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
Failure to monitor Clozaril labs and involve a guardian in psychotropic treatment decisions. Two residents receiving Clozaril had incomplete or unavailable CBC/ANC monitoring despite provider and psychiatry notes recommending regular lab draws, and a third resident with a guardian had an Abilify GDR without documentation that the guardian was notified or participated in the dose-reduction decision.
Medication administration did not follow physician orders for two residents. One resident's traMADol dose was documented in the eMAR as given even though the controlled substance record did not show the afternoon dose as dispensed, and the DON stated it was not administered. Another resident received midodrine on multiple occasions when BP readings were above the ordered parameters, and the DON stated the medication was given outside of parameters.
The facility failed to ensure appropriate interventions to prevent accidents for three residents. One resident with Parkinson's disease, dementia, and spinal stenosis required 2-person assistance for bed mobility and transfers, but a CNA provided incontinent care alone and rolled the resident away from the staff member at the edge of the bed. Two other residents were observed in bed with their call lights out of reach, including one on the floor and another placed behind the resident and personal belongings.
A resident with significant neurologic impairment, malnutrition, and dependence on staff developed a facility-acquired lower back pressure injury that progressed to a stage 4 wound with infection, sepsis, and surgical debridement. Surveyors observed prolonged time in the same position, a nonfunctioning air mattress, delayed meal assistance, and missing turning/repositioning documentation. Records and interviews also showed the wound worsened over time, with inadequate offloading noted in hospital documentation.
Inadequate staffing and supervision resulted in unmet care needs and resident-to-resident altercations. A male resident with dementia who was exit seeking and wandered into other residents’ rooms required more 1:1 oversight than staff could provide, and staff reported they were unable to keep him safe while covering other duties. He was involved in multiple altercations with another resident when staffing was short. A second resident who required 2-person transfer assistance experienced repeated call light delays, with staff turning off the light before completing care and a 54-minute wait for transfer assistance. Staff and residents reported frequent call-offs, long wait times, missed breaks, and difficulty meeting resident needs when the unit was short-staffed.
Failure to report resident-to-resident altercation to SA: A CNA witnessed one resident enter another resident’s room during personal care and open the privacy curtain, exposing the resident. The affected resident later described being naked in bed, feeling embarrassed and afraid, and identified the other resident involved. The DON and NHA were unaware of the incident, and the event was not reported to the SA as required by facility policy.
Failure to Monitor Clozaril Labs and Involve Guardian in Psychotropic Dose Reduction
Penalty
Summary
The facility failed to adequately monitor laboratory values for residents receiving Clozaril and failed to ensure the resident representative was involved with treatment decisions for a resident receiving a psychotropic medication dose reduction. Review of the FDA prescribing information in the report noted Clozaril can cause severe neutropenia and requires ANC monitoring at specified intervals, including monthly monitoring during maintenance therapy. The report identified 3 residents reviewed for unnecessary medication concerns, including two residents on Clozaril and one resident with a guardian whose psychotropic medication was reduced. For one resident with schizoaffective disorder, the record showed Clozaril 250 mg twice daily and multiple notes recommending monthly CBC/ANC monitoring, but recent laboratory results could not be located in the electronic record during review. For a second resident with schizoaffective disorder, the record showed Clozaril 200 mg twice daily, and psychiatry notes recommended regular CBC draws and an updated CBC with differential, but only a limited number of lab reports were available for review. The DON confirmed that the behavioral management team followed provider, psychiatric, and pharmacist recommendations regarding lab testing for residents on Clozaril and confirmed these two residents did not have monthly laboratory testing ordered. For the third resident, who had a guardian and was not his own decision maker, the record showed Abilify was reduced from 5 mg to 2 mg daily as part of a GDR for psychotic disturbance. The chart did not contain documentation that the guardian participated in the decision to continue the GDR or was notified of the dose decrease. Staff interviews reflected differing understandings about whether the guardian needed to be notified or involved, and the DON stated there was no documentation of notification in the chart for the second GDR.
Medication Administration Outside Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 2 residents reviewed for nursing professional standards of practice. One resident had an order for traMADol 50 mg by mouth three times daily for pain, scheduled for 7:00 AM, 2:00 PM, and 9:00 PM. The controlled substance proof of use record showed doses dispensed at 7:59 AM and 8:10 PM on 5/25/26, but the 2:00 PM dose was not documented as dispensed. The medication administration record, however, documented all 3 doses as administered that day. The DON stated the nurse documented the afternoon dose in the eMAR but did not sign it out on the controlled substance record and did not administer the medication. Another resident had an order for midodrine 2.5 mg by mouth three times daily with parameters to hold for SBP >100 and give if diastolic was below 50. Review of the blood pressure summary and medication administration record showed the medication was administered on multiple dates when the resident's blood pressure readings were above the ordered systolic parameter, including readings of 113/65, 111/76, 108/76 and 113/57, 135/69, 115/70, 113/53, and 107/55. The DON stated the midodrine was administered outside of parameters and that education was initiated regarding following provider orders and the risks associated with administering cardiac medications outside ordered parameters.
