Grand Traverse Pavilions

In the surveyor’s words

From the most serious findings on record at Grand Traverse Pavilions, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Aug 4, 2022

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by not sanitizing food contact surfaces, including plates, glasses, cups and flatware used among the entire resident population, and other food preparation equipment/utensils when using the high temperature mechanical dish washer and three compartment sink. This failure included: 1. Staff failing to identify the mechanical dish washer was not reaching a proper water temperature during the sanitizing cycle 2. F\ailing to demonstrate the dish machine had been tested and was properly sanitizing dishes for over a three month period. 3. […]

• Actual harm, isolatedF689Feb 24, 2026

  This pertains to intakes 2687925 and 2741873.Based on observation, interview, and record review the facility failed to ensure adequate supervision and/or implement appropriate interventions to prevent falls for three Residents (#1, #3, & #5) of three residents reviewed for falls, resulting in Resident #3 sustaining a right hip fracture which required hospitalization and surgical intervention.Findings include:Resident #3 (R3)A review of a fall report dated 12/9/25, at 5:03 am, indicated R3 fell in the bathroom. The incident description indicated . CNA heard loud sound from room and when he went into room, he observed the resident on the floor in the bathroom. Resident Description: Resident does not remember what happened but thinks she messed up her footing and slipped on the floor. […]

• Actual harm, isolatedF684Oct 15, 2025

  This deficient practice pertains to Intake 2641153.Based on interview and record review, the facility failed to effectively monitor, report, and respond to a change in condition for one Resident (#1) of three residents reviewed for quality of care. This deficient practice resulted in Resident #1 receiving delayed medical treatment leading to hospitalization and subsequent death.Findings include:Resident #1 (R1)Review of R1's Hospital Transfer Form, dated 10/10/25 at 7:16 PM, read, in part: .Reason(s) for transfer: hypoxic. BP [blood pressure] 158/88. HR [heart rate] 121. RR [Respiratory Rate]: 31. […]

• Actual harm, isolatedF686Jun 12, 2025

  Based on observation, interview, and record review the facility failed to prevent the development and progression of two stage 4 pressure ulcers for one resident (Resident #68) out of five residents reviewed for pressure ulcer development. This deficient practice resulted in Resident #68 experiencing severe pain during dressing changes and subsequently required wound debridement and antibiotics. Findings include: Resident #68 (R68) On 6/10/25 at 2:00 PM, an observation was made of R68 sitting up in his wheelchair eating lunch. R68 was asked if they had a pressure sore on their bottom and replied, Yes. […]

• Actual harm, isolatedF697Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to provide pain management as prescribed by the physician for one Resident (#431) of two residents reviewed for pain. This deficient practice resulted in unrelieved pain and required Resident #431 to be subsequently transfer to the emergency department (ED). Findings include: Resident #431 (R431) Review of R431's EMR revealed initial admission to the facility on 6/4/25 with diagnoses including fracture of the left acetabulum (a break in the socket portion of the hip joint), fracture of the left ulna (a break in one of the two bones of the forearm), fracture of the left tibia (a break in the large bone in the lower leg), displaced fracture of the left acromial process (a break in the bony projection of the shoulder… […]