and face masks were stored on wire racks directly across from the hopper, with some boxes within 10 to 18 inches of the bowl and exposed to possible overspray from the hopper spray nozzle. RN M was later observed retrieving face shields and other PPE from the soiled utility room for staff use. Resident #49 had a history of recent UTIs, including hospitalizations on 12/12/25, 1/13/26, and 2/19/26 for UTI, and stated that staff did not always wear a gown during catheter care. During observed catheter care, CNA O gathered washcloths, placed them over the resident’s bedrail, cleaned the peri area, handled the trash bag and dirty linens, and continued care without changing gloves or using hand sanitizer. The CNA also knocked the resident’s water bottle onto a floor with visible dirt and old French fries and placed it back on the bedside table. When asked about hand hygiene and barriers, the CNA stated she should have used them and normally does use a barrier. Additional observations showed LPN N drawing up insulin lispro for Resident #28 and placing the syringe on the medication cart and later on the dresser without a barrier, stating she forgot to place one. For Resident #12, LPN N administered medication via PEG tube without wearing a gown, despite an order to use enhanced barriers during high-contact activity related to tube feed; the LPN stated she forgot and should have been wearing a gown. For Resident #8, LPN N touched an antianxiety medication with bare hands before administering it, stating the medication was stuck in the packaging and she should have put gloves on. The DON and NHA acknowledged the errors and breaches in infection control during resident care.
Failure to Obtain Timely Consent for Geri Chair Restraints
Penalty
Summary
The facility failed to ensure appropriate consents were in place for the use of geri chairs as restraints for two residents. Resident #54 was admitted with vascular dementia with anxiety and muscle weakness, and her quarterly MDS showed a BIMS score of 2/15, indicating severe cognitive impairment. She was observed sitting in a geri chair in her room and was unable to answer questions appropriately during interview. Her EMR showed a Physical Restraint Elimination Review for the geri chair began on 9/18/25 and was reviewed monthly, with the last assessment completed on 2/23/26. The review identified multiple factors related to the restraint use and stated that the resident utilized the geri chair for positioning and comfort. Her consent was electronically signed by the DPOA on 3/3/26, after the restraint review had already been in place for months. Resident #107 was admitted with Alzheimer's disease and a history of falling, and her quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. She was observed sitting in a geri chair in the hallway, including one observation where she was sleeping and another where her head was reclined all the way back and she attempted to lift her legs to get out of the chair. Her EMR also showed a Physical Restraint Elimination Review for the geri chair beginning on 9/19/25 and reviewed monthly, with the last assessment completed on 2/23/26, and the review stated the resident utilized the geri chair for positioning and comfort. Her consent was electronically signed by the DPOA on 3/3/26. During interview, the NHA stated the facility did not feel geri chairs were being used as restraints, despite labeling them as a restraint in both residents' EMRs, and agreed that consents should have been signed when the geri chairs were set into place in September 2025.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure the Long-Term Care Ombudsman was notified of two residents’ discharges from the facility. Resident #7 was discharged on February 20, 2026, to an apartment, and review of the documentation provided to the Ombudsman in February indicated they were not notified of the discharge. Resident #12 was sent to the emergency department on February 28, 2026, and review of the documentation provided to the Ombudsman in February indicated they were not notified of that discharge either. During an interview on 3/3/2026, the Nursing Home Administrator stated the Ombudsman notification only had to include emergent transfers that were discharged from the facility. However, the facility’s policy titled Transfer and Discharge (including AMA) stated that the Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list, and the policy did not limit notification to emergent transfers or exclude anticipated resident-initiated discharges.
