Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Traverse City during CMS and state inspections, most recent first.
Multiple incidents of resident-to-resident physical abuse occurred in the memory care unit, with a resident repeatedly assaulting others while unsupervised. Staff interventions were insufficient to prevent ongoing altercations, and several incidents were not reported to the State Agency as required by facility policy. The affected residents, all with cognitive impairment, experienced physical harm and distress as a result.
The facility did not report multiple resident-to-resident altercations involving physical aggression in the memory care unit to the State Agency within the required timeframe. Staff observed incidents where a resident grabbed, pinched, and struck another, and several similar events were documented but not reported, as facility leadership incorrectly believed reporting was only necessary if injuries occurred.
Insufficient nursing staff in the memory care unit resulted in residents being left unsupervised, leading to physical altercations and unsafe behaviors such as one resident assaulting another and others moving around without assistance. Staff and family interviews confirmed frequent understaffing, and the facility's assessment acknowledged the need for specialized dementia care staffing, which was not consistently met.
Exhaust ventilation in bathrooms serving multiple rooms was found to be nonfunctional, as confirmed by both observation and testing by the MD. Noxious odors were present throughout the hall, and the MD indicated the exhaust systems may have never worked.
Two residents were allowed to self-administer medications, including a prescription inhaler, without documented assessments for self-administration. Nursing staff provided medications without supervision or verification of ingestion, and the DON confirmed that such assessments are required. The facility was unable to provide a medication administration policy when requested.
Staff failed to review and ensure timely documentation of code status and advance directives for two residents. In both cases, residents were found unresponsive, and staff either did not know the code status or could not access signed documentation, resulting in delays and confusion during emergency response. The required physician-signed orders and advance directive forms were not present in the residents' records as required by facility policy.
A resident with Alzheimer's disease, identified as at risk for falls, was observed without the required Dycem nonslip mat in the wheelchair as specified in the care plan. A CNA confirmed the mat was not in place due to it being soiled and not replaced after care, resulting in failure to implement a key fall prevention intervention.
A facility failed to report a right hip fracture of unknown origin for a resident to the State Agency. The resident, with a history of falls and muscle weakness, was admitted after a fall at home. Initial x-rays showed no fractures, but a later CT scan revealed a fracture. Despite the facility's policy requiring immediate reporting of such injuries, the incident was not reported.
A resident was admitted to a facility after a fall at home, initially showing no fractures. Later, a CT scan revealed a right hip fracture. The facility failed to conduct a thorough investigation into the injury, as required by their abuse policy. Minimal documentation and delayed witness statements were provided, and the Nursing Home Administrator admitted the investigation was incomplete.
A resident with severe cognitive impairment and a history of trauma experienced an undignified care interaction when an RN attempted to prevent them from leaving a secured memory care unit. The RN made a non-verbal gesture to quiet the resident, resulting in accidental contact with the resident's forearm. The incident was deemed undignified, although no physical injury or psychosocial decline was noted.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent multiple instances of resident-to-resident physical abuse involving four residents in the memory care unit. Observations included a resident pacing unsupervised, using derogatory language, and physically assaulting another resident by pinching and hitting her, which caused the victim to scream. Despite staff intervention, the aggressor was left unsupervised and immediately engaged in similar behavior with another resident. Review of incident and accident reports over a six-month period revealed repeated altercations, including hitting, slapping, pushing, and grabbing between residents, with several incidents not reported to the State Agency as required. Interviews confirmed that while staff investigated these altercations, the incidents continued to occur. The facility's own policy mandates the prevention of abuse, neglect, and exploitation, yet the documented events show a pattern of resident-to-resident abuse that was not effectively prevented or reported. The residents involved were in the memory care unit, indicating cognitive impairment, and the altercations often resulted in physical harm such as skin tears and distress.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse to the State Agency within the required two-hour timeframe for four residents reviewed for abuse reporting. Multiple incidents were observed and documented, including an event where one resident in the memory care unit was seen grabbing, pinching, and hitting another resident, causing the latter to scream. Staff intervened to separate the residents, but the aggressor was left unsupervised and subsequently attempted to lead another resident away. Review of incident and accident reports revealed several additional resident-to-resident altercations over a six-month period that were not reported to the State Agency as required. Interviews with facility leadership confirmed that none of the resident-to-resident altercations had been reported, as the Nursing Home Administrator believed such incidents were only reportable if they resulted in injury. The facility's own policy, however, mandates reporting all alleged violations involving abuse to the State Agency immediately, but not later than two hours after the allegation is made. The failure to report these incidents represents a deficiency in following both regulatory requirements and facility policy.
