Citations in Michigan
Statistics, citations 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
An RN failed to complete ordered treatments for seven residents and documented some as done when they were not. The concerns were identified after staff observed the RN inattentive at the nurses station and on a personal cellphone, and camera review showed she spent much of the shift seated and did not enter every room for residents with treatment orders. Affected residents included people with intact and moderately impaired cognition, and the missed care involved dressings, topical creams and powders, wound care, and incision-site cleansing.
Inaccurate documentation of resident treatments: an RN was observed spending much of her shift at the nurses station and on her personal cellphone while charting treatments as completed that had not been done. Two residents initially reported missed treatments, and further review identified five additional residents whose ordered wound and skin treatments were also not completed despite being documented in the EMR as done. The DON confirmed the inaccurate charting and that the facility expects real-time, accurate documentation.
A resident with dementia and impaired cognition left the facility unsupervised after being seen near the exit door, with no staff nearby. Staff searched for the resident, who was later found by a neighbor and returned via EMS. After the resident reported a fall, staff noted a bruised arm and a knot above the eye, and the resident was sent to the hospital with a hematoma to the R forearm.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
Failure to notify the physician and/or pharmacy when meds were unavailable led to missed doses for four residents. A resident with depression, a resident with DM/HTN/HLD, a resident with anemia, and a resident with fibromyalgia, hypothyroidism, DM, depression, and OA all had ordered meds not given because they were not available, on order, or pending pharmacy delivery. The MAR/EMR showed missed doses, but progress notes did not document physician/healthcare provider notification in several cases, and the facility could not provide additional proof of the required notifications.
Failure to Monitor Nebulizer Treatment and Maintain Continuous Oxygen Support A resident with COPD, acute/chronic resp failure, and orders for continuous O2/BiPAP support received a nebulizer tx that the RN started but did not stay to complete. The RN did not verify that O2 and BiPAP were reapplied after the tx, while the CNA stated it was not the CNA’s job to stop the nebulizer or place the BiPAP back on. The resident was later found unresponsive, and records showed missing O2 sat and VS documentation, with the BiPAP device off for a period overnight.
Missed and falsely charted resident treatments
Penalty
Summary
The facility failed to complete ordered treatments for seven residents while they were under the care of an RN. The deficiency was identified after a Facility Reported Incident investigation found that RN F had been inattentive to assigned resident needs, spent prolonged periods at the nurses station and on a personal cellphone, and documented treatments as completed when they had not been done. CNA D and RN E reported concerns to the on-call manager after observing that a dressing had not been completed for one resident despite charting indicating it was done. During interviews and assessments, two residents assigned to RN F reported missed treatments. One resident stated that treatment to neck folds, chin, shoulder, and chest had not been completed, and the wicking sheets placed in those areas were observed to have an odor and did not appear recently changed. Another resident reported not receiving creams for the back or antifungal powder under the breasts, although the treatments had been charted as completed. The facility later reviewed camera footage from RN F's shift and determined she spent about half of the time seated at the nurses station, with the remainder spent sitting or using her personal cellphone, and that she did not enter every room for residents who had ordered treatments. The facility's investigation ultimately identified five additional residents who did not receive ordered treatments during RN F's shift. These included missed topical powder and wound care for one resident, missed hydrogen peroxide gel for sunburn on the forearms for another, missed cleansing and dressing care for a pinky and heel wound for another, missed cleansing of cervical incision sites and wound treatment to the right gluteal area for another, and missed treatments for a fifth resident. The affected residents included individuals with intact cognition as well as residents with moderately impaired cognition, and one resident had been admitted with a history of cervical surgeries.
Inaccurate Documentation of Resident Treatments
Penalty
Summary
The facility failed to ensure accurate medical record documentation for seven residents after RN F documented treatments as completed when they had not been performed. During an investigation initiated after staff observed RN F inattentive at the nurses station and charting a dressing as completed when it had not been done, R4 and R5 reported their ordered treatments had not been completed. RN F had documented those treatments as completed in the electronic medical record, including wicking sheets for R4 and creams and antifungal powder for R5. Further review identified five additional residents who did not receive ordered treatments during RN F's shift, although RN F documented them as completed. The residents included R7, R8, R9, R10, and R11, with missed treatments involving wound care, skin care, and cleansing of incision or wound sites. The DON confirmed that RN F had not completed treatments for R4, R5, R7, R8, R9, R10, and R11 but had documented them as completed in the EMR, and the facility policy required documentation to be concise, accurate, complete, objective, and based only on facts.
