Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maples Benzie County Medical Care during CMS and state inspections, most recent first.
Three residents experienced falls resulting in serious injuries due to the facility's failure to identify and mitigate environmental hazards, ensure proper use of assistive devices, and implement care planned interventions. Incidents included a resident sustaining multiple leg fractures after slipping on a wet floor post-shower without safety equipment, another falling during a transfer due to an unlocked shower chair and lack of gait belt, and a third suffering fractures after a bed alarm was not activated as required by the care plan.
The facility failed to adhere to food safety standards, risking foodborne illness for 77 residents. A pureed salad was improperly stored at 48 F, above the safe holding temperature, and the thermometer used was not sanitized. Additionally, improper sanitization practices were observed with wiping cloths, as staff were not correctly trained to measure sanitizing solution concentration, leading to potential contamination.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to update and document care plan interventions. Despite having a tab alarm, the resident's care plan lacked additional interventions after falls, and there was no routine check for the alarm's placement and operation. Staff interviews revealed uncertainty about intervention implementation, and facility policies on fall risk assessment were not followed.
The facility failed to ensure sanitary storage of respiratory equipment for two residents, leading to a deficiency in care. A resident with COPD and Parkinson's had a nebulizer with condensation stored improperly, while another with hypoxemia and CHF had oxygen tubing not stored in a protective bag. Staff interviews confirmed non-compliance with facility policies on equipment storage.
A resident with dementia and a progressive tremor was not provided with adaptive dining equipment as prescribed, leading to difficulties in self-feeding. Observations showed the resident using standard cutlery, resulting in food spillage and frustration. Staff interviews confirmed the oversight, with adaptive utensils found unused in a kitchen drawer, contrary to the resident's care plan and facility policy.
A facility failed to maintain infection control during a dressing change for a resident with a stage II pressure injury. An LPN did not perform hand hygiene after removing gloves and before applying new ones, contrary to the facility's policy. The LPN was unaware of the requirement, and both the Clinical Care Coordinator and Nursing Home Administrator acknowledged the deficiency.
Failure to Prevent Accidents Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
The facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions, resulting in falls and injuries for three residents. One resident with moderate cognitive impairment and a history of independent ambulation sustained multiple lower leg fractures requiring surgical intervention after slipping on a wet floor while exiting the bathroom post-shower. The resident was barefoot, without a gait belt or non-skid footwear, and the CNA assisting her did not attempt to use a shower chair or other safety devices, assuming the resident would refuse them based on prior behavior. The incident occurred as the resident lost her balance on the floor transition, which was wet from the shower, and fell backward, resulting in an open fracture confirmed by emergency services. Another resident with severe cognitive impairment and mobility issues fell in the shower while being assisted by a CNA. The resident attempted to transfer from a wheelchair to a shower chair, but the shower chair was not properly locked, the floor was wet, and the resident was barefoot without a gait belt. The CNA admitted to forgetting to lock the wheels and not placing a towel on the ground, and the water was running at the time of the fall, making the floor slippery. The care plan for this resident required contact guard assistance with a gait belt and walker for transfers, but these interventions were not implemented at the time of the incident. A third resident with Alzheimer's disease and a history of repeated falls was found on the floor with a right femur fracture and lumbar compression fracture. The care plan included the use of a bed alarm to alert staff when the resident was getting out of bed, but the alarm was not turned on at the time of the fall. Staff interviews confirmed that the bed alarm was in place but not activated, likely due to oversight by the night shift CNA. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices, but these measures were not consistently implemented, leading to actual harm.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 77 residents. During an observation in the Oak dining room, a stainless steel pan containing pureed salad was found to have a temperature of 48 F, above the maximum holding temperature of 41 F. The Food Service Worker (FSW) I initially reported a temperature of 39 F after improperly measuring it by placing the thermometer probe at the bottom of the pan. Upon correction, the temperature was confirmed to be 48 F. FSW I admitted to not sanitizing the thermometer probe before use and was unaware of the correct method for measuring food temperature. No corrective action was taken to address the food's temperature. Further observations in the Pine unit revealed improper sanitization practices. Wiping cloths were stored in a red bucket near the food preparation area, and FSW J demonstrated incorrect use of QT 40 test strips to measure the concentration of quaternary ammonium in the sanitizing solution. FSW J was not instructed to hold the strip still in the solution for the required ten seconds, leading to an inaccurate reading of more than 400 PPM. This indicates a lack of proper training and adherence to the FDA Food Code, which requires equipment food-contact surfaces and utensils to be cleaned whenever contamination may have occurred.
