Grand Traverse Pavilions: Oxygen Equipment Failure - MI
The October 15 complaint inspection at Grand Traverse Pavilions found that the facility failed to ensure an oxygen-dependent resident had appropriate respiratory equipment during transport. The resident's prescribed flow rate was 8 liters per minute, which requires a high-flow nasal cannula. The facility's own oxygen therapy policy states that a standard nasal cannula cannot exceed 6 liters per minute, and that a simple face mask must be used for anything above that threshold. The Director of Nursing confirmed both points when interviewed that afternoon.
What inspectors found was a gap no one had filled. There was simply no data available for what the equipment could deliver at 8 liters per minute.
The facility's transportation policy required that residents be ready at their scheduled departure time with any assistive devices they needed. The oxygen equipment they actually had with them did not meet that standard.
The clinical stakes are not abstract. Guidance from a cardiovascular specialty hospital reviewed during the inspection describes what happens when oxygen saturation falls. Below 91 percent is low. Below 85 percent, the severe lack of oxygen begins to affect the brain, causing vision changes and loss of consciousness. Below 80 percent, the brain, liver, and other vital organs are compromised.
The Director of Nursing told inspectors she understood the concern. A resident whose prescribed flow rate cannot be met during transport is not receiving the oxygen their physician determined they need, for however long that transport takes.
The inspection cited minimal harm or potential for actual harm, affecting few residents. Whether the resident's oxygen levels dropped during that trip, no one recorded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Traverse Pavilions from 2025-10-15 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Grand Traverse Pavilions in Traverse City, MI was cited for violations during a health inspection on October 15, 2025.
The resident's prescribed flow rate was 8 liters per minute, which requires a high-flow nasal cannula.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.