Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paul Oliver Memorial Hospital Ltcu during CMS and state inspections, most recent first.
Incomplete narcotic reconciliation and improper controlled substance storage were found in the medication room and on two med carts. The back-up narcotic box was not double locked and was left on the med counter with zip locks, and multiple narcotic count sheets had missing nurse signatures, times, and dates or only one nurse signing off instead of two. The DON stated two nurses were expected to sign off each shift, and the Pharmacist said narcotics must be double locked and fully signed off after each shift.
Surveyors found unsafe medication storage in two med carts and one med room. The front cart contained two insulin pens with an open date but no expiration date and a loose furosemide tablet with debris, while the back cart contained loose warfarin and pantoprazole tablets with debris. In the med room, the backup narcotic box was left on the counter and not double locked. RNs, the DON, and the pharmacist all acknowledged that loose meds should not be in carts and that narcotics require double-lock storage, and the DON could not explain missing signatures on the narcotic sign-off sheet.
Failure to complete a required PASARR Level II evaluation for a resident with bipolar disorder. The resident had a prior PASARR II that required a new Level II evaluation if the resident remained in the facility, but the evaluation was not completed. The DON said an RN was responsible for monitoring PASARR requests, and the RN acknowledged it was her responsibility and that she had not thought about the PASARR system because the resident was already seeing Behavioral Care Solutions.
Pressure ulcer not prevented and wound measurements not documented. A resident with a stage II pressure ulcer on the ischial area had additional open skin noted during a dressing change, and EMR review showed missing weekly wound measurements and no depth documentation for the ulcer. The ADON stated wound measurements should be documented at least weekly and confirmed gaps in the charting.
Respiratory equipment was left improperly stored for multiple residents. A CPAP mask was observed open to air on a dresser instead of in a bag, and nebulizers with condensation in the medication cup were left on nightstands without being bagged; oxygen tubing was also coiled around bubbler/regulator equipment while not in use. One nebulizer also lacked a date. The ADON stated oxygen equipment should be stored in a bag and nebulizers rinsed, dried, and placed in a bag until the next use.
The facility failed to maintain professional standards for food service safety, with expired frozen yogurt, unsanitary rolling bins, and a dirty Vulcan oven/range. The Registered Dietitian's cleaning schedules were not followed, risking foodborne illness for 29 residents.
A resident with a leg fracture and intact cognition reported being sexually abused by a CNA during a transfer. The CNA made inappropriate gestures and comments, causing the resident to feel embarrassed and anxious. The incident was reported to an LPN and confirmed by the ADON and DON, with the resident expressing a desire to file a police report.
Incomplete Narcotic Reconciliation and Improper Controlled Substance Storage
Penalty
Summary
The facility failed to ensure medication reconciliation and controlled substance sign-off were completed shift to shift for two medication carts and one medication room. During observation of the medication storage room, the back-up narcotic box was found sitting on top of the medication counter with two plastic zip locks and was not double locked. The narcotic sign-off sheet also had missing shift-to-shift signatures confirming the narcotic box maintained the same lock numbers. When asked about the box, an RN stated it had always been that way, and the DON did not answer when asked why the box was not checked after every shift as expected. Record review of the front hall and back hall medication carts showed numerous blank or incomplete narcotic count entries, including missing nurse signatures, missing times, missing dates, and instances where only one nurse signed off on the narcotic count. The DON stated the expectation was for two nurses to sign off from shift to shift, and the Pharmacist stated all narcotics needed to be under double lock and key, no loose medications should be in the medication carts, nurses needed to be counted and signed off after each shift, and blank areas on the reconciliation sheet were unacceptable. The facility policy also stated Schedule II through V medications must be stored in a double-locked container designated for that purpose.
Medication Storage and Controlled Substance Security Deficiencies
Penalty
Summary
The facility failed to store medications in a safe manner in two medication carts and one medication room. During observation of the front hall medication cart, surveyors found two insulin pens with an open date but no expiration date, and one loose furosemide 40 mg tablet in the second drawer with paper debris. RN E stated she did not know the insulin pens needed an expiration date and that no loose medications should be left in the cart. In the back medication cart, surveyors found two loose pills in the second drawer with paper debris: a half tablet of warfarin sodium 5 mg and a pantoprazole 40 mg extended release tablet. RN C stated that pharmacy cleans the carts once a month and that there should not be any loose medications floating around. In the medication storage room, the backup narcotic box was observed sitting on top of the counter and not double locked. RN C stated it had always been left on the counter. The DON stated the facility was getting a different storage unit soon and that nurses check to ensure the same lock is on it each shift, but could not explain holes in the narcotic sign-off sheet. The DON later stated the expectation was for two nurses to sign off from shift to shift. The pharmacist stated that all narcotics need to be under double lock and key, no loose medications should be in medication carts, nurses need to be counted and signed off after each shift, and no missing signatures should be on the sign-off sheet. Facility policies reviewed stated controlled medications must be stored in a double-locked container, insulins expire 28 days after opening, and medication storage equipment and supplies must be clean, functional, and orderly.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a Level II PASARR evaluation was completed for a resident admitted with a diagnosis of bipolar disorder. The resident's record showed a PASARR II had been completed on 8/5/24 and stated that if the individual remained in the nursing facility, a Level II evaluation was needed by August 4, 2025. During interviews, the DON stated RN J was responsible for social services and for monitoring and obtaining PASARR requests. RN J stated it was her responsibility to request the PASARR and acknowledged that it had not been completed, explaining that because the resident was already seeing Behavioral Care Solutions, she had not thought about the PASARR system for the resident.
