TENDERCARE TRAVERSE CITY

Nursing Home Inspector

2585 S LAFRANIER RD
TRAVERSE CITY, MI 49686
Grand Traverse County
Phone: 231-947-9511
Provider Number: 235336
Last Inspection: 12/07/2016

About the Nursing Home

Number of Beds: 84
Number of Residents: 61
Beds Available: 23
Percent Occupancy: 73%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

32

Facility
27

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

32

2016
13

2015
7

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 1/6/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 1/6/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/6/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 1/6/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/6/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 1/6/2017
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Isolated : Minimal 3 1/6/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 1/6/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 1/6/2017
 

12/2/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 1/5/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/5/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 1/5/2016
 

1/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/16/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 2/16/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/13/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/23/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 10/23/2017
 
Failed To: Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Isolated : Minimal 3 10/23/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/23/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/23/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/23/2017
 

5/31/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/23/2017
 

4/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 5/9/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 5/9/2017
 

1/18/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 2/10/2017
 

8/18/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 9/9/2016
 

5/21/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 6/16/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/16/2015
 

2/26/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 3/20/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 61 104.25 85.64
Registered Nurses 1.22 1.13 0.89
Licensed Practical / Vocational Nurses 0.36 0.60 0.84
Certified Nursing Assistants 2.49 2.75 2.54
Total Staff Hours 4.07 4.48 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 2 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 69 91 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 85 95 92
of long-stay residents experiencing one or more falls with major injury 1 4 3
of long-stay residents who have depressive symptoms 5 4 2
of long-stay residents who lose too much weight 9 6 7
of long-stay residents who received an antianxiety or hypnotic medication 11 13 22
of long-stay residents who received an antipsychotic medication 17 16 12
of long-stay residents who self-report moderate to severe pain 13 8 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 16 18 17
of long-stay residents whose need for help with daily activities has increased 18 14 14
of long-stay residents with a catheter inserted and left in their bladder 3 2 2
of long-stay residents with a urinary tract infection 3 2 3
of low risk long-stay residents who lose control of their bowels or bladder 51 58 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 53 85 80
of short-stay residents who had an outpatient emergency department visit 8 11 11
of short-stay residents who made improvements in function 73 73 71
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 25 19 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 61 84 79
of short-stay residents who were rehospitalized after a nursing home admission 24 18 21
of short-stay residents who were successfully discharged to the community 60 61 56
of short-stay residents with pressure ulcers that are new or worsened 1 1 0