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Deficiency Records for Grand Traverse Pavilions
A list of the most recent deficiencies for Grand Traverse Pavilions. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Grand Traverse Pavilions. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-19 | 2024-10-10 | N |
| 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. | Health | 2024-09-19 | 2024-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-19 | 2024-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-19 | 2024-10-10 | N |
| 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. | Health | 2024-09-19 | 2024-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-19 | 2024-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-19 | 2024-10-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-09-19 | 2024-10-10 | N |
| 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. | Health | 2024-09-19 | 2024-10-10 | N |
| Provide or obtain dental services for each resident. | Health | 2024-09-19 | 2024-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-19 | 2024-10-10 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-09-19 | 2024-10-10 | N |
| 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. | Health | 2024-09-19 | 2024-10-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-09-19 | 2024-10-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Have an externally vented heating system. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-17 | 2024-10-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-14 | 2023-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-11-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-14 | 2023-11-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-14 | 2023-11-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-14 | 2023-10-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-14 | 2023-10-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-14 | 2023-10-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-14 | 2023-10-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-14 | 2023-10-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-14 | 2023-10-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-14 | 2023-10-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-14 | 2023-10-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-06 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-09-12 | 2023-10-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-08-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-04 | 2022-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-08-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-08-30 | N |
| 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. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-04 | 2022-08-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-04 | 2022-08-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-04 | 2022-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-08-30 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-04 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-30 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-08-04 | 2022-08-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-03 | 2022-08-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-03 | 2022-08-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-07 | 2022-07-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-07 | 2022-07-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-07 | 2022-07-27 | Y |
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