Citations in Michigan
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Michigan.
Statistics for Michigan (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Michigan
Surveyors found that food service equipment and kitchen areas were not effectively cleaned or maintained, with persistent ice buildup, soiled sinks and vents, lime scale, food debris, and grease accumulation observed during multiple inspections. These unsanitary conditions affected 99 residents.
The facility did not follow its own abuse and neglect policies for two residents who reported rough or rude treatment by staff and a roommate. In both cases, the administrator did not conduct a thorough investigation or report the allegations to the state agency, and documentation was incomplete, failing to meet the facility's written protocols.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
The facility did not report allegations of abuse involving two residents to the State Agency, despite being aware of incidents such as verbal altercations, staff rudeness, and rough handling during care. The administrator determined these incidents were not reportable and only minimal internal documentation and follow-up were completed, with no thorough investigation or external reporting.
An LPN prepared a resident's medication in advance, placed it in a labeled cup, and stored it in an unlocked medication cart after the resident declined to take it immediately. The LPN then left the cart unattended and unlocked while assisting another resident, contrary to professional standards requiring medication carts to be locked and medications not to be pre-poured and stored for later use.
Two residents reported incidents involving staff rudeness, rough handling, and verbal altercations, but the facility failed to conduct thorough investigations or maintain adequate documentation. The administrator determined these incidents did not meet abuse criteria and did not report them, resulting in insufficient follow-up and lack of comprehensive inquiry.
An LPN documented the administration of medications for a resident with multiple health conditions before the medications were actually given. The resident initially declined the medications, which were then labeled and stored in the medication cart. The LPN left the cart unlocked and unattended while preparing another resident's medication, and later administered the medications to the resident. The MAR showed the medications as given before actual administration, contrary to facility policy and professional standards.
A resident with neuropathy and other chronic conditions experienced unnecessary pain when staff failed to continue administering Neurontin as ordered by the provider. The medication, which had been effective in managing the resident's pain, was stopped without family notification, and there was a delay of several days before the provider's order to resume the medication was implemented.
The facility did not ensure proper disposal of garbage, medical supplies, and yard debris, resulting in an open dumpster with exposed waste, litter, and flies in the surrounding area. Interviews revealed unclear staff responsibility for cleaning the area and the absence of a facility policy for dumpster cleanliness, despite expectations for the area to be kept clean.
A resident with significant physical limitations and upper extremity contractures was unable to access a specialty call light, which was not within effective reach, resulting in unmet care needs. The LPN assigned to the resident was initially unaware of how the call light should be used and only corrected its placement after being prompted. The facility's policy required call lights to be within reach, but this was not followed.
Failure to Maintain Clean and Sanitary Food Service Equipment and Environment
Penalty
Summary
Surveyors observed multiple failures in the facility's food service area regarding the cleaning and maintenance of equipment and surfaces. During initial and follow-up tours, the main freezer was found to have ice accumulation on the floor, and the walk-in cooler had food debris on the floor. The dishwasher exhibited lime scale and red deposits both inside and outside, with the surrounding floor also visibly soiled. Several hand sinks and faucets throughout the kitchen were stained and covered with lime deposits, and the toaster on the tray line had visible breadcrumbs on all sides. Oven racks were soiled with layers of burnt residue, and old grease and dust were present on top of the oven. Dust and cobwebs were noted on the sprinkler system above the stove, and the vent hood above the stove was covered with old grease. Additionally, five air vents in the kitchen ceiling and the surrounding ceiling tiles were observed to be soiled. These deficiencies were present during both the initial and follow-up inspections, indicating a lack of effective cleaning and maintenance practices. The issues affected the food service environment for 99 residents, as the unsanitary conditions persisted over multiple days and were not addressed between surveyor visits.
