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Inspection visit

Health inspection

Grand Traverse PavilionsCMS #23508814 citations on this visit
14 citations recorded

Citations

14 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0623GeneralS&S Epotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625GeneralS&S Dpotential for harm

    F625 - Transfer and discharge-

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0849GeneralS&S Dpotential for harm

    F849 - Hospice services

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0684SeriousS&S Gactual harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0825GeneralS&S Dpotential for harm

    F825 - Specialized rehabilitative services

    Provide or get specialized rehabilitative services as required for a resident.

FAQ · About this visit

Common questions about this visit

What happened during the September 19, 2024 survey of Grand Traverse Pavilions?

This was a inspection survey of Grand Traverse Pavilions on September 19, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Grand Traverse Pavilions on September 19, 2024?

Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.