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Complaint Investigation

Grand Traverse Pavilions

October 15, 2025 · Traverse City, MI · 1000 Pavilions Circle
Citations 2
CMS Rating 2/5
Beds 240
Provider ID 235088
Healthcare Facility
Grand Traverse Pavilions
Traverse City, MI  ·  View full profile →
Inspection Summary

Grand Traverse Pavilions in Traverse City, MI — inspection on October 15, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Actual Harm

blood oxygen levels drop below 80%, the brain, liver, and other vital body organs get affected. (https://www.medanta.org/)Review of an article titled Hypoxia written by the Cleveland Clinic and reviewed on 5/12/2022, read, in part: .Hypoxia is when the tissues of your body don't have enough oxygen.

While some of your tissues can adjust to temporary dips in oxygen levels, prolonged hypoxia can cause organ damage. hypoxia symptoms vary depending on the severity, underlying cause and what parts of your body are affected .

Some hypoxia symptoms include: .Confusion, Anxiety, Rapid heart rate (tachycardia), Rapid breathing (tachypnea), Difficulty breathing or shortness of breath (dyspnea). If you experience symptoms like confusion, rapid heart rate or breathing.you should seek medical attention immediately.

Hypoxia should be treated right away to prevent permanent organ damage.Hypoxia can be a life-threatening condition. Go to the emergency room if you have any symptoms of hypoxia or if others notice a sudden change in your behavior or awareness. (https://my.clevelandclinic.org/health/diseases/23063-hypoxia)

Review of the facility policy titled, Telemedicine dated 9/1/24, read, in part: A physician will be contact promptly in the following situations: a resident change in condition. if telehealth services are unable to provide assistance, please refer to the [physician ground] on-call calendar to contact a provider.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Traverse Pavilions

1000 Pavilions Circle Traverse City, MI 49684

SUMMARY STATEMENT OF DEFICIENCIES

Review of a document titled Oxygen duration with Tanks from the facility's portable oxygen vendor revealed the E-tank duration for a 6 LPM [liter per minute] flow rate equaled 75 minutes. No data was available for an 8 LPM flow rate.On 10/15/25 at 1:42 PM, an interview was conducted with the Director of Nursing (DON) who understood the concerns related to accessibility of respiratory equipment and services at all times for oxygen dependent residents.

The DON verified a flow rate of 6 LPM or above would necessitate a high flow nasal cannula.

Review of guidance from a cardiovascular specialty hospital titled, Blood Oxygen Levels: Everything you Need to Know, dated 5/19/2022, read, in part: .Blood oxygen levels:.Below 91%: low blood oxygen level.

Below 85%: Very low oxygen levels (Hypoxemia).Below 80%: Severe Hypoxemia.if the oxygen saturation drops below 85%, the severe lack of oxygen affects the brain.

The person may experience vision changes and lose consciousness.When the blood oxygen levels drop below 80%, the brain, liver, and other vital body organs get affected. (https://www.medanta.org/)Review of the facility policy titled, Transportation, dated, 1/29/25, read, in part .Resident scheduled for transportation will need to be ready at the time indicated in the transportation scheduled with.any assistive devices needed.

Review of the facility policy titled, Oxygen Therapy, dated, 2/2/23, read, in part: .Nasal cannula is to be used when low to medium concentration of oxygen is required and accuracy is not essential. Do not use for flow rates in excess of six (6) liters. when flow rate in excess of six (6) liters is ordered, use the simple face mask.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Traverse City, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Grand Traverse Pavilions or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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