Inadequate Staffing Leads to Resident Altercations and Unsafe Supervision in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate nursing staff in the locked memory care unit, resulting in insufficient supervision and care for residents. On multiple occasions, residents were observed without staff supervision, leading to resident-to-resident altercations and unsafe behaviors. One incident involved a resident pacing the hallway unsupervised, using derogatory language, and physically assaulting another resident by pinching and hitting her, which caused the victim to scream. Staff intervened only after the altercation had escalated, and the aggressive resident was left unsupervised again, leading her to interact inappropriately with another resident. Further observations revealed that a group of residents was left alone in the dining room without any staff present, during which time one resident attempted to push another in a wheelchair, causing visible distress. Other residents were seen moving around the dining room without assistance, and one resident was observed entering other residents' rooms unsupervised. Interviews with staff and a family member confirmed that the memory care unit was often understaffed due to call-ins, resulting in residents being left without adequate supervision. The facility's own assessment indicated that dementia care is a specialty area and requires specific staffing, which was not consistently provided.
Failure to Maintain Functional Bathroom Exhaust Ventilation
Penalty
Summary
The facility failed to ensure that exhaust ventilation was functioning in resident bathrooms on three halls, affecting 22 out of 74 residents. On two separate occasions, noxious odors were observed throughout the D hall, prompting an investigation into the bathroom exhaust systems. The bathrooms serving rooms 1, 5, and 6 on D hall were tested for adequate negative pressure using a paper towel method, and all failed to demonstrate proper exhaust function. The Maintenance Director confirmed the lack of negative pressure and stated that these exhaust systems have likely never worked.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for safety prior to allowing them to self-administer medications. In one instance, a registered nurse handed a resident a cup containing multiple medications and allowed the resident to leave unsupervised without verifying ingestion or providing supervision, despite no assessment for self-administration being present in the resident's chart. In another case, a resident was found with a prescription inhaler on their bedside table and reported self-administering the medication earlier in the morning after the nurse left it there, again without any documented assessment for self-administration. The Director of Nursing confirmed that assessments are required for residents self-administering medications, and the facility was unable to provide a medication administration policy when requested.