Failure to Monitor Hypotension and Notify Physician Promptly
Penalty
Summary
The facility failed to monitor acute illness and provide timely physician notification of changes in condition for two residents who later required hospitalization. For one resident, the record showed a critically low blood pressure on 12/26/25, but there was no further monitoring after that finding and no documentation explaining the clinical justification for the resident’s hospitalization on 12/28/25. The resident had diagnoses including a tracheostomy, gastrostomy, and COPD, and was later hospitalized for streptococcal bacteremia, hypovolemic shock, sepsis, chronic respiratory failure with hypoxia, and COPD. For the second resident, the record showed a drop in blood pressure from 101/71 mmHg at 9:04 a.m. to 70/43 mmHg at 4:39 p.m. on 2/16/26. There was no documentation of a physical assessment, manual blood pressure recheck, or physician notification by the attending nurse in response to that change, and no documentation referencing the continued hypotension before the next recorded blood pressure of 75/52 mmHg early the next morning. The resident had diagnoses including sarcoidosis of the lung, pneumonia, and pneumothorax, and was cognitively intact with a BIMS score of 15. The resident was transferred to the hospital on 2/17/26 and the hospital summary documented shortness of breath, hypotension, acute anemia, and GI bleed, with acute blood loss anemia secondary to esophagitis with esophageal ulcer. The facility record showed that the first documented provider notification about the low blood pressure occurred nearly four hours after the 70/43 mmHg reading, and the intervention to treat hypotension did not occur until nearly 16 hours after the initial drop in blood pressure. The DON confirmed there was no documentation in the EMR showing follow-up assessment or physician notification at the time of the change in condition.
Smoking paraphernalia left unsecured in resident area
Penalty
Summary
The facility failed to ensure smoking paraphernalia was stored in a secure location for one resident who smoked. The resident had diagnoses including COPD, lung cancer, and a personality disorder, and was observed with a vape in his lap, an unopened package of four pocket lighters on an unused electric fireplace, and an oxygen concentrator positioned next to his bed with a nasal cannula on an adjacent bedside table. The resident confirmed he was a smoker and stated he kept his own cigarettes and lighter because he was independent and could leave the building when he wanted to smoke. During observation, the resident was seen walking to the designated smoking area at the scheduled smoking time, removing a lighter from his jacket pocket and a box of cigarettes from a bag attached to his walker, lighting the cigarette, and then returning the items to their places. Later, the opened package of pocket lighters was observed on top of the unused electric fireplace with one lighter missing. The resident's plan of care included an intervention to keep oxygen away from smoking materials and remove it prior to smoking if applicable, and the DON stated that all smoking paraphernalia should be locked up and stored by staff when not in use. The facility's smoking policy stated that smoking items, including electronic cigarettes, would be kept secured in a designated area with limited staff access and that residents with smoking privileges would not be permitted to retain smoking articles in their room or on their person.
Failure to Timely Address Resident Weight Loss
Penalty
Summary
The facility failed to appropriately assess and implement timely interventions for unintentional weight loss for one resident with vascular dementia with anxiety and muscle weakness. The resident was admitted on 7/11/25, and a quarterly MDS completed on 1/23/26 showed a BIMS score of 2/15, indicating severe cognitive impairment. On 3/3/26, the resident was observed sitting in a geri chair in her room, unable to answer questions appropriately, and appeared well dressed but thin with fragile skin. Review of the resident’s weights showed a decline from 142 lbs on 8/5/25 to 124.4 lbs on 2/8/26, with 9.4% weight loss in three months and 11.7% in six months. Progress notes showed a 1/19/26 entry stating the resident weighed 131 lbs and had been 141 lbs 180 days earlier, with a recommendation for med pass 2.0 60 cc daily. A later RD note on 2/26/26 documented a 6 lb loss from the prior month and recommended increasing med pass 2.0 to BID and weekly weights. The NHA, DON, and Regional RD confirmed the RD was late documenting the more recent weight loss and implementing interventions, and the RD could not explain why the documentation and intervention were delayed two weeks after the most recent weight loss. The resident’s DPOA stated the facility had not contacted him about the weight loss and that he had no idea what med pass 2.0 was.
