Traverse Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Oct 30, 2024

  Based on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R54) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and for 5 of 5 residents (R151, R157, R152, R202, R206) observed for COVID-19 transmission based precautions (TBP). In addition, the facility failed to to provide sanitary catheter care to help prevent the development of infections for 1 of 1 resident (R54) observed who utilized a urinary catheter. […]

• No harm, potential for more than minimal, isolatedF609Jul 27, 2026

  Based on observation, interview and document review, the facility failed to report an allegation of an injury of unknown origin to the State Agency (SA) within two hours for 1 of 1 resident (R1) investigated for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition with no behaviors and rarely socially isolated herself. R1 had impaired lower bilateral extremity range of motion (ROM) and used a walker and wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel. R1 required partial/moderate assistance with all transfers and was dependent upon staff for shower/bath and toileting. R1's diagnoses included non-Alzheimer's dementia (e.g. […]

• No harm, potential for more than minimal, isolatedF689Jul 27, 2026

  Based on observation, interview, and document review, the facility failed to ensure a call light was within reach for 1 of 3 residents (R5) who had severe cognitive impairment and was at high risk for falling, leaving the resident unable to summon assistance. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to facility on 1/29/26 from an acute hospital setting. R5 had minimal difficulty hearing in some environments, did not wear hearing aids, wore glasses, and had severely impaired cognition. R5 used a walker and wheelchair for mobility. R5 required partial/moderate assistance with toilet transfer, substantial/maximal assistance with toileting hygiene and supervision or touching assistance to walk 10 to 150 feet. […]

• No harm, potential for more than minimal, isolatedF880Jul 27, 2026

  Based on observation, interview, and document review the facility failed to ensure proper hand hygiene was used after removal of gloves for 1 of 3 residents (R1) during toileting and personal cares. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) recommendations were followed during a high contact care activity and failed to ensure proper was followed when emptying a urine collection bag for 1 of 1 resident (R4) who required enhanced barrier precautions (EBP).R1R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition with no behaviors. R1 had lower bilateral extremity range of motion (ROM) impairment and used a walker and wheelchair for mobility. […]

• No harm, potential for more than minimal, isolatedF554Jan 14, 2026

  Based on observation, interview, and document review, the facility failed to ensure that nebulizer medications were administered safely for 3 of 3 residents (R14, R1, R2) who were observed to self-administer a nebulizer and had not been approved to self-administer medications.Based on observation, interview, and document review, the facility failed to ensure that nebulizer medications were administered safely for 3 of 3 residents (R14, R1, R24) who were observed to self-administer a nebulizer and had not been approved to self-administer medications. Findings include: R24's annual Minimum Data Set (MDS) identified that R24 was moderately cognitively impaired. R24 had a diagnosis that included diabetes, anxiety, and depression. […]