Failure to Ensure Timely and Complete Documentation of Code Status and Advance Directives
Penalty
Summary
The facility failed to ensure that staff reviewed residents' medical records for code status, obtained physician signatures on code status orders, and uploaded code status documentation to the resident charts in a timely manner for two residents. In one case, a resident admitted with a right femur head and neck fracture was found unresponsive in bed. The nurse who discovered the resident did not know the resident's code status and had to check the computer to confirm DNR status. There was no signed advance directive or DNR consent form found in the resident's electronic medical record, and the Director of Nursing confirmed the absence of this documentation. In another instance, a resident admitted with orthostatic hypotension became unresponsive after experiencing shortness of breath and collapsing. Staff initiated CPR and used respiratory support equipment until another nurse checked the computer and found the resident was a DNR, at which point CPR was stopped. EMS requested code status paperwork, but it was not available in the digital chart, and the facility was unable to provide a signed advance directive or code status form for this resident as well. The facility's policy required staff to verify advance directives and obtain physician orders upon admission or after any change in preference or condition. However, in both cases, the required documentation was not present or accessible in the residents' records at the time of the incidents, leading to confusion and delays in following the residents' wishes regarding resuscitation.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to follow established interventions to prevent further falls for a resident with Alzheimer's disease. The resident had a documented history of sliding from a dining room chair, after which the care plan was updated to require a Dycem nonslip mat in both the wheelchair and dining room chair. During an observation, the resident was seen being wheeled into the dining room without the required Dycem mat in the wheelchair. A CNA confirmed that the Dycem was not in place because it was soiled and had not been replaced after providing care. The care plan specifically indicated that the Dycem mat should be used to reduce fall risk, but this intervention was not implemented at the time of observation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin, specifically a right hip fracture, to the State Agency for a resident. The resident was admitted to the facility from a hospital after a fall at home, with initial x-rays showing no fractures. However, a subsequent CT scan at the hospital revealed a nondisplaced fracture line through the right femoral neck. Despite this finding, the facility did not report the injury to the State Agency as required by their policy. The resident's medical history included rhabdomyolysis, a history of falls, and muscle weakness, and she was cognitively intact with a BIMS score of 15. The facility's policy mandates reporting physical injuries of unknown origin to the appropriate authorities within specified timeframes, but this protocol was not followed in this case. The failure to report the injury was confirmed during an interview with the Nursing Home Administrator, Interim Director of Nursing, and a Unit Manager/Registered Nurse.
Incomplete Investigation of Resident's Hip Fracture
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who sustained a right hip fracture. The resident was admitted to the facility from the hospital after a fall at home, with initial hospital x-rays showing no fractures. However, a subsequent CT scan revealed a nondisplaced fracture line through the right femoral neck. Upon notification of the fracture, the facility did not perform a complete investigation as required by their abuse policy. The investigation folder presented to the surveyor contained minimal documentation, including a handwritten note from a physical therapist and an unsigned witness statement from the resident's roommate. Additional witness statements from staff were provided later, but the Nursing Home Administrator acknowledged that the investigation was incomplete. The facility's policy mandates an immediate and thorough investigation into any suspicion of abuse, neglect, or exploitation, which was not adhered to in this case.
Undignified Care Interaction with Resident
Penalty
Summary
The facility failed to provide dignified care for a resident, resulting in an undignified interaction. The incident occurred when a resident, who had severe cognitive impairment and a history of trauma, attempted to exit a secured memory care unit. A registered nurse (RN A) attempted to prevent the resident from leaving by standing in front of the door and making a non-verbal gesture to quiet the resident, which involved moving a hand towards the resident's mouth. During this interaction, RN A's arm accidentally made contact with the resident's forearm. The resident, who was admitted with diagnoses including kidney disease, urinary tract infection, and dementia, was observed by another nurse (RN B) to be yelling loudly during the incident. RN A's response to the resident's yelling was to make a shushing gesture, which was described as undignified by both RN A and RN C. The resident did not sustain any physical injury, and no psychosocial decline was noted after the incident. However, the interaction was considered undignified due to the manner in which RN A attempted to quiet the resident. Interviews with staff and review of the facility's policy on promoting and maintaining resident dignity revealed that the actions taken by RN A were not in line with the facility's standards for treating residents with respect and dignity. The incident was reported to the Nursing Home Administrator, who acknowledged the concerns related to the undignified care interaction. The facility's policy emphasizes the importance of recognizing each resident's individuality and maintaining or enhancing their quality of life.
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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 Traverse City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Gtc | 0.4 mi | ★★★★★ | 20 | 1 |
| The Villa At Traverse Point | 1.5 mi | ★★★★★ | 1 | 0 |
| Grand Traverse Pavilions | 3 mi | ★★★★★ | 6 | 0 |
| Orchard Creek Skilled Nursing | 5.8 mi | ★★★★★ | 14 | 0 |
| Maple Valley Nursing Home | 16 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.