Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Traverse Care Center during CMS and state inspections, most recent first.
Nebulizer medications were not administered safely for multiple residents who were not approved for SAM. Residents with cognitive impairment, dementia, schizophrenia, Alzheimer’s disease, COPD, and other diagnoses were observed using nebulizers while staff were absent or left after setup, even though their records showed no SAM orders and assessments found they could not self-administer inhalants or medications. Nursing staff and administration confirmed that residents without SAM approval should have staff present during nebulizer administration.
A resident with a neurogenic bladder and indwelling Foley catheter was discharged from the hospital with orders for a urology follow-up, but the LTC facility failed to schedule or complete this appointment. The resident experienced multiple catheter-related complications, including bleeding and a UTI, leading to an ER visit and further hospitalization. Staff interviews confirmed the urology follow-up was not arranged, and family members were not informed, resulting in a deficiency related to failure to follow discharge orders.
A long-term care facility failed to ensure proper PPE use and infection control, leading to potential infection risks. Staff did not consistently wear required PPE for residents under enhanced barrier precautions and COVID-19 precautions. Observations showed improper handling of catheter care and inadequate hand hygiene. The facility's infection control program lacked comprehensive surveillance and analysis of resident infections.
A resident with moderate cognitive impairment and multiple diagnoses reported feeling scared of a nursing assistant due to alleged abusive behavior. Despite the resident informing the assistant director of nursing, the facility failed to report the allegation to the administrator and the State Agency within the required two-hour timeframe. Interviews revealed that the director of nursing and assistant director of nursing were aware of the incidents but did not classify them as abuse requiring immediate reporting, resulting in a deficiency finding.
A resident with severe cognitive impairment and multiple diagnoses received medications that were crushed against physician orders, potentially altering their efficacy. The facility's staff failed to notify the physician or pharmacist about the resident's medication administration issues, leading to a deficiency in adhering to professional standards of practice.
A resident with Alzheimer's and dementia, at high risk for pressure ulcers, was not repositioned for over two hours, contrary to their care plan. Despite having an unhealed pressure ulcer on the coccyx, the resident remained in the same position for an extended period, as staff attended to other residents. The facility's policy required repositioning every two hours to prevent skin breakdown, which was not adhered to, as confirmed by staff interviews.
Two residents at high risk for falls did not receive appropriate interventions as outlined in their care plans. One resident's wheelchair cushion slipped due to the absence of a Dycem mat, and another resident did not receive 30-minute safety checks, leading to multiple self-transfers to the floor. Staff were unaware of these interventions, contributing to the deficiency.
The facility failed to date insulin pens for three residents and did not discard a Tubersol solution after 30 days as recommended. Insulin pens were found undated, and the Tubersol solution exceeded the manufacturer's usage timeframe. Interviews with staff confirmed the expectation for proper dating and discarding of these medications, which was not followed, leading to this deficiency.
A facility failed to prevent drug diversion involving a Fentanyl patch for a resident with osteoarthritis. The patch was found to be tampered with, and a TMA was suspected of reapplying the old patch and forging nurse signatures. The facility's policy requiring two staff to verify and destroy controlled substances was not followed, and the administration did not adequately investigate or address the issue.
A facility failed to report a suspected drug diversion involving a resident's Fentanyl patch. Discrepancies were noted by an LPN, including mismatched dates and forged signatures. Despite internal findings and the TMA's admission of reapplying an old patch, the incident was not reported to the State Agency as required. The facility's policy lacked specific guidance on reporting suspected diversions, leading to non-compliance with state requirements.
A facility failed to prevent further drug diversion after a resident's Fentanyl patch was found to be suspicious. The patch lacked expected markings, and required verification protocols were not followed, with evidence of forged signatures. Despite reporting the incident, no staff education or retraining on controlled substance procedures occurred, and the Director of Nursing did not investigate further upon returning to the facility.
Nebulizer Medications Given Without SAM Approval
Penalty
Summary
The facility failed to ensure that nebulizer medications were administered safely for residents who were not approved to self-administer medications. The report states that residents were observed using nebulizer treatments without staff present, even though their records did not include self-administration orders and their self-administration assessments indicated they were not capable of self-administering inhalants or inhalers, or were not approved for self-administration of medications. One resident had a care plan identifying altered respiratory status and difficulty breathing, with staff to administer medications and treatments as ordered, and another care plan note stating the resident could not self-administer medications because of dementia and cognitive impairment. That resident’s physician orders included budesonide and ipratropium-albuterol nebulizer treatments, and the self-administration assessment stated the resident was not capable of administering inhalants or inhalers. During observation, the resident was found sitting with a nebulizer mask on and the machine running with no staff in the room. A TMA later entered, turned off the machine, administered budesonide into the nebulizer mask, turned it back on, and left the room. Another resident had severe cognitive impairment, schizophrenia, and Alzheimer’s disease, and was dependent on staff for dressing, hygiene, and toileting. The care plan stated the resident was not able to self-administer medications, and the self-administration assessment found the resident could not cognitively participate in self-administration. The resident had an order for ipratropium-albuterol nebulizer treatment but no self-administration order. A third resident had diagnoses including heart failure, COPD, anxiety, and bipolar disease, and the care plan and SAM assessment stated the resident was not able or not interested in self-administering medications. During observation, the resident was seen with a nebulizer mask on while the machine was running and staff were not continuously present; later, an RN shut off the nebulizer, added another medication, replaced the mask, turned the machine back on, and left the room. Interviews with nursing staff and administration confirmed that residents without SAM approval should have staff present during nebulizer administration.
