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 Medilodge Of Leelanau during CMS and state inspections, most recent first.
A resident had a nasal spray left on a nightstand and another resident had a new inhaler left on a bedside table without an order to keep it there. A medication cart was found with debris, loose pills, and an unlabeled medication cup, and another cart was observed unlocked and unattended. Staff acknowledged the bedside medications, unlabeled cup, and unsecured cart, while the DON stated medications should not be left at the bedside and carts should be kept clean and locked.
A resident was given oral medications along with two identical, unlabeled cups of clear liquid—one containing water and the other acetic acid intended for a catheter flush—by an RN who was still in orientation. The RN left the resident alone without identifying which cup was water and did not observe the medication pass. The resident took his medications using the acetic acid before realizing it was not water and reported prior concerns about the same nurse bringing incorrect medications. Interviews indicated the acetic acid was not prepared in a sterile manner, the orienting RN had only explained (not observed) the catheter flush procedure, and the orientee RN lacked documented competency for urinary catheter flushing.
Surveyors observed multiple medication administration errors resulting in a 14% error rate. One resident’s RN mishandled oral medications by touching pills with bare hands while searching for a diuretic, administered the diuretic after the resident had requested it be held, documented it as held on the MAR, and omitted an ordered nasal spray that was not available on the cart. The same RN failed to follow insulin lispro pen instructions, including not cleaning the rubber seal, priming the pen incorrectly, and not holding the injection site for the recommended time. For another resident, an RN initially prepared the wrong aspirin formulation (enteric-coated instead of chewable) before recognizing the discrepancy. These events occurred despite a policy requiring adherence to professional standards and accurate MAR documentation.
The facility failed to complete a recapitulation of stay and failed to notify the LTC Ombudsman of a resident’s discharge. The resident was discharged in police custody, but the EMR showed no recapitulation of stay, and the Ombudsman documentation did not include the discharge. The NHA stated he believed only emergency transfers were expected on the Ombudsman list, while the DON confirmed no recapitulation of stay was completed.
A resident with severe cognitive impairment and a diagnosis of malignant neoplasm of the brain did not receive routine fingernail and toenail trimming as directed in the care plan. Staff observed the resident with very long nails and debris under the nails, and a CNA stated hospice was supposed to trim them but had not been routinely coming to the facility. The NHA and RN confirmed the nails were extremely long and that podiatry would be needed to assess them.
Failure to provide restorative ROM and splint assistance for a resident with cerebral infarction and moderate cognitive impairment. The resident had a severely contracted L hand, used only the R hand for eating and drinking, and had a wool therapy carrot at the bedside. The Therapy Director stated the resident was discharged from restorative services for therapy evaluation but was not placed back on restorative, and the Restorative Aide said no PROM or splint assistance was done after the discharge despite the care plan calling for ongoing ROM services.
A cognitively intact male resident inappropriately touched a non-communicative female resident with cerebral palsy and speech/language developmental disorders on two separate occasions, including squeezing her breast over clothing, rubbing her thigh, and lifting her shirt to touch and bounce her breast. Another resident reported witnessing these events to a CNA, and the male resident later admitted to lifting the female resident’s top and touching her breasts. The facility’s failure to prevent this conduct violated its abuse, neglect, and exploitation policy and resulted in sexual abuse and mental trauma to the female resident.
The facility failed to maintain adequate staffing levels, affecting resident care. A resident reported a decline in care quality due to insufficient nursing staff, leading to inadequate meal assistance and long wait times for call light responses. During a resident council meeting, attendees raised concerns about staffing shortages impacting meal assistance and safety. An LPN confirmed the staffing inadequacies, stating that corporate management dismissed concerns about staffing levels.
The facility did not conduct and document an annual facility-wide assessment, leading to a potential inadequacy in resources for resident care. The NHA provided an outdated Facility Assessment Tool, and confirmed no updates were made to meet annual review requirements. The assessment indicated an average resident population of 63, not reflecting the current 68 residents, showing a discrepancy in population assessment.
