Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Munson Healthcare Otsego Memorial Hospital Ltcu during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition, identified as a fall risk, was found on the floor after ordered fall precautions were not in place. The care plan required a mat on the left side of the bed and a bed alarm while in bed, but the mat was placed on the wrong side and the alarm was not turned on. The resident had a hematoma to the forehead and was later found to have an indeterminate fracture of the left 5th digit.
Food Service Plumbing and Storage Sanitation Deficiencies: The facility failed to prepare food in accordance with professional standards when the three-compartment sink was observed without a proper air gap and soap was bubbling up from the floor drain, the vegetable wash sink had an air-break instead of an air gap, and the ice machine drain extended into the floor drain without an air gap. Surveyors also observed the floor and drain lines under the sink and utensil rack soiled with grease, grime, and debris, and damaged pipe insulation near shelving where clean utensils were stored.
Failure to Track and Monitor Infections: The facility did not maintain an IPCP with infection identification and surveillance for all residents. A resident transferred in with CDI was not included in the infection control mapping, line listings, logs, or data analysis, and several residents with symptomatic infections were listed but not reflected in the facility’s tracking documents. Staff could not explain how CDI or other GI symptoms were being monitored, and no infection documentation was available for one month.
The facility failed to complete a discharge medication reconciliation for one resident discharged with home health services, with the discharge summary lacking a physician’s order listing and resident signatures. The facility also failed to provide written transfer notification for another resident sent to the hospital ED; staff stated they only sent bed-hold information instead of the required transfer notice.
Missing MRR documentation and physician rationale for pharmacist recommendations were found for three residents. One resident with dementia and behavioral symptoms had pharmacist GDR requests for divalproex, but the related reports were missing and the physician declined without documenting clinical reasoning. Another resident with osteoporosis had a pharmacist recommendation to add calcium/vitamin D to alendronate therapy, but the report was missing and the physician’s declination had no rationale. A third resident with dementia and anxiety had a pharmacist GDR request for risperidone, but the report was missing and no physician explanation for declining was found.
The facility failed to maintain hospice documentation for two residents who were receiving hospice services. One resident with CHF and intact cognition had hospice participation documented in the MDS and care plan, but no hospice visit notes, care records, or service documentation were found in the EMR. Another resident with CAD, vascular dementia, hemiplegia, COPD, and PVD also had hospice participation documented, but the EMR lacked hospice visit notes showing the care and services provided by the hospice agency. Staff stated the notes should be in the EMR, but they were not uploaded or available in the record.
The facility failed to ensure the QAPI committee met quarterly with required members, potentially affecting care for all 27 residents. The Medical Director or designee did not attend the February meeting, and no attendance record was found for October. The interim NHA could not locate the missing records by the survey exit.
The facility failed to document monthly pharmacy medication regimen reviews and did not follow pharmacy recommendations for four residents with various diagnoses, including dementia and heart failure. The physician order reports lacked evidence of ordered labs as recommended by the consultant pharmacist, and the Medical Director admitted not seeing all recommendations. This deficiency could lead to adverse medication side effects.
The facility failed to follow regulations for psychotropic medications, including not specifying an end date for a PRN lorazepam prescription and lacking documented rationale for its continued use. Additionally, two residents on antipsychotic medications did not receive required AIMS assessments to monitor for side effects, contrary to facility policy.
A resident with moderate cognitive impairment and limited mobility experienced a non-functional call light system, leading to dissatisfaction with care timeliness and fear of unmet needs in emergencies. Despite multiple work orders and staff awareness, the issue persisted due to a lack of a contract with a third-party contractor for repairs and no facility policy on call light maintenance.
Failure to Implement Ordered Fall Precautions
Penalty
Summary
The facility failed to implement fall prevention measures for one resident with dementia and severely impaired cognition who was identified as a fall risk due to gait and balance problems and being unaware of safety needs. The resident’s care plan called for an anti-fatigue mat to be placed on the left side of the bed and for a bed alarm mat to be used at all times while in bed, with the devices in place and functioning properly. After the resident was put to bed by an RN, the resident was later found on the floor on the left side of the bed with a hematoma to the left forehead and was sent to the ED for evaluation. During the investigation, it was noted that the fall mat had been placed on the wrong side of the bed and the bed alarm had not been turned on. In the ED, the resident was noted to have pain in the left hand, and x-ray showed an indeterminate fracture of the left 5th digit.