Failure to Act on Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to complete, readily act upon, and implement monthly pharmacy recommendations for two residents reviewed for medication regimen review. One resident was admitted with diagnoses including dementia, repeated falls, and PTSD. Pharmacy medication review notes were documented in the EMR, and a consultant pharmacist recommendation dated 11/7/25 stated that the resident’s antipsychotic medication may cause orthostatic hypotension and suggested periodic blood pressure checks for orthostatic hypotension, with monthly or quarterly checks added to the MAR. The EMR contained no physician response, and the only notation was a handwritten entry indicating orthostatic blood pressure checks were added in 2/1/26 quarterly, more than two months after the recommendation. For another resident admitted with chronic systolic heart failure, the EMR showed a pharmacy medication review note with a recommendation that lidocaine patches remain in place for up to 12 hours in any 24-hour period and that the MAR include a note clarifying the patch should be left on for 12 hours and then removed. The recommendation was signed off by a physician, but the NHA confirmed during interview that the resident’s monthly medication regimen review for 11/20/25 was not correctly entered into the EMR. The facility policy required pharmacist irregularities to be documented on a separate report, sent to the attending physician, medical director, and DON, and addressed in the resident’s medical record within the required timeframe.
Insulin Dose Drawn Incorrectly and Injection Technique Not Followed
Penalty
Summary
The facility failed to accurately dispense insulin for one resident who was receiving insulin lispro on a sliding scale. During observation, an LPN drew up the resident’s insulin and placed the syringe on the medication cart before proceeding to the resident’s room. When asked to verify the dose, it was observed that the LPN had drawn up 14 units instead of the ordered 9 units for the resident’s blood glucose level of 144. The LPN then reviewed the order and acknowledged that the dose had been incorrect, stating that she should have double checked the dose. The same LPN was then observed administering the insulin and held the subcutaneous injection site for four seconds. When interviewed, she stated that she was supposed to hold the injection site for ten seconds and acknowledged that she had only held it in place for four seconds. Interviews with the RN/Unit Manager, DON, and NHA confirmed that nurses were expected to double check insulin doses and follow the five rights of medication administration before giving medications. The facility policy also required review of the MAR and comparison of the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time of administration.
Failure to Initiate Timely CPR and Improper Code Status Handling for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely emergency medical care and CPR to a resident who had a documented full code status. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis, and had an advance directive and physician order indicating “Full Resuscitate.” His BIMS score showed intact cognition, and he had signed a CPR consent form requesting resuscitation in the event of cardiac arrest. Therapy and rehabilitation documentation indicated he had good rehab potential and personal goals to walk again and relocate, and staff, including the Director of Rehabilitation and a Nurse Practitioner, later stated they were surprised by his death. On the morning of the incident, a CNA entered the resident’s room to obtain vital signs and found him unresponsive, appearing not to be breathing and not responding to touch or name. The CNA immediately alerted the RN assigned to the hall, who was at the medication cart. The CNA reported that the RN initially responded verbally from a distance, then took approximately two minutes to secure medications before going to the room. Upon arrival, the RN assessed for a pulse at the wrist and ankle, concluded the resident had passed, and covered him completely with a sheet. The RN then left the room to retrieve a stethoscope from the medication cart, administered another resident’s medications, and later returned to listen for an apical pulse and again covered the resident, without initiating CPR or calling a code blue at that time. The RN stated she did not know the resident’s code status during this initial assessment and believed the resident was “very cold and very dead,” and reported observing mottling of the legs. Subsequently, another RN on a different unit learned there had been a death and questioned the situation. This RN asked the first RN for the resident’s code status and observed that the chart being referenced was for a different patient. After directing the first RN to the correct chart, the second RN identified the resident as full code and instructed that CPR be started, a code blue be called, and 911 be contacted. When the second RN entered the room, the resident was fully covered with a sheet, pulseless, and not breathing, but without observed rigor mortis, lividity, or mottling, and not recalled as cold to the touch. CPR and BVM ventilation