Failure to Maintain Safe Bed Mobility Assistance and Call Light Access
Penalty
Summary
The facility failed to ensure that three residents had appropriate interventions in place to prevent accidents. One resident with Parkinson's disease, dementia, and spinal stenosis required assistance with ADLs and had care plan interventions for 2-person assistance with bed mobility and transfers, and 1 to 2 people for toileting needs. During incontinent care, a CNA provided care without another staff member present and rolled the resident away from the staff member without support at the edge of the bed, while the resident's ability to assist with bed mobility was noted to vary. Two other residents were observed in bed with their call lights not within reach. One resident's call light was on the floor on the right side of the bed, out of sight and out of reach. Another resident's call light was hanging behind and to the right of the resident, while the activation button was on a bedside table behind personal belongings, also out of sight and out of reach. The facility policy stated that with each interaction in the resident's room or bathroom, staff would ensure the call light is within reach of the resident and secured as needed.
Pressure Ulcer Care and Offloading Failure
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who had multiple risk factors, including hemiplegia/hemiparesis following cerebral infarction, aphasia, vascular dementia, protein-calorie malnutrition, and dependence on staff for repositioning, transfers, dressing, hygiene, and eating. The resident’s MDS reflected she was at risk for pressure ulcers and was not on a turning/repositioning program at earlier assessment points. The resident later returned from the hospital with a stage 4 pressure ulcer and continued to have a facility-acquired wound on the lower back/spinal area that was documented as unstageable/deep tissue injury and later progressed to a stage 4 pressure ulcer with exposed bone and undermining. Record review showed the wound was first documented as a new in-house pressure ulcer on the lower back with erythema, edema, slough, and eschar, and subsequent notes described worsening size, depth, undermining, pain, and seropurulent drainage. The resident was hospitalized for sepsis secondary to an infected stage 4 lumbar pressure ulcer with deep soft tissue infection, and hospital records noted surgical debridement. Infectious disease documentation stated the lumbar decubitus ulcer was associated with likely spinous process erosion in the setting of inadequate offloading and recommended aggressive offloading and nutritional supplementation. Survey observations showed the resident remained in the same bed position for extended periods, with a wedge under the hip and the bed alarm/beeping noted, while meal assistance was delayed and the resident called out for food. On another observation, the air mattress pump was not functioning and the mattress appeared deflated, with the resident sunk into the bed. Staff interviews and record review also found missing turning/repositioning documentation, and the facility could not provide a complete investigation when requested. The resident’s care plan included turning/repositioning, pressure-reducing devices, and skin checks, but the report documented that the resident’s wound developed and worsened while these measures were not consistently evidenced in the record or during observations.
Inadequate staffing and supervision led to unmet resident care needs and resident-to-resident altercations
Penalty
Summary
The facility failed to provide adequate staffing to meet resident needs and to have sufficient supervision for residents requiring close monitoring. Resident #22, a male with dementia and a care plan identifying him as at risk for elopement due to memory deficit, confusion, and inability to read or write, was repeatedly described by staff as wandering into other residents’ rooms, going through belongings, and exit seeking. Staff reported that he needed more one-to-one supervision than the facility could provide, especially when staffing was short, and that they could not keep him safe while also completing other resident care tasks. On 5/23/26, staff reported Resident #22 wandered throughout the day and was frequently in and out of other residents’ rooms. The facility schedule showed 1 nurse and 2 CNAs in the building at the time of the incident, although 3 CNAs were scheduled and one had called off. Staff interviews stated that when staffing was short, they were rushing through care, working through lunch, and unable to address psychosocial needs. An incident report documented that Resident #22 initiated a resident-to-resident altercation on 5/23/26 at 3:20 PM. Later, on 5/26/26, the family was told the resident would not receive 1:1 supervision because of staffing issues, and an incident report documented that at 4:44 PM he grabbed a female resident in a choke hold and punched her in the face, chest, and upper back multiple times. The schedule for that time showed 1 nurse and 3 CNAs in the building. Resident #26, who had reduced mobility and used a wheelchair, required a sit-to-stand mechanical lift for transfers and was identified on the care plan as needing care needs met. During observation, he activated his call light repeatedly while waiting to get out of bed, but staff entered, turned off the light, and told him to wait or that they would get help. It took 54 minutes from the first call light activation until two staff members arrived to transfer him from bed to wheelchair. Resident #26 reported that long call light wait times of more than 30 minutes happened regularly and that staff often turned off the light without completing the requested care. Other residents in a confidential meeting also reported long waits for assistance and frequent unsupervised wandering by a resident with advanced dementia. Staff interviews and payroll-based journal information further described repeated staffing shortages, missed breaks, and difficulty covering call-offs, including low weekend staffing.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to notify the State Agency of a resident-to-resident altercation involving two residents who were both cognitively intact, with each scoring 15/15 on the BIMS. One resident entered the other resident’s room while personal care was being provided, opened the privacy curtain, and exposed the resident. The other resident later reported that a man burst into her room while she was being changed, pulled the privacy curtain open about 2 feet, and saw her naked while she was lying in bed. She stated she felt embarrassed, exposed, and afraid, and identified the other resident as the person involved. During interviews, the CNA reported witnessing the resident enter the room and open the curtain while the other resident was receiving personal care. The DON stated this was the first time she had read the charting and that no one had told her about the incident. The NHA reported being unaware of the event and stated they did not know what could be done to make staff report incidents to management. Facility policy required staff to immediately report allegations or suspicions of mistreatment, abuse, neglect, or exploitation to the Administrator and DON, and required the Administrator or DON to report incidents and accidents to the State Agency.