The facility did not update its infection control policies annually, affecting all 68 residents. Policies for COVID-19, influenza, and pneumococcal vaccinations, among others, were outdated. An LPN/IP was unaware of the annual update requirement, and the NHA confirmed the policies were the most recent. Frequent changes in IP managers contributed to this oversight.
The facility failed to ensure proper medication security and assessment for self-administration for two residents. One resident had unsecured medication and lacked comprehensive physician orders for self-administration, while another resident self-administered water flushes without a physician's order or assessment. The facility's policy requirements for documentation and storage were not met, leading to unsecured medications and unauthorized self-administration.
The facility failed to provide written bed-hold information to two residents or their representatives during hospital transfers. One resident was hospitalized due to hypoxia, and another due to aggressive behavior, but neither received the required Bed Hold Authorization form. Interviews confirmed the absence of these notices, despite the facility's policy requiring them at the time of transfer.
The facility failed to provide timely showers and baths for residents, leading to a deficiency in ADL care. A resident with diabetes experienced delays due to a malfunctioning boiler, resulting in late or refused showers. Another resident reported staff shortages affecting their ability to receive preferred bed baths, while a third resident received fewer showers than scheduled. The facility's policy on ADLs was not adhered to, contributing to the deficiency.
A resident with a neck fracture and history of falls was found wearing non-grip socks, contrary to her care plan, which specified gripper socks for fall prevention. The resident's daughter noted the absence of the socks she provided, raising concerns about fall risks. The DON acknowledged the care plan should have been updated to reflect the resident's preferences, highlighting a deficiency in the facility's adherence to its Fall Prevention Program and Accidents and Supervision policy.
A facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. Despite discharge instructions recommending monthly catheter changes and assessment for sensation to void, the facility did not change the catheter monthly and lacked documentation of a voiding trial. Interviews with the DON revealed no specific policy for Foley catheter insertion, and the existing policy was not followed, contributing to the deficiency.
A facility failed to ensure that MRRs were addressed by the physician and documented in a resident's clinical record. The pharmacist's recommendations from two MRRs were not found in the record, and the DON was unaware of the need to provide these to the physician. The facility's policy requires documentation of irregularities and physician responses, which was not followed in this instance.
The facility failed to provide evening snacks to three residents with diabetes, as per their needs and preferences. Residents reported not receiving snacks on multiple occasions and expressed dissatisfaction with the limited and unhealthy options available. The snack distribution process was inconsistent and unsanitary, with the dietary manager acknowledging that the snack list had not been updated for some time.
A resident requested a COVID-19 vaccination in September but did not receive it due to delivery issues from the contracted pharmacy. The resident contracted COVID-19 in November, and the facility did not attempt to secure the vaccine from alternative sources, despite having a policy that allows for such measures.
A facility failed to report an allegation of sexual abuse involving a resident and an occupational therapist to the State Agency. Despite a CNA reporting the incident to the NHA, the facility's legal team advised against reporting, believing the resident was on leave. The facility's policy requires immediate reporting of such allegations, which was not followed.
The facility failed to thoroughly investigate a sexual abuse allegation involving a resident and an OT. A CNA reported the incident to the NHA, but no further statements were collected, and the investigation did not comply with the facility's abuse policy. The OT was transferred, but the investigation remained incomplete.