were initiated, and multiple nurses and CNAs responded to the code. During the code, the first RN contacted the DON by phone; staff in the room reported that the first RN entered and instructed them to stop CPR, stating the DON had ordered it, although the DON later denied giving an order to stop and stated that for a full code, staff were to run the code until EMS arrived or a physician order was obtained. Another nurse recalled the first RN saying she thought the resident had been dead for a couple of hours. During the resuscitation efforts, the first RN also contacted an on-call provider and requested a change in the resident’s code status to DNR because imminent death was suspected. A PA documented being notified that the resident had passed away and that CPR had been started, and recorded that the code status changed to DNR. When questioned later, both the RN and the PA were unable to explain how the code status could be changed from full code to DNR without the resident’s consent and without the statutory requirements for a DNR order being met. A Nurse Practitioner stated that such a change was impossible without the declarant’s signature, a physician signature, and two witnesses, and that qualified staff were obligated to perform CPR on full code residents until an order to stop was received from an on-site physician or medical control. Multiple staff, including a CNA who was a CPR instructor, indicated that too much time elapsed between finding the resident unresponsive and initiating CPR. The facility’s own CPR/BLS policy and the American Heart Association BLS algorithm, as cited in the report, required initiation of CPR for a pulseless, non-breathing full code resident in the absence of obvious signs of irreversible death, which were not consistently observed or documented by responding staff. The Immediate Jeopardy was determined to have begun when the RN first found the resident without pulse or respirations and failed to initiate emergency life-sustaining measures despite his full code status, and the resident was later pronounced dead by a hospital physician. Interviews and record review documented conflicting accounts regarding the resident’s physical condition (coldness, mottling, and signs of irreversible death), the timing of assessments and interventions, and the communication between the RN, DON, and on-call provider about stopping CPR and changing code status. Staff statements consistently described a delay in initiating CPR, initial misidentification of the resident’s code status, and the resident being fully covered with a sheet before a code was called, all in the context of a documented full code order and signed CPR consent. The report also cites state law requirements for executing a DNR order, including that an individual of sound mind or a patient advocate may execute a DNR, and that the order must be dated, voluntary, and signed by the declarant or patient advocate, the attending physician, and two witnesses. These statutory requirements were contrasted with the events in which the resident’s code status was documented as changed to DNR during or immediately after the code, based solely on nursing staff communication to the PA, without evidence of the required signatures or the resident’s participation. Facility policy required staff to provide basic life support, including CPR, for full code residents who did not show obvious clinical signs of irreversible death, and to coordinate rescue efforts until EMS arrival, but the actions described in the report show that these procedures were not followed for this resident. Overall, the deficiency centers on the failure of nursing staff to promptly verify the resident’s full code status, initiate CPR immediately upon finding him pulseless and not breathing, and maintain life-sustaining efforts in accordance with facility policy, professional guidelines, and state law governing resuscitation and DNR orders. The sequence of events, as corroborated by multiple staff interviews and documentation, shows delays in response, premature assumption of death, miscommunication about code status, and an improper attempt to change the resident’s code status to DNR without the required legal process, all occurring before and during the emergency response that ended with the resident’s death.
Removal Plan
- Provide education to licensed nurses on the CPR policy, including confirming code status in the medical record, assessing when to initiate CPR, when CPR can be stopped, and pronouncing death.
- Educate licensed nurses on properly assessing prior to initiating CPR (check for pulse, observe chest rise, listen and feel for breathing, observe skin and body findings).
- Educate licensed nurses on the facility Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy, including that full code residents must receive BLS/CPR prior to EMS arrival unless obvious clinical signs of irreversible death are present, and defining those signs (rigor mortis, dependent lividity, decapitation, transection, decomposition).
- Educate licensed nurses that the licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort until EMS has arrived.
- Educate licensed nurses that a resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy.