Failure to Supervise Resident Who Left Facility Unattended
Penalty
Summary
The facility failed to ensure adequate supervision for one resident with impaired cognition who left the building unsupervised and was later found after a search by staff and a neighbor. The resident had diagnoses of unspecified dementia and age-related physical debility, and the most recent MDS showed a BIMS score of 7, indicating impaired cognition. An incident report documented that another resident notified an RN that the resident had left the facility, staff searched for approximately 15 minutes, and the resident was then found by a neighbor and returned via EMS. After the resident was returned, staff documented that the resident reported falling, and an assessment found a bruised right arm with intact skin and a small knot above the right eye. The physician was contacted and the resident was sent to the hospital. A subsequent nursing progress note documented hospitalization with a hematoma to the right forearm. The resident’s care plan identified fall risk related to deconditioning, gait and balance problems, and vision/hearing problems, and a fall risk evaluation noted a history of 3 or more falls in the prior 3 months, intermittent confusion, and balance problems.
Failure to Initiate CPR and Call EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate CPR and call EMS for a resident who was found unresponsive and had Full Code status. The resident had been admitted from an acute care hospital and had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, as well as COPD. Advance directives, the order summary, and the MAR/TAR all identified the resident as Full Code, and a progress note documented that the resident wanted to remain Full Code. According to the record and staff interviews, the resident was last seen at about 4:45 AM when a breathing treatment was started. At about 5:50 AM, an RN entered the room to tell the resident the shift was ending, found no response, touched the resident, and checked for a radial pulse, which was absent. The RN then went to the hallway and alerted the incoming nurse that the resident was gone. The RN later checked the chart and confirmed Full Code status, but CPR was not started and EMS was not called. Another nurse was present and also assessed the resident, with absent apical pulse confirmed, and the resident was pronounced dead at 6:00 AM. Family members stated they were told the RN panicked and did not start CPR or call EMS. The DON confirmed that the resident was Full Code and that the RN who found the resident unresponsive did not initiate CPR or check code status right away. The facility policy stated that when a resident is found without heartbeat and respirations, the nurse on duty identifies code status and, if the resident is Full Code, CPR is started and 911 is activated.
Failure to Notify Physician and Pharmacy When Medications Were Unavailable
Penalty
Summary
The facility failed to notify the physician and/or pharmacy when prescribed medications were unavailable and residents did not receive them for 4 of 4 residents reviewed. The deficiency involved multiple missed medication administrations documented in the MARs and EMRs, with progress notes showing pharmacy notification in some cases but not showing that the physician/healthcare provider was notified when medications were not available or not administered. For one resident with depression, dysphagia, and anxiety and a BIMS score of 10, morning doses of bupropion, duloxetine, esomeprazole, and levothyroxine were not given because the medications were not available and the back-up medication machine was not working. The record showed pharmacy was notified, but it did not show that the physician/healthcare provider was notified. Another resident with diabetes, hypertension, and hyperlipidemia missed hydrochlorothiazide, Mounjaro, pantoprazole, losartan, metformin, and metoprolol because the medications were not available, and the progress notes did not show notification to the physician/healthcare provider and/or pharmacy. A third resident with anemia missed a weekly Epogen dose because it was pending pharmacy delivery, and the record did not show that the physician/healthcare provider was notified that the medication was not administered or that it was not administered after arrival. A fourth resident with fibromyalgia, hypothyroidism, diabetes, depression, and osteoarthritis missed multiple medications, including prednisolone ophthalmic, levothyroxine, paroxetine, pioglitazone, and prednisone, because they were on order or unavailable. The EMR did not show physician/healthcare provider notification for these medications, and the facility did not provide additional documentation showing that the physician/healthcare provider and/or pharmacy were notified before survey exit. The facility policy stated that if a prescribed medication is not available, staff should attempt the back-up box and, if still unavailable, notify the provider and follow up with directives given.
Failure to Monitor Nebulizer Treatment and Maintain Continuous Oxygen Support
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, and orders for continuous oxygen support, BiPAP use, oxygen saturation monitoring, and scheduled nebulizer treatments. The resident’s orders included ipratropium-albuterol nebulizer treatments every 4 hours, oxygen 4L via nasal cannula while eating, and BiPAP with 4L oxygen bleed-in during naps, daytime use, and at bedtime. The care plan also directed staff to document breath sounds, vital signs with O2 sats, respiratory treatment effectiveness, activity tolerance, and any changes in level of consciousness or respiratory status. During the early morning hours, the resident requested a nebulizer treatment, and the RN started the treatment but left after only a few minutes to attend to other duties. The RN stated the resident was left during the treatment, and the CNA stated it was not the CNA’s job to stop the nebulizer treatment or place the BiPAP mask back on. The RN later stated the CNA removed the nebulizer mask and put the BiPAP mask back on, but the RN did not verify that BiPAP or oxygen had been reapplied after the treatment. The facility’s procedure stated the nurse should obtain vital signs, assess respiratory status, remain with the patient until the nebulizer sputtered, and document the procedure. After the treatment, the resident was found unresponsive. Family members reported the BiPAP mask was off to the side of the resident’s face and the straps were not secured as expected. The BiPAP compliance report showed the device stopped at 4:42 AM and was not used again until 6:21 AM for only 3 minutes. The record review also showed no oxygen saturation readings documented on the O2 sats summary form and no vital signs documented on the vital signs forms for the relevant dates.
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Compliance trends in Michigan
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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