Grand Traverse Pavilions

through support of resident choice.

facility failed to follow resident choices for one Resident (#7) of three residents reviewed.

This

(R7)Review of R7's Electronic Medical Records (EMR) revealed admission to the facility on 2/17/26 with diagnosis including aftercare following joint replacement surgery. R7 was noted self-responsible for his medical and financial decisions.An interview was conducted with R7 on 2/23/26 at 11:01 a.m.

R7 stated that he has been feeling very frustrated since his admission, I wake up between 6:00 a.m. and 7:00 a.m. I put on my call light to get dressed and ready for the day.

Over the weekend, they did not get me up and dressed until 9:00-9:30 a.m.

The staff came in and told me I had to wait because they don't get people up that early, or I wasn't a priority for them to get up. I even missed my shower today because of waiting.

Also, I had an accident over the weekend and soiled myself because of staff not getting me up. It was embarrassing. R7 confirmed with this surveyor, he had discussed with staff what time he would like to get up in the morning, They don't listen and they refuse to get me up.A review of R7's Bowel and Bladder record showed R7 was noted to be incontinent of bowel and bladder on 2/22/26. A follow-up interview was conducted with R7 on 2/24/26 at 9:00 a.m. R7 was noted to be sitting in his recliner chair, visibly upset. R7 stated, I woke up again around 6:30 a.m., and they refused to get me up. I didn't receive any help until 7:45 a.m.

Then by the time they got me ready my breakfast was here, but they sent me down to get weighed so when I came back it was already cold. I don't understand why they won't help me.

Why won't they listen?An interview was conducted with the Director of Nursing (DON) on 2/24/26 at 11:15 a.m.

The DON stated the admitting nurse is responsible to interview residents for their preferences on what time to get up, and those preferences would be listed on the residents Kardex sheets. A request was made for R7's Kardex.An interview was conducted with Registered Nurse (RN)/Education Director G on 2/24/26 at 11:35 a.m. RN G stated all staff are educated on resident rights and choices, with the Social Services Directors and Assistant Director of Nursing on each unit responsible for noting residents' personal preferences.Review of R7's Kardex dated 2/24/26 read, in part, Dressing: The resident is totally dependent on (2) staff for dressing.

Further review of R7's Kardex did not indicate his preferences regarding what time he would like to get up in the morning.

235088 02/24/2026

Grand Traverse Pavilions 1000 Pavilions Circle Traverse City, MI 49684

Post-Traumatic Stress Disorder (PTSD) (a mental health condition that develops after experiencing or

score of 5/15, indicating severe cognitive impairment.The EMR indicated R1 had a fall in her room on

from Certified Nursing Assistant (CNA) C stated 1:1 w/(with) res (resident) (sic) in.

Resident went to grab phone and slipped of bed.

Resident proceeded to climb back in bed.An incident report on 2/4/26 12:22 AM stated in part This nurse was notified by CNA that resident had a fall.

Upon arriving to the room, resident was already in bed.

Head involvement. No pain or injury reported or observed upon assessment.

Initial VS obtained, neuros intact.

Resident remained in bed after assessment to rest.

Resident Description: I was reaching for my phone and slipped off the bed, but I am good.On 2/24/26 at 9:14 AM, R1 was observed laying across her bed with legs hanging off, head against the wall, making resident half on half off her bed.

Tray table to right about 12 inches away from the bed, no phone noted on tray table.On 2/24/26 at 9:31 AM a phone interview was conducted with CNA C, who stated R1 had sat up in bed, stated she was looking for her water, then the remote, and then turned and reached for her phone when R1 started to slide out of bed.R1's care plan was reviewed and revealed a focus was initiated on 10/24/23 R1 is at HIGH risk for falls related to confusion, gait and balance problems.

Interventions on 4/28/25 Keep my frequently used items within my reach and on 2/9/26 I require 1:1 supervision due to poor safety awareness were initiated. R1 did not have frequently used items within reach.Resident #5 (R5)A review of the EMR for R5 indicated admission to the facility on 2/17/26, with diagnosis including secondary malignant neoplasm of other specified sites (cancer that has spread), squamous cell carcinoma of skin, scalp and neck (cancer arising from flat cells in a layer of skin), Diabetes Mellitus Type II (body develops insulin resistance and cannot use insulin efficiently, leading to high blood sugar levels), chronic kidney disease stage 4 (kidneys are significantly damaged, functioning at 15-29% of capacity), benign prostatic hyperplasia (enlarged prostate gland), and essential tremor(neurological disorder causing involuntary, rhythmic shaking, in the hands, head, or voice during movement). R5 was responsible for his own medical and financial decisions.On 2/17/26 at 3:00 PM, a fall risk evaluation indicated R5 was . alert oriented x 3.requires use of assistive devices (i.e. cane, wheelchair, walker, furniture).

Gait / balance: Gait / balance Normal.Fall Risk Score: 13.0 Indicating R5 as a moderate risk for falls.On 2/17/26 at 3:02 PM, a clinical admission indicated . ?Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking.

Level of cognitive impairment: Alert (some forgetfulness).On 2/18/26 at 1:47 PM a therapy note indicated R5 is Assist of 1 to walk with walker.The fall report was completed on 2/21/26 at 7:34 PM, .

Nursing Description: The CNA reported to RN that upon entering the room to do vitals, the patient was observed on the floor next to his bed.

Neuro assessment completed.

Patient denies hitting his head.Patient is noted to have a small skin tear on his right lateral knee area with scant amount of blood.

Patient Description: Patient stated he was trying to get up to go to the bathroom.Other Info: Patient requires assistance with ambulation.

Patient does at times ambulate with walker without assistance, but this time walker was left in the bathroom, and he wasn't able to get to it so he attempted to ambulate without it.On 2/21/26 at 8:07 PM an incident report documented a statement which read as follows: Patient fell, no head involvement.

Alert with clear speech.

Able to move all 4 extremities, Vitals are stable.A review of R5's care plan indicated a focus was initiated on 2/17/25 stating the resident is at high risk for falls r/t poor safety awareness, with interventions including ensure all necessities are within reach of the patient, encourage proper ambulatory assist device if applicable. R5 did not have his walker, a necessity within reach.The facility's policy titled Fall and Injury Reduction Policy dated 7/8/24, stated its purpose was To prevent or minimize resident falls and injury, while promoting the highest level of resident independence possible.

Federal health inspectors cited Grand Traverse Pavilions in Traverse City, MI for a deficiency under regulatory tag F-F0806 during a complaint investigation conducted on 2026-02-24.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of Grand Traverse Pavilions.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-23.