Failure to Schedule and Complete Urology Follow-Up After Hospital Discharge
Penalty
Summary
The facility failed to ensure that a hospital physician's discharge order for a follow-up appointment with urology was scheduled and completed for a resident who was readmitted from the hospital. Upon re-entry, the resident had a history of severely impaired cognition, impaired mobility, neurogenic bladder, renal failure, diabetes mellitus, and was dependent on an indwelling urinary catheter. Hospital discharge instructions specifically directed that the Foley catheter was to remain in place until a follow-up with urology, and that the catheter should be changed every four weeks. However, review of the resident's medical records did not identify that a urology appointment was scheduled or completed as ordered. Progress notes and interviews revealed ongoing complications with the resident's urinary catheter, including episodes of no urine output, unsuccessful irrigation, bleeding at the catheter insertion site, and eventual trauma during catheter removal that resulted in an emergency room visit and hospital admission for catheter complications and UTI. The hospital discharge summary after this event noted a fissure caused by the catheter and provided specific instructions for catheter care, including a referral to urology for possible supra-pubic catheter placement. Despite these ongoing issues, staff interviews confirmed that the resident had not been scheduled for a urology appointment after the initial hospital discharge, and the last known urology visit was several years prior. Multiple staff members, including the assistant director of nursing and the director of nursing, acknowledged that the follow-up with urology was not completed and that the facility did not ensure the appointment was scheduled as ordered. Family members also expressed concern and were unaware of any urology follow-up. The deficiency was attributed to a lack of follow-through on discharge orders and inadequate documentation and communication regarding specialist appointments.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for residents under enhanced barrier precautions (EBP) and COVID-19 transmission-based precautions (TBP). Observations revealed that a nursing assistant did not maintain proper PPE protocol while providing catheter care to a resident with a Foley catheter. The catheter bag was observed lying on the floor, and the nursing assistant removed her gown prematurely during the care process, acknowledging the mistake afterward. The clinical manager confirmed that catheter bags should not be on the floor and that PPE should be worn during catheter care. Additionally, the facility did not adhere to proper PPE protocols for residents with COVID-19. Observations showed that staff, including the infection preventionist and nursing assistants, did not consistently wear the required PPE, such as N95 masks, gowns, gloves, and eye protection, when entering rooms of COVID-19 positive residents. There were instances where staff wore surgical masks over N95 masks, which compromised the seal and effectiveness of the N95 masks. Staff also failed to perform hand hygiene between resident interactions, increasing the risk of cross-contamination. The facility's infection control program was inadequate, lacking comprehensive surveillance and analysis of resident infections. The infection control logs did not include assessments of residents on EBP or those with active infections, such as urinary tract infections or wound infections. The infection preventionist admitted that the facility's tracking system was a work in progress and that not all infections were being monitored. The director of nursing confirmed the expectation for staff to follow CDC guidelines for PPE use and infection prevention, but the facility was not conducting audits to ensure compliance.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required timeframe of two hours to the administrator and the State Agency (SA). The incident involved a resident with moderate cognitive impairment and multiple diagnoses, including heart failure, diabetes mellitus, and anxiety disorder, who required extensive assistance with activities of daily living. The resident reported feeling scared of a nursing assistant (NA-C) due to two incidents where NA-C allegedly raised his fist and voice at the resident. Despite the resident informing the assistant director of nursing (ADON) about these incidents, the facility did not document the report to the SA, and the ADON did not consider it necessary to report the allegation to the administrator or the SA. Interviews with staff revealed that the ADON and the director of nursing (DON) were aware of the resident's fear of NA-C and the verbal incident but did not classify it as abuse requiring immediate reporting. The facility's policy on abuse, neglect, and exploitation mandates reporting all alleged violations to the administrator and the SA within two hours if the events involve abuse. However, the DON and ADON did not adhere to this policy, as they believed the situation was resolved by ensuring NA-C did not work with the resident alone. The administrator was unaware of the allegation, and the facility's failure to report the incident as per policy resulted in a deficiency finding.