Failure to Obtain Informed Consent Before Changing Code Status During CPR Event
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent before changing a cognitively intact resident’s code status from full code to DNR. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. His EMR showed a physician’s advance directive order for full resuscitation initiated on 11/17, and a BIMS score of 15 on 11/22 indicating intact cognition. An advance directives/CPR consent form signed by the resident on 11/17 documented that he requested CPR in the event of cardiac arrest. On the morning of 12/7, staff discovered the resident unresponsive. An IDT progress note by the NHA documented that a CNA found the resident unresponsive, RN Q assessed him and believed he was deceased, and later RN M verified the resident’s full code status and initiated CPR at approximately 9:30 AM. Multiple staff, including CNAs and nurses, participated in the code. Witness statements and interviews indicated that during the code, RN Q entered the room and instructed staff to stop CPR, stating that the resident’s code status had changed to DNR and that this direction came from the DON. Staff reported confusion about how the code status had changed and stopped CPR based on RN Q’s statements. Interviews with the DON and RN Q revealed conflicting understandings of the instructions given during the event. The DON stated she told RN Q that if the resident was a full code, staff should run the code and stop only when EMS arrived or a physician order was received, and denied ordering cessation of life-sustaining efforts. RN Q later acknowledged she misunderstood the DON and also reported that she contacted an on-call provider during the code to change the resident’s status to DNR. A telehealth note by PA BB documented that nursing staff notified her the resident had passed away, that CPR was started, and that the code status was changed to DNR; PA BB stated she changed the code status based on nursing’s report of imminent death and did not address how this could occur without the resident’s consent. NP L stated that such a code status change was impossible without the declarant’s signature, a physician’s signature, and two witnesses, and the report cites the Michigan Do-Not-Resuscitate Procedure Act requirements, underscoring that no proper DNR order process was followed before the code status change.
Inaccurate and Misattributed Documentation of Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medical records were accurately documented in accordance with professional standards for one resident. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. On the morning in question, an IDT progress note authored by the Nursing Home Administrator (NHA) documented that at 9:15 AM a CNA entered the resident’s room to obtain vital signs and found the resident unresponsive, with eyes and mouth open, no response to touch or name, dry oral mucosa, and mottling from the waist to the feet. The note further stated that RN Q assessed the resident by checking for a pulse, feeling the ankles, and listening for respirations with a stethoscope for one minute, and that at 9:24 AM RN Q notified the NHA and DON that the resident was deceased and that it was an irreversible death. During a subsequent telephone interview, RN Q confirmed she was the primary nurse responsible for the resident’s care that morning and that she ultimately called a code blue. When asked if the event was documented in the resident’s medical chart, RN Q stated she remembered charting it somewhere in the EMR but was unsure of the exact location. A separate report titled “#1154 Code Blue,” dated the same morning at 9:30 AM, listed the resident and identified the DON as the person preparing the report. In an interview, the DON stated she was not in the facility at the time of the incident and had not documented that report, assuming instead that it was RN Q’s documentation and suggesting that another staff member may have opened the assessment for RN Q because RN Q did not know how to do so herself. In another interview, the NHA stated that all staff are required to document under their own name in the medical record, highlighting that the code blue documentation was not accurately attributed to the staff member who provided care.