Failure to Implement Abuse and Neglect Policies and Procedures
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect prevention for two residents. One resident reported waiting two hours for assistance, after which a staff member entered her room, acted disgusted, and provided care in a rough manner, causing the resident pain and distress. Documentation showed that the incident was not thoroughly investigated, as required by facility policy. There was no evidence of interviews with the resident or staff, nor was the incident reported to the state agency, despite the policy stating that any suspicion or allegation of abuse warrants immediate investigation and reporting. Another resident, with moderate cognitive impairment and multiple medical diagnoses, reported that a staff member was rude to her and also described a verbal altercation with a roommate that made her feel unsafe. The facility's documentation of these incidents was minimal, with only brief notes indicating that the resident was moved or that the staff member received verbal education. There was no evidence of a comprehensive investigation, interviews with involved parties, or reporting to the state agency as outlined in the facility's abuse and neglect protocol. In both cases, the administrator determined that the incidents did not meet the criteria for abuse and therefore did not initiate a full investigation or report the allegations. The facility's actions did not align with its own policies, which require thorough investigation and timely reporting of all allegations or suspicions of abuse, neglect, or exploitation. The lack of proper documentation and follow-up demonstrates a failure to protect residents and ensure compliance with regulatory requirements.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, despite being aware of the incidents. One resident, who had Huntington’s Disease and moderate cognitive impairment, reported that a staff member was rude to her and also described a verbal altercation with a roommate, expressing that she did not feel safe. These concerns were documented in facility grievance forms, and immediate actions such as moving the roommate were taken. However, the Nursing Home Administrator, who served as the abuse coordinator, determined that these incidents did not meet the criteria for abuse and did not report them to the state. Documentation provided for these events was minimal, with no thorough investigation records available beyond brief notes indicating the incidents were considered non-reportable and that no harm or distress was observed. Another resident reported waiting two hours for assistance and described being handled roughly by a staff member, which caused her pain. This concern was documented in a grievance form and a non-reportable allegation form, with a nursing assessment performed that found no new information or injury. The administrator and DON interviewed the resident, who stated she was in pain but could not identify the staff member involved. The administrator concluded that the incident was related to the resident’s underlying pain rather than staff mistreatment, and therefore did not report the allegation to the state agency. In both cases, the facility’s actions were limited to internal documentation and brief follow-up, without conducting or documenting thorough investigations or reporting the allegations to the appropriate authorities as required. The decision not to report was based on the administrator’s judgment that the incidents did not meet the threshold for abuse, despite the residents’ statements and the facility’s own documentation of their concerns.
Medication Security and Storage Deficiency
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) prepared a resident's medication by placing multiple prescribed drugs into a medication cup and labeling it with the resident's name. The LPN placed the cup in the top drawer of the medication cart after the resident declined to take the medication immediately, stating she wanted to use the bathroom first. The LPN then left the medication cart unlocked and unattended while preparing and administering medication to another resident. The cart remained unlocked and unattended for several minutes before the LPN returned and locked it. The resident involved had a complex medical history, including aortic valve stenosis, muscle weakness, dysphagia, congestive heart failure, diabetes, and other chronic conditions. The Director of Nursing (DON) confirmed that professional practice requires medication carts to be locked when not in use or not under direct supervision by a licensed nurse, and that medications should not be pre-poured and stored in the cart for later administration. The observed actions did not comply with professional standards for medication security and storage.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of four reviewed. One resident with Huntington’s Disease and moderate cognitive impairment reported that a staff member was rude to her, and also reported a verbal altercation with a roommate that made her feel unsafe. Documentation showed that the facility moved the roommate temporarily and provided verbal education to staff, but there was no evidence of a thorough investigation or interviews with the resident regarding the acceptability of the solutions. The facility administrator, who also served as the abuse coordinator, determined these incidents did not meet the criteria for abuse and did not report them to state agencies, nor did she maintain comprehensive investigation files beyond brief notes indicating no harm or distress. Another resident reported waiting two hours for assistance, after which a staff member allegedly acted disgusted, turned her roughly, and told her to stop yelling despite her pain. The concern was documented, and a nursing assessment was performed, but there was no documentation of a thorough investigation, interviews with the resident about the acceptability of the solution, or interviews with other staff or residents. The administrator concluded the incident was related to the resident’s pain and did not identify it as an abuse allegation, documenting only a brief summary on a non-reportable allegation form. In both cases, the facility did not conduct comprehensive investigations into the allegations of abuse or mistreatment, did not interview all relevant parties, and did not maintain adequate documentation of their investigative process. The administrator relied on her own judgment to determine that the incidents did not constitute abuse, resulting in a lack of proper reporting and investigation as required.