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and standards of practice for a resident, identified as R210, who was observed to receive medication. R210 had severe cognitive impairment and multiple diagnoses, including type two diabetes, chronic kidney disease stage four, bipolar disorder, anxiety, borderline personality disorder, depression, congestive heart failure, hypertension, and anemia. The resident required extensive assistance with daily activities and was at risk for adverse reactions to medications. The care plan specified that medications should be administered as ordered and monitored for side effects and effectiveness. During an observation, a registered nurse (RN-C) was seen preparing medications for R210 outside the resident's room. Another nurse (RN-B) advised RN-C to crush the medications as R210 was not feeling well. RN-C proceeded to crush the medications, mixed them with applesauce, and handed them to RN-B, who then administered them to R210. It was later confirmed that the medications were labeled 'do not crush' and were intended to be given whole, as indicated in R210's electronic health record. The physician had not been notified that R210 was receiving medications crushed or chewing them, which could affect the medication's absorption and efficacy. Interviews with RN-C, RN-B, the consultant pharmacist, and the director of nursing (DON) confirmed that the medications should not have been crushed, as this could alter their delivery and effectiveness. The facility's policy on medication administration required that medications be given as ordered by the physician and in accordance with professional standards. The failure to adhere to these standards resulted in the resident potentially not receiving the correct dose of medication, as the medications were altered by being crushed.
Failure to Reposition Resident Leads to Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident, identified as R206, who had a history of pressure ulcers and was at high risk for further development. R206's quarterly Minimum Data Set (MDS) indicated diagnoses of Alzheimer's disease, dementia, and anxiety, requiring assistance for bed mobility and transfers. The resident had an unhealed pressure ulcer on the coccyx and was assessed with a Braden scale score of 14, indicating high risk for pressure ulcers. The care plan required skin preparation twice daily and as needed, along with the use of an air mattress overlay. Observations on a specific day revealed that R206 was not repositioned for over two hours and thirty-five minutes, despite being in isolation precautions and having a care plan that required repositioning every two hours. The resident was observed in the same position multiple times between 7:25 a.m. and 10:40 a.m. A registered nurse (RN-B) confirmed the presence of a pressure ulcer on the coccyx, measuring 2 x 1.4 cm, with serosanguinous drainage. The RN acknowledged that the resident should have been repositioned every two hours, as per the care plan, but was not due to attending to other residents. Interviews with nursing assistants and the director of nursing (DON) confirmed the failure to reposition R206 as required. Nursing assistants admitted to not having been in the resident's room for repositioning due to attending to other residents' call lights. The DON was unaware of the lapse in repositioning and reiterated the expectation for staff to reposition residents every two hours to prevent skin breakdown. The facility's policy on pressure injury prevention emphasized the importance of redistributing pressure to prevent and manage pressure injuries.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for two residents, R53 and R206, who were at high risk for falls. R53, who was cognitively intact and had a history of falls with major injury, was found on the floor after her wheelchair cushion slipped out. Despite the care plan specifying the use of a Dycem non-slip mat under the cushion to prevent such incidents, it was not in place during an observation. Staff interviews revealed a lack of awareness and implementation of this intervention, contributing to the deficiency. R206, diagnosed with Alzheimer's disease, dementia, and anxiety, had a history of self-transferring to the floor. The care plan included 30-minute safety checks as a fall prevention measure. However, documentation showed numerous missed checks, and continuous observation confirmed that staff did not perform these checks over a two-hour and 35-minute period. Interviews with staff and the DON revealed a lack of awareness and adherence to the care plan, leading to the deficiency. The facility's Fall Prevention Program Policy required individualized care and monitoring of interventions for effectiveness, which was not adhered to in these cases. The failure to implement and monitor fall prevention interventions as outlined in the care plans for R53 and R206 resulted in deficiencies in ensuring a safe environment free from accident hazards.
Failure to Date Insulin Pens and Discard Tubersol Solution
Penalty
Summary
The facility failed to ensure that insulin pens were accurately dated when opened for three residents who received insulin injections. During an observation, it was found that insulin pens for these residents were not dated when opened, which is against the manufacturer's specifications that require insulin pens to be discarded after a certain period once opened. The residents involved had various medical conditions, including diabetes mellitus, hypertension, and other health issues, and required assistance with activities of daily living. Additionally, the facility did not discard a Tubersol solution after 30 days as recommended by the manufacturer. The Tubersol solution, used for tuberculosis testing, was found in the medication refrigerator with an open date that exceeded the 30-day usage recommendation. The LPN verified the undated insulin pens and the Tubersol solution, acknowledging that they should have been dated and discarded according to the manufacturer's guidelines. Interviews with the pharmacy consultant and the director of nursing revealed that there was an expectation for insulin pens to be dated upon opening to ensure they were used or discarded within the recommended timeframe. The pharmacy consultant initially believed the Tubersol solution was acceptable to use until the expiration date but later confirmed it should have been discarded after 30 days. The facility's policies on insulin pen usage and medication storage were not adhered to, leading to this deficiency.