Improper Medication Storage and Unsecured Medication Carts
Penalty
Summary
The facility failed to store medications properly and failed to maintain a clean medication cart for one of two medication carts and for two residents reviewed for medication storage. Resident #24 had a bottle of fluticasone propionate solution nasal spray sitting on top of the nightstand in the resident’s room, and Resident #48 had a fluticasone furoate/vilanterol inhaler on the bedside table. When asked, Resident #48 said the inhaler was new and had been there for about two months. The DON stated that Resident #24 did not have an order for that medication and no care plan or assessment to self-administer medications, and that Resident #48 did not have an order for the medication to be left at the bedside. The DON also stated that medications should not be left at the bedside and that inhalers, nasal sprays, and insulins should be administered and returned back to the cart. The medication cart on the Wharf unit was observed to be out of compliance with debris in the second drawer, two loose medications identified as famotidine 20 mg and bethanechol chloride 25 mg, and a medication cup in the top right small drawer containing a pill without a label identifying who it belonged to or what it was. RN D stated the pill had been prepared for a resident who was unavailable and acknowledged that the cup should have been labeled. RN D also stated that nightshift nurses were responsible for cleaning medication carts. In addition, the medication cart on the Cedar unit was observed unlocked and unattended, and RN F acknowledged that she normally does not leave the cart unlocked and unattended. The facility policy stated that medications are to be stored in locked compartments and that medication carts should be kept clean, organized, and stocked with adequate supplies.
Resident Ingests Acetic Acid Due to Unsupervised, Unlabeled Medication Setup
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe medication administration and observation of medication consumption, resulting in a resident ingesting acetic acid intended for catheter flushing. A complaint filed with the State Agency alleged that a nurse gave the resident acetic acid in a regular cup without informing him what it was, and he drank it, believing it was his fluid for taking medications. During interviews, an RN explained that another RN who was in training brought the resident’s oral medications along with two identical glasses containing clear liquid—one with water and one with acetic acid—both in the same type of glass. The RN in training then left the resident alone with the medications and both unlabeled glasses, without instructing the resident which glass contained water and without witnessing the medication administration. The resident reported that the nurse placed two glasses of clear liquid and a cup of medications on his bedside table and left the room without observing him take his medications. While taking his medications, he realized that what he was drinking was not water and then discarded it, later becoming upset about the incident. The resident also stated that the same nurse had previously brought him the wrong medications and that he did not trust her. Additional interviews revealed that the acetic acid was not drawn up in a sterile manner, contrary to the expected use of a syringe or sterile collection cup, and that the orienting RN had only explained the catheter flush procedure verbally and had not witnessed the trainee RN perform an indwelling catheter flush. Review of the trainee RN’s competencies showed no documented check-off for flushing urinary catheters, and the RN was noted to be on an extended orientation process at the time of the incident.
Medication Administration Errors Resulting in 14% Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 14% (4 errors out of 29 opportunities), exceeding the 5% threshold, related to medication administration practices for two residents. For one resident, an RN prepared oral medications and subcutaneous insulin and brought them to the resident’s room. When the resident asked if her diuretic was in the cup and requested that it be removed so she could take it later, the RN stated that it was present, left the room, and then searched through the medication cup at the cart, touching three pills with bare hands while attempting to identify the diuretic. The RN then returned and administered all medications, including the diuretic, without informing the resident that the diuretic remained in the cup. During the same medication pass, the RN was unable to locate the resident’s ordered nasal spray, stated she would obtain a new one from backup supply, and did not administer the nasal spray. Medication reconciliation later showed the diuretic was documented as “held” even though it was given, and the nasal spray was omitted and not given, and the medication cart lacked the nasal spray. During preparation and administration of the resident’s insulin lispro, the RN did not follow manufacturer instructions: she failed to clean the pen’s rubber seal with alcohol, primed the pen while holding it horizontally instead of with the needle pointing up, and held the injection site for only two seconds, after which a drop of blood appeared at the site. The DON confirmed these steps were inconsistent with expectations and standards of practice. For a second resident, another RN prepared medications and initially dispensed an enteric-coated aspirin 81 mg instead of the ordered chewable aspirin 81 mg, placing it in the medication cup with other medications. When questioned, the RN reviewed the order and acknowledged the aspirin form was incorrect and needed to be replaced with the chewable form. These observed errors and omissions occurred despite a facility policy requiring medications to be administered as ordered, in accordance with professional standards, and with proper verification and documentation on the MAR.