Failure to Implement Revised Fall Interventions
Penalty
Summary
The facility failed to implement revised care plan interventions for a resident who experienced multiple falls. The resident, identified as having severe cognitive impairment due to conditions such as cerebral infarction, aphasia, and dementia, was observed with a tab alarm device intended to alert caregivers if the resident attempted to rise without assistance. Despite this, the resident experienced several falls, including an unwitnessed fall from a wheelchair resulting in facial trauma and a witnessed fall in the TV room while reaching for items. The resident's care plan, initially created in May, did not include additional interventions following falls in June, September, and October. The care plan lacked documentation of post-fall evaluations and fall risk assessments for incidents in June and September. Furthermore, there was no documentation on the Kardex or care plan to routinely check the placement and operation of the resident's tab alarm, which was a critical intervention for fall prevention. Interviews with facility staff, including a CNA and the DON, revealed uncertainty about when the tab alarm was added as an intervention and highlighted a lack of documentation and communication regarding the resident's fall interventions. The facility's policies on fall risk assessment and post-fall assessment were not adhered to, as evidenced by the absence of updated care plan interventions and the lack of a documented post-fall checklist. This deficiency in implementing and documenting fall prevention measures resulted in the potential for additional falls and subsequent injury to the resident.
Deficiency in Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of respiratory equipment for two residents, leading to a deficiency in respiratory care services. Resident #20, who has chronic obstructive pulmonary disease (COPD) and Parkinson's Disease, was observed with an assembled nebulizer stored on top of a dresser with condensation in the nebulizer cup over multiple days. This indicates that the nebulizer equipment was not properly cleaned and stored according to facility protocols, which require rinsing and drying the equipment before storing it in a designated case or bag. Resident #19, diagnosed with hypoxemia and congestive heart failure, was observed with oxygen tubing hanging on the back of their wheelchair and resting on their bed without a protective storage bag. Interviews with facility staff, including an LPN and a Clinical Care Coordinator, confirmed that the respiratory equipment was not stored according to the facility's policies, which require oxygen tubing and nasal cannulas to be stored in a bag when not in use. The staff acknowledged the need for additional education to meet these storage expectations.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment for a resident with a progressive tremor, resulting in increased difficulty with independent eating. The resident, who has dementia, muscle weakness, and activity limitations, was observed using standard stainless-steel cutlery instead of the prescribed built-up and curved utensils. This led to difficulties in self-feeding, as evidenced by food spilling onto the resident's chest and the resident resorting to eating with their hands due to frustration. Interviews with staff revealed a lack of adherence to the resident's plan of care, which specified the use of adaptive utensils. A Certified Nursing Assistant confirmed that the resident was supposed to receive adaptive utensils with every meal but was unsure if they were provided during breakfast. Another staff member retrieved the adaptive utensils from a kitchen drawer, indicating they were not placed on the resident's meal tray. The Director of Nursing verified that residents should receive adaptive equipment as per their care plan, aligning with the facility's policy on adaptive eating devices.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with an in-house acquired stage II pressure injury. During an observation, an LPN did not perform hand hygiene after removing gloves following the removal of an old dressing and before applying new gloves to cleanse and apply a new dressing. The LPN acknowledged the oversight and indicated a lack of awareness regarding the necessity of hand hygiene between these steps. The facility's hand hygiene policy, reviewed in the presence of the Nursing Home Administrator, clearly states that hand hygiene should be performed before and after handling clean or soiled dressings and after removing gloves. The policy emphasizes that the use of gloves does not replace the need for hand hygiene. The Clinical Care Coordinator and the Nursing Home Administrator both acknowledged the deficiency in hand hygiene practices as per the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paul Oliver Memorial Hospital Ltcu | 2.1 mi | — | 0 | 0 |
| Maple Valley Nursing Home | 21.3 mi | — | 0 | 0 |
| Manistee County Medical Care Facility | 26.7 mi | — | 11 | 0 |
| Grand Traverse Pavilions | 28.8 mi | — | 6 | 0 |
| The Villa At Traverse Point | 28.9 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.