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87/100Munson Healthcare Otsego Memorial Hospital LTCU Inspection Report, Violations & Safety Grade (Gaylord, Michigan)
825 North Center Street, Gaylord, Michigan 49735
Phone: 9897312131
CMS Overall:4/5
Overview & Bed Count
Certified Beds
34
Avg Residents/Day
31.3
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Otsego
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing5/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Michigan Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.84 | 0.78 | +1.06 |
| Total Nurse Hours per Resident per Day | 4.56 | 4.03 | +0.53 |
| CMS Staffing Rating | 5/5 | 3.6/5 | - |
| Nursing Staff Turnover | 34.3% | 44.6% | - |
Health Citation History
15 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-01 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-04-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2026-04-01 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-04-01 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2026-04-01 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-04-01 | Administration Deficiencies | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D – Moderate Harm Potential |
| 2025-02-13 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2025-02-13 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2025-02-13 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2025-02-13 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2024-03-27 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | F – Moderate Harm Potential |
| 2024-03-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-03-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-03-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-03-27 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
Fire Safety Citation History
10 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-01 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | F – Moderate Harm Potential |
| 2026-04-01 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2026-04-01 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-04-01 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2026-04-01 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2024-03-27 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2024-03-27 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2024-03-27 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | E – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-03-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Gaylord area at no cost.
Find Safe, Vetted Facilities Near Gaylord
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.