Failure to Follow Professional Standards for Medication Documentation
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow professional standards for medication documentation for a resident with multiple complex medical conditions, including aortic valve stenosis, congestive heart failure, diabetes, and vascular dementia. During a medication pass, the LPN prepared the resident's medications and documented their administration in the Medication Administration Record (MAR) before the resident actually received them. The resident initially refused to take the medications until after using the bathroom, prompting the LPN to label the medication cup and store it in the medication cart. The LPN then left the medication cart unlocked and unattended while preparing another resident's medication, only returning to lock it a few minutes later. The resident eventually took the medication after notifying the LPN that she was ready. However, the MAR reflected that the medications had been administered at an earlier time, prior to actual administration. Facility policy and the Director of Nursing's expectations require that medication administration be documented only after the medication has been given to the resident. The LPN's actions did not align with these standards, resulting in inaccurate documentation of medication administration.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to follow provider orders for a resident with multiple diagnoses, including congestive heart failure, COPD, muscle weakness, and neuropathy. The resident had impaired mobility and was dependent on staff for most activities of daily living. The resident had been prescribed Neurontin 100 mg capsules for neuropathy pain, which was reported by the family to be effective in managing the resident's burning and pain. However, the medication was stopped without discussion with the family, and the resident's pain returned. The family brought the issue to the attention of staff after noticing the resident's increased pain. Review of the medication administration records and interviews revealed that the provider had ordered Neurontin 100 mg three times daily after a two-week evaluation period, and this order was documented as received by the facility. Despite this, the medication was not administered from the date the order was received until several days later. Staff were unable to explain how the order was missed during this period, resulting in the resident experiencing unnecessary pain due to the lapse in medication administration.
Failure to Maintain Cleanliness and Proper Waste Disposal in Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage, medical supplies, and yard debris, resulting in unsanitary conditions in the dumpster and surrounding area. Observations revealed an open dumpster lid exposing boxes, loose paper, and tree branches, as well as a wheelbarrow filled with additional debris. The area around the dumpster and compressor was littered with leaves, paper, Styrofoam cups, plastic water bottles, medical gloves, yellow face masks, broken tree branches, cigarette butts, and flies swarming the dumpsters. No staff were present in the area during the observations. Interviews with facility staff indicated a lack of clear responsibility for maintaining cleanliness in the dumpster area. The Director of Maintenance stated that the staff member previously assigned to clean the area had been terminated, and that he was now responsible for cleaning it. The Nursing Home Administrator confirmed that the expectation was for the area to be kept clean but acknowledged that there was no facility policy addressing dumpster or compressor area cleanliness. The Director of Maintenance's job description included responsibility for groundskeeping and overall facility appearance.
Failure to Ensure Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, upper extremity contractures, and impaired mobility, was found unable to access their specialty call light. The call light, designed to be activated using the resident's shoulder or the back of the head due to their inability to use their hands, was observed pinned to the bed covers on the right side of the bed, out of effective reach. The resident reported attempting to get staff attention for approximately half an hour without success, resulting in unmet care needs such as oral care and assistance with getting out of bed. During the observation, the resident demonstrated that the call light could only be activated with the back of the head, and its placement did not allow for this use. Further interviews revealed that the assigned LPN was initially unaware of how the resident could use the call light and only realized after re-entering the room that it was a motion-activated device. The LPN repositioned the call light under the resident's head, confirming that the previous placement was not accessible. The resident's care plan documented extensive assistance needs and encouraged participation in ADLs, but the failure to ensure the call light was within reach directly impacted the resident's ability to request assistance. The facility's policy required call lights to be within reach of residents, but this was not followed in this instance.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Revised Safe Water Temperatures policy to align with regulatory standards (J - F0689 - MI)
- Educated all staff on Safe Water Temperatures policy, removing untrained personnel from the schedule (J - F0689 - MI)
- Implemented ongoing audits of resident-area water temperatures (daily for seven days, then twice weekly) with QAPI Committee oversight (J - F0689 - MI)
- Verified proper transmission of exit-door alarm notifications to staff pagers and facility monitors (J - F0689 - MI)
- Provided refresher training to clinical staff on locating care-plan details in EMR devices and keeping devices on their person (G - F0689 - MI)
- Established weekly audits of five care plans, five transfers, and staff device usage to ensure transfer practices match care-plan directives (G - F0689 - MI)
Unsafe Hot Water Temperatures, Inadequate Fall Response, and Unsupervised Tobacco Use
Penalty
Summary
The facility failed to ensure that hot water temperatures in resident care areas were maintained within the safe and comfortable range of 100-120 degrees Fahrenheit. Multiple observations revealed that water temperatures in several resident rooms, including those occupied by individuals with severe and moderate cognitive impairment, were significantly above the recommended maximum, with some readings as high as 152.6 degrees Fahrenheit. The facility's maintenance logs did not reflect these excessive temperatures, and there were missing documentation sheets for the required monitoring period. Staff interviews indicated inconsistent practices in temperature monitoring and a lack of immediate recognition or reporting of hazardous water temperatures. Additionally, the facility did not adequately investigate or implement interventions following multiple falls experienced by a resident with severe cognitive impairment and a history of wandering and difficulty walking. Despite several documented falls, including one resulting in a head laceration and hospitalization, the care plan was not updated with new interventions, and incident reports or investigations were not consistently completed. Observations further showed that safety measures, such as ensuring the resident's walker and call light were within reach, were not reliably maintained. The facility also failed to prevent potential accidents by allowing a visually impaired resident unsupervised access to chewing tobacco and a spit cup in his room. Staff were aware of the resident's use of chewing tobacco, but there was no specific policy addressing its use, and the tobacco was left accessible at the bedside. Interviews with staff and family confirmed that the resident had been using chewing tobacco in his room for an extended period, and the facility's smoking policy did not address smokeless tobacco products or their safe storage and supervision.