Failure to Prevent Drug Diversion of Fentanyl Patch
Penalty
Summary
The facility failed to adhere to its policy and procedure to prevent drug diversion, specifically concerning the administration and management of a Fentanyl Transdermal Patch for a resident. The resident, who was receiving the patch every 72 hours for osteoarthritis, was found to have a patch that did not match the expected appearance, raising suspicions of drug diversion. The facility's policy required two nurses or a licensed nurse and a trained medical assistant (TMA) to verify the administration and destruction of controlled substances, but this protocol was not followed. During the investigation, it was discovered that a TMA was suspected of not removing the old Fentanyl patch and instead reapplying it, while also forging the signatures of nurses in the narcotic book. The TMA admitted to reapplying the old patch but claimed it was unintentional. The incident was reported to the director of nursing (DON), but there was a lack of awareness and follow-up from the administration, as the DON was out of the office and did not conduct further investigation or implement preventive measures upon returning. The report highlights multiple failures in the facility's controlled substance management, including improper verification and destruction of the Fentanyl patch, lack of immediate action from the administration, and inadequate communication among staff. The investigation revealed that the facility's policy was not followed, and there was no conclusive evidence to prove drug diversion, although the circumstances strongly suggested it. The lack of adherence to protocol and insufficient administrative response contributed to the deficiency.
Failure to Report Suspected Drug Diversion
Penalty
Summary
The facility failed to report a suspected drug diversion incident involving a resident who was prescribed a Fentanyl Transdermal Patch for osteoarthritis. The issue was identified when a Licensed Practical Nurse (LPN) noticed discrepancies with the patch, including mismatched dates and signatures that did not match her own. The facility's policy required two nurses to verify the removal and application of Fentanyl patches, but the process was not followed, leading to suspicions of drug diversion by a Trained Medical Assistant (TMA). The internal investigation revealed that the TMA was suspected of reapplying an old patch and forging signatures, which was reported to the Director of Nursing (DON). Despite these findings, the facility did not report the incident to the State Agency (SA) as required. The Clinical Services Manager from a contracted agency confirmed that the TMA admitted to reapplying the old patch but claimed it was unintentional. The TMA's contract was terminated, but the facility's administrators were not fully aware of the incident or the need to report it to the SA. The facility's Controlled Substance Administration and Accountability policy required immediate reporting of unresolved discrepancies to various authorities, including the SA. However, the policy lacked specific guidance on when to report suspected drug diversion to the SA. The administrators assumed that since the investigation did not conclusively prove diversion, reporting was unnecessary. This oversight led to a failure in compliance with state reporting requirements, as the facility did not report the suspected drug diversion incident to the SA.
Failure to Prevent Drug Diversion in LTC Facility
Penalty
Summary
The facility failed to implement appropriate interventions to prevent further drug diversion after an incident involving a resident's Fentanyl patch. The resident, who was receiving a Fentanyl Transdermal Patch every 72 hours for osteoarthritis, was found with a patch that did not appear to be authentic. The patch lacked the expected green writing indicating it was Fentanyl, and there were discrepancies in the signatures required for verification. The facility's procedure required two nurses or a nurse and a trained medical assistant to verify the application and removal of the patch, but this protocol was not followed. Additionally, there was evidence of forged signatures in the medication destruction log, suggesting a breach in the controlled substance handling process. Despite the incident being reported to the Director of Nursing (DON) and other administrators, there was no evidence of staff education or retraining on the controlled substance procedure following the event. The DON, who was out of the office at the time, did not conduct further investigation or implement measures to prevent recurrence upon returning. The internal investigation by a registered nurse confirmed that the facility's policy was not adhered to, but there was no conclusive evidence of tampering with the patch. The lack of follow-up actions and staff education contributed to the deficiency in handling the suspected drug diversion.
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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 Wheaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Grace Home | 16.8 mi | ★★★★★ | 0 | 0 |
| Browns Valley Health Center | 21.6 mi | ★★★★★ | 7 | 1 |
| St Gerard's Community Of Care | 26.9 mi | ★★★★★ | 0 | 0 |
| Tekakwitha Living Center | 28.5 mi | ★★★★★ | 15 | 0 |
| Barrett Care Center Inc | 30 mi | ★★★★★ | 0 | 0 |
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