Food Service Plumbing and Storage Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. On 03/31/2026 at 2:45 PM, the three-compartment sink was observed to not be properly air gapped, and soap was bubbling up out of the floor drain. Kitchen staff had just emptied the first compartment (wash) of the sink when the observation was made, and cook H stated that this happens all of the time, with other staff in the room agreeing. On 03/31/2026 at 3:00 PM, the vegetable wash sink was observed to have an air-break rather than an air gap between the food compartment drain-line and the floor drain. On 04/01/2026 at 10:05 AM, the Symphony Plus ice machine drain in the Clean Storage Room was observed extending down into the floor drain without an air gap. On 03/31/2026 at 2:49 PM, the floor and drain lines under the three-compartment sink and metal utensil storage rack were observed to be soiled with grease, grime, and debris. On 03/31/2026 at 2:48 PM, the insulation wrapping water lines behind the storage shelving units to the left of the three-compartment sink was observed to be damaged, while clean utensils were stored on the shelving unit a couple inches away from the damaged insulation covering the pipes.
Failure to Track and Monitor Infections
Penalty
Summary
The facility failed to implement an infection prevention and control program that included infection identification and surveillance for all residents. Resident #25 was transferred from the hospital to the facility with Clostridium difficile infection, but the February 2026 infection control documentation did not include this CDI in the infection mapping, line listings, logs, or other tracking documentation. Several residents with symptomatic infections were listed on the infection line listing, but they were not reflected in the facility’s mapping or data analysis documentation. There was no infection documentation provided for March 2026. During interview, the Infection Preventionist was unavailable, and RN B and the NHA were unable to explain why the CDI was not tracked or how the facility was monitoring and correlating other residents with gastrointestinal symptoms. RN B confirmed the CDI was not documented in the infection control information and stated she did not know how the facility was tracking or monitoring for CDI. The NHA reviewed the records and confirmed the CDI was missing from the infection control program documentation and that the IPCP was not in place.
Missing discharge medication reconciliation and transfer notification
Penalty
Summary
The facility failed to ensure that a discharge summary for one resident included a reconciliation of pre-discharge medications with post-discharge medications. The resident was discharged with home health care services, and the discharge summary documented that medications were called into a pharmacy, but the section directing the reader to a physician’s order listing was left blank and no physician’s order listing was included. The discharge summary also had blank resident and/or resident representative signature sections despite a date entry, and a signed copy was not found in the resident’s electronic medical record. Social Worker A stated that medication information was contained in the discharge summary, but the record review did not show documentation that a medication reconciliation was completed or that a discharge medication list was provided. The facility also failed to provide written notification of transfer for another resident who was transferred from the facility to the hospital emergency department. The electronic medical record did not contain documentation showing that written transfer notification was given to the resident or the resident representative. When asked for the written notification, Social Worker A stated that the facility did not do that and that only bed-hold information had been sent. The facility policy stated that the resident and/or representative would be notified of the transfer or discharge and provided information including the reason for transfer, the effective date, the location of transfer, and contact information for the state LTC ombudsman and the state agency handling appeals.
Missing MRR Documentation and Physician Rationale for Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were addressed by the attending physician for three residents reviewed for MRRs and unnecessary medications. For Resident 16, the record showed a diagnosis of dementia with behavioral disturbance and an order for divalproex twice daily. The pharmacist’s MRRs referenced gradual dose reduction (GDR) requests, but the related pharmacist reports could not be located in the resident’s electronic medical record. An undated pharmacist report to the physician recommended evaluating the resident for a GDR of divalproex, and the physician checked the disagree box and signed the form on 1/22/26, but did not document any clinical rationale for declining the recommendation in the form or in progress notes. For Resident 3, the record showed a diagnosis of osteoporosis and a pharmacist’s monthly MRR that referenced a medication addition request. The pharmacist report itself was not located in the resident’s record. An undated pharmacist report to the physician recommended considering adding a calcium/vitamin D supplement to augment alendronate therapy. The physician wrote declined and signed the report on 10/23/25, but there was no rationale documented on the report or elsewhere in the resident’s EMR explaining the declination. For Resident 4, the record showed diagnoses including non-Alzheimer’s dementia and anxiety disorder, with routine antipsychotic use and no GDR completed. A pharmacist recommendation on 11/19/25 requested a GDR of risperidone for hallucinations, but the corresponding pharmacist report was not located in the record. The physician response area showed decline see form with a signature dated 12/5/25, yet no physician rationale for declining the GDR recommendation was found in the resident’s record. The facility policy required the consultant pharmacist to report irregularities and for the prescriber’s response, including an explanation when disagreeing, to be recorded in the resident’s clinical record or on the consultant’s written report.