Failure to Complete Discharge Documentation and Ombudsman Notification
Penalty
Summary
The facility failed to ensure a recapitulation of stay was completed and failed to notify the Long-Term Care Ombudsman of a resident’s discharge from the facility for Resident #74. The resident was discharged on December 31, 2025, in police custody, and review of the electronic medical record showed that no recapitulation of stay was completed. Review of the documentation provided to the Long-Term Care Ombudsman in December 2025 showed that the resident’s discharge was not reported. During interviews, the Nursing Home Administrator stated he had always been told that only emergency transfers were expected on the Ombudsman list, and the Director of Nursing stated there had been a call with department heads from a sister facility regarding the discharge, but no recapitulation of stay was completed. The facility policy titled Transfer and Discharge (including AMA) stated that emergency transfers/discharges initiated by the facility for medical reasons or immediate safety and welfare of a resident require documentation in the medical record and 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.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide ADL care by not ensuring finger and toenail trimming for a resident with severe cognitive impairment and a diagnosis of malignant neoplasm of the brain. The resident’s MDS assessment showed a BIMS score of 3/15, and the care plan directed that fingernails and toenails be trimmed biweekly and as needed, with the plan initiated on 2/26/25. During observation, the resident was seen sitting in her room and later walking in the hallway without socks or shoes, with fingernails and toenails that appeared very long. Debris was noted under the nails, and a CNA confirmed the nails were approximately a quarter inch in length. Staff stated the resident received hospice services for nail trimming, but hospice staff had not been routinely coming to the facility. The NHA and RN confirmed the nails were extremely long and noted they had been attempted to be trimmed, but an order for podiatry would be needed to assess the resident’s nails.
Failure to Provide Restorative ROM and Splint Assistance
Penalty
Summary
The facility failed to provide restorative therapy services per the resident care plan for one resident with diagnoses including cerebral infarction and a BIMS score of 6/15, indicating moderate cognitive impairment. The resident’s 2/27/26 MDS showed receipt of four days of PROM and three days of splint or brace assistance. On 3/23/26 and 3/24/26, the resident was observed in bed with a wool therapy carrot on the bedside table and a severely contracted left hand with no open space or view of the fingernails; the resident used only the right hand for eating and drinking and asked why she was at the facility during interview. On 3/25/26, the Therapy Director stated the resident had been discharged from restorative therapy on 3/5/26 so she could be evaluated by therapy for her contracture, but she was not placed back on restorative services and had not received any ROM or splint assistance since 3/5/26. The Restorative Aide stated that after the resident was discharged from restorative, she was unable to pull the medical record showing restorative services and therefore did not perform PROM or splint assistance, although the resident was willing to participate. The care plan directed restorative ROM for contracture, decreased strength, hemiplegia, and limited ROM, including PROM to the left upper and lower extremities and ROM program three times weekly.
Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident. During routine morning care on 12/30/25, a CNA was informed by a resident witness that he had observed a male resident (R1) fondling a female resident (R2) on two separate occasions approximately four weeks earlier, two days apart. The witness reported that the first incident occurred at a puzzle table, where R1 squeezed R2’s breast over her clothes and then rubbed her thigh. The second incident reportedly occurred in a hallway near the therapy gym, where R1 again squeezed R2’s breast over her clothes, then lifted her shirt and bounced her breast. R1 later admitted in an interview with the NHA and DON that he had lifted R2’s top and touched her breasts, describing the incident as very quick. R1’s EMR showed he was cognitively intact, responsible for his own medical and financial decisions, and had been admitted with diagnoses including hydronephrosis. R2’s EMR documented that she had cerebral palsy, developmental disorders of speech and language, was non-communicative, and had a legal guardian/conservator for medical and financial decisions. A personal protection order was issued on behalf of R2, citing that she had a reasonable apprehension of sexual assault because R1 had sexually assaulted or threatened her with sexual assault. The facility had an Abuse, Neglect and Exploitation policy intended to prohibit and prevent abuse, neglect, and exploitation, but the events described show that R2 was subjected to inappropriate sexual touching by R1, resulting in mental trauma based on the reasonable person concept.