Pressure ulcer not prevented and wound measurements not documented
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and failed to document wound measurements per standards of practice for Resident #4. On 5/4/26, the resident stated she had a pressure ulcer on her buttocks that “comes and goes.” During a dressing change on 5/5/26, the resident was observed with padded dressings over both buttocks and another padded dressing between the knees on the inner side of the right knee. After the buttock dressings were removed, an additional open area was observed just above the original pressure ulcer on the right buttocks, measuring 1.0 cm by 1.0 cm, while the right lower buttocks measured 2.5 cm by 1.5 cm. Record review showed an order dated 3/27/26 to document skin and wound assessments and follow-up actions in a clinical nurse note, and to monitor the right and left ischial tuberosity and between the knees. Progress notes documented blanchable redness to the coccyx and a stage II pressure ulcer on the right ischial tuberosity measuring 2.25 cm by 2 cm on 3/9/26, and later an open area on the right ischial tuberosity measuring 2 cm by 5.25 cm on 3/27/26. Review of the EMR from 3/9/26 through 5/5/26 showed missing wound measurements for the weeks of 3/23/26, 4/13/26, 4/20/26, and 4/27/26, and the documentation did not include any measurements describing the depth of the stage II pressure ulcer. The ADON stated that measurements should ideally be documented with every dressing change, but at least weekly, and confirmed there were gaps in the weekly measurements and that the pressure ulcer developed on 3/9/26.
Respiratory equipment left improperly stored between uses
Penalty
Summary
The facility failed to ensure respiratory equipment was stored in a clean and sanitary manner between resident uses for three residents reviewed for respiratory care. For Resident #5, a CPAP mask was observed draped across a small dresser next to the bed and left open to air rather than stored in a plastic bag on two separate observations. For Resident #37, an intact nebulizer with condensation in the medication cup was observed on the nightstand, and a bubbler with oxygen tubing coiled around it was also left on the nightstand; neither piece of respiratory equipment was stored in a bag while not in use. The same resident was later observed with the nebulizer still on the nightstand with condensation in the medication cup and the oxygen tubing coiled around the bubbler and regulator device in the oxygen wall port. For Resident #38, an intact nebulizer with condensation inside the medication cup was observed lying on the nightstand, and the nebulizer lacked a date. On a later observation, the nebulizer was still present without a date and was coiled around the regulator device in the oxygen wall port. During interview, the ADON stated oxygen equipment should be stored in a bag and nebulizers are to be rinsed, dried, and then placed in a bag until the next use. The facility document titled Inhalers-Nebulizers stated treatment is complete when the medication cup is empty, the mouthpiece should be rinsed with water, allowed to dry, and stored in a clean location.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a tour of the dietary department. The reach-in freezer contained frozen yogurt with an expired use-by date. In the kitchen's hood area, two large rolling bins were found with a yellowing film and brown crumbs on the covers. One bin contained a 20-pound bag of flour with no indication of when it was opened or when it should be used by, and debris, including a metal clip, was found at the bottom. The other bin, containing oats, also had dry debris. Additionally, the Vulcan oven/range had drip pans with a buildup of blackened overflow juices and noodle remains, and the grease trap required cleaning. Four small steam-table metal pans used for serving utensils and equipment parts were observed with drips and crumb debris. The Registered Dietitian presented cleaning schedules indicating that the areas noted should be regularly cleaned, including the hood area, grease traps, stove, and inside cabinets and drawers. The FDA Food Code requires food storage containers to be identified with the common name of the food and for food-contact surfaces and utensils to be clean to sight and touch. The deficiency in maintaining sanitary conditions and proper food storage had the potential to result in foodborne illness among the 29 residents in the facility.
Failure to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a certified nursing assistant (CNA), resulting in a deficiency. The incident involved a resident with a displaced fracture of the right lower leg and intact cognition, as indicated by a BIMS score of 15. The resident reported that on a specific date, the CNA made inappropriate sexual gestures and comments while assisting her with a transfer to the bathroom. The CNA allegedly grabbed the resident's breasts and made a sexual comment, causing the resident to feel embarrassed, anxious, and fearful. The resident reported the incident to a Licensed Practical Nurse (LPN) the following day, who then informed the Assistant Director of Nursing (ADON). The ADON confirmed the details of the allegation with the resident, and the Director of Nursing (DON) later interviewed the resident, who expressed a desire to file a police report. The facility's policies on abuse prevention, dignity, and resident rights emphasize the protection of residents from abuse and maintaining their dignity, which were not upheld in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maples Benzie County Medical Care | 2.1 mi | ★★★★★ | 13 | 0 |
| Maple Valley Nursing Home | 23.4 mi | ★★★★★ | 11 | 0 |
| Manistee County Medical Care Facility | 25.3 mi | ★★★★★ | 11 | 0 |
| Grand Traverse Pavilions | 30.8 mi | ★★★★★ | 4 | 0 |
| The Villa At Traverse Point | 30.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Paul Oliver Memorial Hospital Ltcu.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.