Removal Plan
- Community residents are assessed by the Director of Nursing and designees to ensure no negative effects related to water temperatures. Resident showers are taken offline to ensure safety of water temperatures, including bed baths.
- The water temperature is adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conduct a community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance.
- The Administrator reviews the policy and procedure related to Safe Water Temperatures with changes completed as necessary. Community staff are educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule.
- The Maintenance Director or designee conducts an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits are brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process are determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, behavioral disturbances, and frequent exit-seeking behaviors successfully eloped from the facility. The resident had a documented risk of elopement, as evidenced by a recent assessment and multiple progress notes indicating repeated attempts to leave the facility, including a prior successful exit. The care plan included the use of a Wanderguard device, but the resident refused to wear it on her wrist, so it was attached to her walker, which she rarely used. On the day of the incident, the resident exited through a delayed egress door that alarmed, but staff did not immediately respond to the alarm or recognize the resident's absence until several minutes later. Staff interviews and record reviews revealed that the alarm on the exit door was heard by a CNA, who checked the area briefly but did not conduct a thorough search before resetting the alarm, assuming the resident was elsewhere in the building. Other staff members began searching rooms only after realizing the resident was missing, and the charge nurse was unfamiliar with the elopement protocol, leading to delays in initiating a missing person alert. The resident was ultimately found outside the facility by emergency personnel after being unsupervised for approximately 19 minutes near a busy street and ambulance garage. Further review showed that staff had not received adequate education or debriefing following the elopement, and there was a lack of consistent implementation of interventions for the resident's exit-seeking behaviors. The resident's room was located near an exit that was not easily visible from the nurses' station, and staff responses to alarms were inconsistent, with some assuming others would respond. The facility's policy required specific precautions for residents at risk of elopement, but these were not effectively implemented in this case.
Removal Plan
- All staff will be educated that they acknowledge and understand that in the event they hear an exit door alarming, they observe the alarm on the facility monitors or a page is obtained stating that an exit door has been opened or is alarming they will respond to investigate.
- If staff are caring for a resident when this alert is obtained, they will ensure their resident is safe and then respond.
- Staff that have not signed stating understanding will not be permitted to work until education has been obtained.
- Any staff who are found not to be compliant will be reeducated.
- Door alarms were set off and notifications were verified to be sent to staff pagers and facility monitors.
- Resident #1 will be moved to the locked unit in LTC once appropriate notifications have been made due to her noncompliance to wear a wanderguard and her risk of elopement.
- Until this move occurs Resident #1 will be placed on 1:1 monitoring when out of her room.
- All residents who score a 1.0 or higher on the elopement assessment have been reassessed to ensure proper interventions are in place.
- Any resident in the facility that is deemed to be an elopement risk a wanderguard will be placed and care planned for that resident.
- Any resident that is refusing to wear a wanderguard will be moved to the locked unit in long term care for increased supervision and safety.
- If a bed is not available in the locked unit, the resident will be placed on 1:1 supervision until an appropriate room is available.
Failure to Follow Transfer Protocols Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.
Plan Of Correction
1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.
Deficient Fire Safety Training and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.
Plan Of Correction
Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.
Missing Circuit Breaker Locking Device for Fire Alarm Booster Module
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation in the Mechanical Room (Memory Care), it was found that the required circuit breaker locking device was not provided in the circuit breaker panel for the installed fire alarm booster module. This omission was confirmed through an interview with the facility Maintenance Director at the time of observation. The lack of the locking device could potentially allow for unauthorized tampering with the fire alarm system, and this deficiency could affect all 64 residents in the facility.
Plan Of Correction
ELEMENT 1 The circuit breaker locking device has been placed on in the circuit breaker panel in the Mechanical room on Orchard View. ELEMENT 2 The Maintenance Director and/or designee did an audit on all circuit breaker panels in the facility to ensure there is a locking device present. Any areas of noncompliance were addressed immediately. ELEMENT 3 The Maintenance Director has been reeducated to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 2 months to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
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