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels, impacting the care of several residents. Resident #37 reported a decline in care quality, noting that often only one nurse was available for large sections of the facility, leading to inadequate assistance during meal times. Resident #41 experienced long wait times for call light responses and was only receiving one shower per week, contrary to the facility's policy of a 15-minute maximum wait time for call light responses. Observations confirmed that call lights were left unanswered for extended periods, and staff were not available to assist residents promptly. During a resident council meeting, attendees expressed concerns about staffing shortages, which affected meal assistance and overall safety. Resident #63 highlighted the lack of staff in the dining room, resulting in inadequate feeding assistance for their blind spouse, Resident #11. Additionally, Resident #8 observed that some residents were eating off others' plates due to the lack of assistance. An LPN confirmed the staffing inadequacies, stating that the facility's corporate management dismissed concerns about staffing levels, which were insufficient to meet the residents' needs and acuity.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document an annual facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. During the entrance conference, the Nursing Home Administrator (NHA) provided a Facility Assessment Tool covering the period from July 2023 through June 2024. However, upon inquiry, the NHA confirmed that there were no updates to the facility assessment to meet the requirement of being reviewed and updated annually. Additionally, the review of the Facility Assessment tool revealed that the section titled Average Daily Census Analysis indicated an average patient population of 63, which did not reflect the current resident population of 68, highlighting a discrepancy in the facility's assessment of its resident population.
Failure to Update Infection Control Policies Annually
Penalty
Summary
The facility failed to update its infection control policies annually, which has the potential to affect all 68 residents regarding infection control practices. During a review of the infection control policies, it was found that several policies, including those for COVID-19, influenza, and pneumococcal vaccinations, as well as the water management program, transmission-based precautions, laundry, and handling clean linen, were not updated annually. The COVID-19, influenza, and pneumococcal vaccination policies were last updated in October 2023, while the transmission-based precautions policy was last updated in May 2023. The water management program was undated, and the laundry and handling clean linen policies were last updated in October 2023. An interview with the LPN/Infection Preventionist revealed a lack of awareness that the policies needed to be updated annually, citing frequent changes in IP managers and involvement from other management and corporate personnel. The Nursing Home Administrator confirmed that the provided policies were the most recent updates available.
Failure to Ensure Proper Medication Security and Assessment for Self-Administration
Penalty
Summary
The facility failed to ensure proper medication security and assessment for self-administration for two residents, R14 and R46. For R14, a clear plastic medication cup with tablets was left unsecured on the over-bed table, and a bottle of acetaminophen was found on the nightstand, contrary to the requirement for locked storage. R14's medical record indicated a self-administration evaluation, but it lacked a comprehensive physician's order for self-administration throughout the day, only covering evening medications. The care plan did not adequately address storage expectations or specify procedures for day shift medication administration, and the MAR lacked documentation for self-administration during the day. For R46, the resident was observed self-administering water flushes through a feeding tube without a physician's order or a self-administration assessment. R46's MAR did not include an order for self-administration of water flushes, and the care plan indicated that all fluids should be provided by staff. The DON acknowledged the facility's difficulty in preventing R46 from accessing syringes and confirmed the absence of a physician's order or assessment for self-administration. The facility's policy on resident self-administration of medication required documentation of the resident's preference and capability to follow directions, as well as proper storage arrangements. However, these requirements were not met for R14 and R46, leading to unsecured medications and unauthorized self-administration. The DON confirmed the deficiencies in physician orders, MAR documentation, and storage practices, contributing to the facility's failure to comply with self-administration protocols.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed-hold information to two residents or their representatives during transfers to a hospital, as required by their policy. Resident #22 was hospitalized due to hypoxia and oxygen needs from 9/15/24 to 9/25/24, but no Bed Hold Authorization form was completed or scanned into the electronic medical record (EMR). Interviews with the Nursing Home Administrator and Medical Records Staff confirmed the absence of the bed hold notice for Resident #22 at the time of transfer. Similarly, Resident #57 was transferred to a hospital for further evaluation following aggressive behavior, including attempting to attack staff and other residents. This resident was hospitalized from 9/1/24 to 9/9/24, yet no Bed Hold Authorization form was completed or scanned into the EMR. The Director of Nursing stated that nurses are responsible for providing the bed hold policy and completing necessary forms at the time of transfer, but this was not done for Resident #57. The facility's policy, dated 2/1/22, requires written notice of the bed-hold policy to be provided at the time of transfer.