Failure to Implement Infection Control Measures During Scabies Outbreak
Penalty
Summary
The facility failed to implement effective infection control measures and comprehensive infection surveillance to prevent the transmission of scabies among residents. A resident with a history of anoxic brain damage and cognitive communication deficit was diagnosed with scabies following dermatology appointments, with clinical notes indicating a spreading, itchy, and bleeding rash. Despite a physician's order for scabies treatment and recommendations for contact precautions, the facility did not document the resident's treatment for scabies, implement transmission-based precautions, or monitor other residents for symptoms as part of their infection control program. The Assistant Director of Nursing acknowledged that CDC guidelines recommend contact precautions after initiation of therapy but stated these were not enacted due to the belief that the treatment was prophylactic rather than for an active infection. Subsequent dermatology evaluation confirmed crusted scabies and recommended enacting scabies protocols according to facility and state guidelines, including isolation of contaminated clothing and treatment of household contacts. The Director of Nursing reported that after this diagnosis, skin assessments were conducted on all residents, and 19 additional residents with rashes were treated with a scabicidal. However, prior to this, there was no evidence of early detection, isolation, or infection control practices being implemented following the initial diagnosis, as required by both facility policy and CDC guidelines. Multiple residents developed symptoms consistent with scabies, including pruritic rashes, severe itching, and discomfort. Progress notes for several residents documented exposure to a confirmed scabies case and the presence of rashes consistent with scabies infestation. Interviews with affected residents confirmed ongoing symptoms and discomfort. The facility's infection prevention and control program policy required surveillance, early detection, and control of communicable diseases, but these measures were not effectively carried out, resulting in the transmission of scabies among residents.
Failure to Ensure Safe Discharge and Adequate Preparation for Colostomy Care
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who required ongoing care for a new colostomy following abdominal surgery. The resident was admitted for subacute rehabilitation after surgery and had limited family support, living alone with only one relative nearby who was unable to provide daily assistance. Despite clear hospital discharge instructions for a surgical follow-up within 10-14 days, the facility did not schedule the necessary appointment for staple removal or arrange for adequate post-discharge support. The resident was discharged home while still requiring supervision or assistance for activities of daily living, including colostomy care, transfers, and ambulation, as documented by therapy assessments. Multiple staff interviews and medical record reviews revealed that the resident expressed concerns about her ability to manage colostomy care independently at home. Nursing and therapy staff noted that the resident was not able to perform all aspects of colostomy care without significant cues and was not at her functional baseline for mobility, with an increased fall risk. The resident and her family both reported feeling unprepared for discharge, and the resident was only provided with a single colostomy care education session, which was insufficient for her to achieve independence in this area. The facility's social services director confirmed that only limited home health services were arranged, and not all necessary follow-up appointments were scheduled. Following discharge, the resident required repeated emergency room visits due to complications related to her colostomy, including staple removal, wound infection, and inability to manage the colostomy appliance. Emergency department documentation and provider notes indicated that the resident was unable to care for her colostomy, experienced leakage and skin issues, and was not safe to be living independently. The facility's failure to ensure the resident was adequately prepared and supported for discharge resulted in repeated hospitalizations and ongoing health complications.
Failure to Coordinate Post-Surgical Care and Follow Bowel Protocol
Penalty
Summary
The facility failed to coordinate post-surgical care and follow established bowel protocol for two residents. For one resident with a recent colostomy and abdominal surgery, the facility did not ensure timely removal of surgical staples or schedule a required follow-up appointment with the surgeon, as directed in the hospital discharge instructions. Despite multiple staff being aware of the need for post-operative follow-up and staple removal, there was no documentation of communication with the surgeon’s office, and the staples remained in place for 28 days post-surgery. The resident was ultimately sent to the emergency department for staple removal after being seen by her primary care provider, who noted the lack of follow-up and the presence of redness and inflammation at the surgical site. For another resident with a history of anoxic brain damage and chronic constipation, the facility did not follow physician orders or its own bowel management protocol. The resident went seven days without a bowel movement, during which time there was no documentation of abdominal or bowel assessments, and prescribed interventions such as Milk of Magnesia, Dulcolax suppository, or Fleet enema were not administered as ordered. The facility’s policy required nursing staff to assess residents and administer interventions after three days without a bowel movement, but this was not done, and the resident was eventually transferred to the hospital for evaluation of possible bowel impaction. Interviews with facility staff confirmed that protocols for post-surgical care and bowel management were not followed. Staff members were either unaware of the need for certain interventions or failed to document and communicate necessary actions, resulting in lapses in care for both residents. The deficiencies were identified through record review, staff interviews, and review of facility policies.