Missing Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to provide hospice documentation for two residents who were documented as receiving hospice care. One resident was admitted with congestive heart failure, had a BIMS score of 15/15 indicating intact cognition, and the MDS and care plan documented hospice participation and a terminal prognosis related to heart disease. Although a physician order indicated the resident may sign on to a hospice agency of choice with a start date of 3/2/26, the EMR contained no hospice visit notes, cares, or services provided by hospice during the course of care, and the facility was unable to provide additional documentation before the end of the survey. The second resident was admitted with diagnoses including CAD, vascular dementia, left-sided hemiplegia, COPD, PVD, and palliative care, and the MDS documented hospice participation with a BIMS score of 9/15. The EMR contained a hospice election statement and a hospice care plan, but the miscellaneous tab had no hospice visit notes showing care and services provided by the hospice agency since October 2025. During interviews, staff stated the daily hospice visit notes should be in the EMR, that notes had not been uploaded yet, and that hospice papers were being placed in the scanning bin. The facility’s hospice policy stated the facility would maintain a medical record on each hospice resident and retain hospice progress notes as part of the resident’s permanent record.
QAPI Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, which could potentially affect the quality of care for all 27 residents. During a review on February 13, 2025, it was found that the Medical Director or their designee did not attend the QAPI meeting held on February 5, 2025. Additionally, there was no attendance record available for the meeting held on October 24, 2024. The interim Nursing Home Administrator (NHA) was unable to locate the October 2024 attendance record and confirmed the absence of the Medical Director or designee at the February 2025 meeting. The missing attendance records were not provided by the time of the survey exit on February 13, 2025.
Failure to Document and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to provide evidence of documented monthly pharmacy medication regimen reviews (MRRs) and did not appropriately follow pharmacy recommendations for four residents. These residents had various diagnoses, including dementia, rheumatoid arthritis, and heart failure, and were on multiple medications that required regular laboratory monitoring as per the consultant pharmacist's recommendations. However, the physician order recapitulation reports did not show any labs ordered in response to these recommendations, indicating a lack of action on the part of the facility to ensure proper medication management. During an interview, the Medical Director acknowledged not having seen all the pharmacy recommendations, particularly those related to laboratory tests, and admitted that the physician should be aware of all recommendations. The facility's policy on Medication Regimen Review states that the consultant pharmacist's evaluation should include reviewing laboratory results and that the prescriber's response should be recorded. This deficiency in following the established policy and procedures resulted in the potential for adverse medication side effects for the residents involved.
Failure to Adhere to Psychotropic Medication Regulations
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of psychotropic medications for residents. Specifically, a resident was prescribed lorazepam PRN for anxiety without a specific end date, and there was no documented rationale for the continued use of this medication beyond the 14-day standard reevaluation period. The facility's policy requires that PRN orders for antianxiety medications not exceed 14 days without physician documentation, which was not followed in this case. Additionally, the facility did not conduct required Abnormal Involuntary Movement Scale (AIMS) assessments for two residents who were prescribed antipsychotic medications. One resident had no AIMS assessment documented in their electronic medical record, while another resident was missing two quarterly AIMS assessments. The facility's policy mandates that nursing staff are responsible for initiating AIMS assessments to monitor for adverse consequences or side effects of psychoactive medications, which was not adhered to in these instances.
Non-Functional Call Light System in Resident's Room
Penalty
Summary
The facility failed to ensure a functional call light system for a resident, leading to dissatisfaction with the timeliness of care and fear that care needs may not be met in an emergency. The resident, who had moderate cognitive impairment and limited physical mobility due to a history of stroke, reported that their call light was non-functional and that staff were aware of the issue. Despite multiple work orders being submitted to the maintenance department, the call light remained unrepaired, causing the resident to rely on their roommate's call light for assistance. Observations confirmed that the resident's call light was not working, as pressing the button did not trigger the indicator light inside or outside the room. Interviews with staff, including a CNA and an RN, revealed that they were aware of the issue and had submitted work orders, but the maintenance department had not addressed the problem. The maintenance director indicated that the facility staff were supposed to contact a third-party contractor for repairs, but there was no contract in place, and the facility lacked a policy regarding call light repairs. The review of work orders showed that the call light issue had been ongoing, with several closed work orders indicating attempts to fix the problem, but the issue persisted. The facility's interim NHA and DON acknowledged the problem and the lack of a contract with a third-party contractor for call light repairs. The deficiency highlights a breakdown in communication and responsibility between the facility's staff and maintenance department, resulting in unresolved safety concerns for the resident.
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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 Gaylord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Gaylord | 0.5 mi | ★★★★★ | 13 | 0 |
| Grandvue Medical Care Facility | 25.1 mi | ★★★★★ | 2 | 0 |
| Munson Healthcare Crawford Continuing Care Center | 25.3 mi | ★★★★★ | 7 | 0 |
| Meadow Brook Medical Care Facility | 26.4 mi | ★★★★★ | 9 | 0 |
| Grayling Nursing & Rehabilitation Community | 26.4 mi | ★★★★★ | 13 | 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.