Failure to Provide Timely Showers and Baths
Penalty
Summary
The facility failed to provide necessary showers during preferred times for two residents, leading to a deficiency in the care provided for Activities of Daily Living (ADLs). Resident #6, who has diabetes mellitus and intact cognition, reported issues with the facility's boiler, resulting in cold water and delayed showers. This resident prefers morning showers on specific days but had to wait due to the boiler malfunction, leading to refusals or late showers. The task list for this resident showed multiple instances of late or refused showers over a period of several weeks. Resident #22, also with diabetes mellitus and intact cognition, expressed concerns about staff shortages affecting their ability to receive preferred bed baths twice a week. This resident reported having to beg for a bed bath and experienced inconsistencies in receiving them. The task list indicated missed showers or baths over several weeks. Additionally, Resident #41, who requires assistance due to left-sided hemiplegia, reported receiving only one shower per week on several occasions, contrary to their care plan. The facility's policy on ADLs emphasizes minimizing the loss of residents' functional abilities, but the facility failed to adhere to this policy, resulting in the deficiency.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for a resident who had a history of falls and was at risk for further injury. The resident, who had a neck fracture and was on hospice care, experienced a fall resulting in a head laceration and high blood pressure. Despite the resident's care plan indicating the use of gripper socks as a fall prevention measure, the resident was observed wearing regular socks without grips, which were not the ones purchased by her daughter. The daughter expressed concern about the absence of the gripper socks she had provided, which were intended to prevent further falls. The Director of Nursing confirmed that the care plan should have been updated to reflect the resident's preference for different socks, as the resident did not like the facility-provided gripper socks. The facility's Fall Prevention Program and Accidents and Supervision policy require that each resident's risk factors and environmental hazards be evaluated, and interventions be monitored and revised as needed. However, the facility did not adhere to these policies, resulting in a deficiency in providing adequate supervision and assistive devices to prevent accidents.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care and maintenance for a resident with an indwelling urinary catheter. The resident, who was admitted to the facility after hospitalization, had discharge instructions recommending monthly catheter changes and assessment for sensation to void due to Guillain-Barre syndrome. However, the facility did not change the catheter monthly in August, September, and October, and there was no documentation of a voiding trial or monitoring of the resident's sensation to void. The resident's treatment administration record and progress notes lacked detailed documentation of catheter changes, including the procedure tolerance, equipment used, and urinary return following insertion. Interviews with the Senior Director of Nursing revealed that the facility did not have a specific policy for Foley catheter insertion, and the existing policy for suprapubic catheter changes was not followed. The DON acknowledged that the discharge recommendations should have been completed monthly and documented, and that the physician should have been monitoring the resident's sensation to void. The lack of adherence to the discharge instructions and inadequate documentation contributed to the deficiency in catheter care for the resident.
Failure to Document Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were properly addressed by the physician and maintained in the clinical record for one resident. Specifically, the pharmacist's documentation for the resident revealed that monthly MRRs conducted on two occasions resulted in recommendations written to the physician. However, neither the pharmacist's written recommendations nor the physician's written responses were found in the resident's medical record. Upon inquiry, the Director of Nursing (DON) admitted to being unaware of the need to obtain and provide these written recommendations to the physician, resulting in the absence of the necessary documentation in the resident's record. The facility's policy on addressing medication regimen review irregularities requires that the pharmacist report any irregularities to the attending physician, medical director, and DON, and that these reports must be acted upon. The policy also mandates that the attending physician document in the resident's medical record that the identified irregularity has been reviewed and what actions, if any, have been taken. In this case, the lack of documentation indicates a failure to adhere to these established procedures.