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine the clinical appropriateness of self-administration of medications for two residents. Resident #18 was observed using a nebulizer alone in his room without any documented interdisciplinary team (IDT) assessment or care plan indicating his ability to self-administer medications. His admission assessment indicated that he did not wish to self-administer medications, yet there was no further documentation or comments regarding this decision. Resident #49 was also observed using a nebulizer without supervision, and the most recent assessment for self-administration was dated several months prior, with a critical section left blank. The Director of Nursing confirmed that assessments for self-administration were not conducted regularly, only if there was a physical decline, which contradicts the facility's policy requiring regular assessments and documentation in the resident's medical record.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to ensure appropriate assessments and timely notification of a change in condition for a resident diagnosed with influenza. The resident, who had severe cognitive impairment and multiple health conditions including esophageal cancer and heart failure, was observed with signs of respiratory infection but did not receive timely documentation or assessment of these symptoms. The resident's electronic medical record lacked documentation of the influenza diagnosis, signs, symptoms, and the need for droplet precautions. On multiple occasions, staff failed to document the resident's respiratory status and changes in condition, such as the development of a severe cough and the need for supplemental oxygen. The Director of Nursing was unaware of the lack of documentation, and the Infection Preventionist noted that pertinent charting was not completed as required. The resident's oxygen saturation levels dropped, and there was no documentation of a complete respiratory assessment or provider notification until the resident's condition worsened. The resident was eventually transferred to the emergency department for evaluation after a nurse practitioner was informed of the change in condition. The facility's policy required notification of changes in a resident's condition, including the need for new treatments like oxygen administration, but these protocols were not followed. The lack of timely assessment and documentation potentially delayed necessary treatment for the resident's influenza and respiratory issues.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident was admitted without any wounds or pressure injuries, but later developed a stage 2 pressure injury on the right lateral malleolus. The wound was not accurately documented, as it was initially recorded as a stage 2 pressure injury despite the presence of slough, which should have classified it as unstageable. The wound nurse acknowledged the inconsistency but continued to document it as a stage 2 pressure injury without further evaluation or physician notification. The facility did not ensure proper physician assessment and documentation of the wound. There was no physician's order or care plan for Enhanced Barrier Precautions (EBP), and the resident's room lacked signage indicating EBP were in place. The Treatment Administration Record showed a missed treatment on one occasion, with no documentation to confirm its completion. Additionally, the physician did not assess the wound unless there was an infection or changes, which was not documented in this case. Staff failed to implement EBP and complete wound treatments as ordered. Certified Nurse Aides and a Registered Nurse were observed not wearing appropriate personal protective equipment (PPE) during high-contact activities, such as incontinence care, transferring the resident, and dressing changes. The Director of Nursing confirmed that PPE should be worn during these activities and that residents with wounds should be placed on EBP, but this was not done for the resident in question.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling catheter, leading to a potential risk of infections. The resident, who was cognitively intact with a BIMS score of 15/15, was observed on multiple occasions with their urinary collection bag uncovered and placed on the floor, with the drainage tube touching the ground. This was noted during observations on two consecutive days, with approximately 300 cc of urine visible in the bag during one observation. The facility's Director of Nursing and a Registered Nurse confirmed that the catheter bag should not be on the floor due to infection concerns. However, the facility's catheter care policy did not specify that urinary catheter bags should remain off the floor, indicating a gap in the policy that could contribute to the deficient practice. The observations and interviews highlight a failure to adhere to infection control protocols, potentially compromising the resident's health.