Failure to Provide Evening Snacks as per Residents' Needs and Preferences
Penalty
Summary
The facility failed to offer evening snacks to three residents, all of whom have diabetes mellitus, as per their needs and preferences. Resident #6 reported not receiving a bedtime snack on multiple occasions and expressed concerns about the lack of healthy options and the potential infection control issues due to the way snacks were distributed. Resident #22 also did not receive a snack on several nights and expressed dissatisfaction with the limited variety and quality of the snacks offered. Resident #31 highlighted similar issues, noting the lack of healthy options and the unsanitary conditions of the snack distribution process. The facility's policy requires that snacks be offered in accordance with residents' needs and preferences, but this was not adhered to. The snack cart was not consistently distributed, and the options provided were limited and not updated regularly. The dietary manager confirmed that the snack list had not been updated for some time, and the current offerings did not align with the residents' preferences or dietary needs. The facility's failure to provide appropriate snacks as per the residents' needs and preferences constitutes a deficiency in care.
Failure to Administer COVID-19 Vaccine as Requested
Penalty
Summary
The facility failed to administer a COVID-19 vaccination to a resident who had requested it. The resident, identified as R14, asked for the COVID-19 vaccine when she received her influenza vaccination in September 2024. Despite her request, the vaccine was not administered, and she subsequently contracted COVID-19 in November 2024. The resident's medical record indicated that her COVID-19 vaccination status was pending, and her last documented COVID-19 vaccination was in January 2024. The Director of Nursing (DON) acknowledged that the COVID-19 vaccine was ordered from the facility's contracted pharmacy but was not delivered on multiple occasions. The DON did not attempt to secure the vaccine from a backup local pharmacy or contact the health department for alternative sources. The facility's policy allows for the vaccine to be administered directly or through arrangements with a pharmacy partner or local health department, but these options were not utilized in this case.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the State Agency (SA) as required by their policy. The incident involved a resident, identified as R900, and an occupational therapist (OT C). A complaint was filed with the SA, stating that the therapist had been having sexual relations with the resident, and it was alleged that everyone in the facility was aware of the situation. A certified nurse aide (CNA D) reported the allegation to the Nursing Home Administrator (NHA) on August 30, 2024, but the NHA initially stated that no abuse allegations had been reported in the last 30 days. Further interviews revealed that the Director of Nursing (DON) was aware of the allegation and had consulted the facility's legal team, who advised that the incident was not reportable because the resident was believed to be on a leave of absence when the alleged abuse occurred. However, the facility's policy mandates immediate reporting of such allegations to the SA and other relevant authorities within two hours if the events involve abuse or result in serious bodily injury. The facility did not adhere to this policy, as confirmed by the NHA, who acknowledged the failure to report the allegation to the SA.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident and a staff member. The complaint, filed with the State Agency, alleged that an Occupational Therapist (OT) was having a sexual relationship with a resident. A Certified Nurse Aide (CNA) reported the allegation to the Nursing Home Administrator (NHA) but was not asked to provide a written statement or further questioned about the incident. The Director of Nursing (DON) confirmed that the allegation was reported, and the facility's legal team was consulted due to the belief that the resident was on a leave of absence when the alleged incident occurred. The investigation file provided by the DON and NHA contained only one interview with the resident involved, with no additional interviews or witness statements collected. The NHA admitted that the investigation was incomplete and did not adhere to the facility's abuse policy, which requires identifying and interviewing all involved parties, including the alleged perpetrator and witnesses. The OT was transferred to another facility by the corporate therapy company, but no further investigative actions were documented.
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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 Suttons Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Creek Skilled Nursing | 11.7 mi | ★★★★★ | 14 | 0 |
| Maple Valley Nursing Home | 13.6 mi | ★★★★★ | 1 | 0 |
| Grand Traverse Pavilions | 14.6 mi | ★★★★★ | 6 | 0 |
| The Villa At Traverse Point | 16.4 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Gtc | 16.8 mi | ★★★★★ | 20 | 1 |
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