Failure in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents receiving supplemental oxygen. For one resident, there was a lack of completion of respiratory assessments and documentation of vital signs, as well as a failure to notify the provider about the need for supplemental oxygen. This resident, who had multiple diagnoses including esophageal cancer and heart failure, was observed receiving supplemental oxygen without a documented order or assessment, indicating a lapse in the facility's protocol for managing changes in the resident's condition. Another resident with chronic obstructive pulmonary disease was found to be receiving supplemental oxygen at a rate higher than the physician's order. Despite multiple observations of the incorrect oxygen flow rate, there was no documentation of any amended orders to justify the increased rate. The facility's Director of Nursing confirmed that oxygen should be administered according to physician orders and that there were no standing orders allowing nurses to modify oxygen delivery rates without a physician's directive. This oversight highlights a failure to adhere to prescribed treatment plans and ensure accurate documentation and communication regarding residents' respiratory care.
Failure to Provide Adequate Supervision During Mealtimes
Penalty
Summary
The facility failed to provide adequate supervision during mealtimes for three residents, resulting in severe consequences, including the death of one resident. Resident #508, who had a history of traumatic brain injury, dysphagia, and severe cognitive impairment, experienced two choking incidents due to lack of supervision. Despite clear instructions from the hospital and speech therapy evaluations recommending direct supervision during meals, the resident was left unattended on multiple occasions. The first incident involved choking on a hot dog, and the second, more severe incident involved choking on a tuna fish sandwich, leading to hospitalization and subsequent death due to acute hypoxic respiratory failure and aspiration pneumonia. Resident #509, who had a history of cerebral infarction, dysarthria, and dysphagia, was observed eating lunch without the required 1:1 supervision. Despite being care planned for 1:1 supervision during mealtimes, the resident was left unsupervised, which could have led to potential harm. The staff members present in the dining room were not providing the necessary supervision or assistance, indicating a lack of communication and adherence to care plans. Resident #510, diagnosed with dysphagia, cognitive communication deficit, and schizophrenia, was also left unsupervised during breakfast. The resident's care plan required 1:1 assistance due to a history of choking and aspiration pneumonia. However, the Assistant Director of Nursing placed the meal tray in front of the resident and walked away, leaving the resident to eat without supervision. This repeated failure to implement care-planned interventions for residents requiring supervision during meals highlights significant lapses in communication and staff training within the facility.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceuticals for a resident, resulting in the resident going without a prescribed medication for an extended period. The resident, who had diagnoses including achondroplasia, PTSD, recurrent depressive disorder, adjustment disorder, anxiety disorder, and Raynaud's syndrome, did not receive her prescribed Nifedipine for four days. This led to increased anxiety, chest pain, and fatigue for the resident. The missed doses were documented in the Medication Administration Regimen (MAR) and progress notes, indicating the medication was unavailable and on order from the pharmacy. The facility's correspondence history with the pharmacy supplier revealed that the Unit Manager/Registered Nurse first called to inquire about the missing prescription three days after the initial missed administration. The Director of Nursing (DON) was unaware of the pharmacy issue until the resident's guardian contacted the Nursing Home Administrator (NHA) with concerns. The DON admitted a system failure, including delayed communication with the pharmacy supplier, delayed communication with the facility physician, and lack of staff education regarding escalation protocol for missed prescriptions, notification procedures, and documentation of medication omissions. The facility's policy on medication administration and errors was not followed, as evidenced by the lack of timely action to rectify the issue and inadequate documentation. The policy required immediate notification of the physician, obtaining alternative treatment orders, and detailed documentation of efforts to obtain the medication. The facility also failed to complete a medication error incident report and monitor the resident for adverse reactions to the medication omission.
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What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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Nursing homes near Traverse City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Traverse City | 0.4 mi | ★★★★★ | 0 | 0 |
| The Villa At Traverse Point | 1.3 mi | ★★★★★ | 1 | 0 |
| Grand Traverse Pavilions | 2.6 mi | ★★★★★ | 6 | 0 |
| Orchard Creek Skilled Nursing | 5.4 mi | ★★★★★ | 14 | 0 |
| Maple Valley Nursing Home | 15.8 mi | ★★★★★ | 1 | 0 |
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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.