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Compliance trends in Michigan
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Reviewed elopement and missing person policies and procedures (J - F0689 - MI)
- Modified the elopement assessment tool scoring to enhance identification of safety risks (J - F0689 - MI)
- Initiated wander guards for residents identified as elopement risks based on the updated elopement assessment tool (J - F0689 - MI)
- Checked all wander guards and alarms for functionality (J - F0689 - MI)
- Provided comprehensive education on elopement prevention including ongoing assessments, definitions, exit-seeking behaviors, and role expectations to all licensed nursing staff and certified nursing assistants (J - F0689 - MI)
- Reviewed education material and completion quarterly at the QAPI meeting (J - F0689 - MI)
- Created a workstation at the main entrance and scheduled staff to monitor traffic in and out of the building (J - F0689 - MI)
- Installed a Red Box Audible Alarm at the main entrance (J - F0689 - MI)
- Maintained the alarm by the entrance attendant and activated the alarm any time the door was opened (J - F0689 - MI)
Failure to Prevent Elopement and Unsafe Hoyer Transfer Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to elopement risk and safe mechanical lift transfers. One resident with a history of falls, multiple rib fractures, and recent head trauma was admitted from a hospital with documented confusion, agitation, paranoia, and impulsive behaviors. On admission, the RN completing the elopement assessment marked the resident as not at risk for elopement, despite her own verbal report that the resident was terrified, disoriented, repeatedly stated she wanted to leave, believed people were trying to harm her, and was frequently up and wandering in the room. Progress notes and the admission history and physical documented that the resident was quite confused, agitated, impulsive, and exhibiting abnormal behaviors, including asking staff to help her commit a mass murder, making accusations that hospital staff and paramedics had stolen from her, and expressing delusional beliefs about being harmed. The care plan addressed potential changes in mental status and mood but did not identify or address elopement risk. Nursing and CNA staff interviews showed that staff relied primarily on the presence of a wander guard to identify elopement risk and did not reference other assessments or tools to determine risk. Staff reported that when a resident was identified as an elopement risk, a wander guard was applied and this was communicated in shift report; if a resident was not assessed as a risk, no wander guard was used and no reevaluation occurred unless triggered by preset intervals or events. The admitting RN initially stated she believed she had documented the resident as an elopement risk, but later clarified she had not, explaining she did not think the resident was physically capable of reaching the door and was hopeful the resident would adjust. Subsequent nursing staff on the night shift were informed only that the resident was new, had fallen at home, had a knot on her head, and was "fine," and they were unaware she was an elopement risk. During that night, the CNA and LPN observed the resident as confused, wanting to call her son, not knowing how she arrived at the facility, asking for her husband and son, and stating she wanted to leave. The resident was kept at the nurse’s station for a time, then assisted back to bed around 3:30 AM. Later, camera footage showed the resident self-propelling in a wheelchair to the main entrance, using the handicap button to open the door, and exiting the building without staff awareness. She walked away from the facility and was not discovered missing until the LPN went to administer medications and found her room empty, prompting a search that ended with the resident being located outside near a neighboring house. A second deficiency involved the facility’s failure to ensure safe use of a mechanical lift and appropriate sling selection for another resident with moderate cognitive impairment and generalized weakness, who was dependent on staff for all bed mobility and transfers. During a transfer from bed to recliner using a Hoyer lift, two CNAs used a hygiene sling that was present in the resident’s room and that they reported had been used for months. As the lift was pulled away from the bed, the resident was unable to maintain the upper body and arm support required for that type of sling, slid out of the sling, and fell onto the legs of the lift, sustaining a head laceration that required four staples in the emergency department. Therapy staff, including the supervisor of rehabilitation, PT, and OT, later stated that the hygiene sling is a specialized sling intended for toileting, requires sufficient shoulder engagement and core strength, and is not appropriate for routine bed-to-chair transfers without prior assessment. They confirmed that therapy had not assessed this resident for hygiene sling use and had expected a standard full-body Hoyer sling to be used. The RN unit coordinator acknowledged that the hygiene sling had been used, described it as the resident’s preference, but could not provide documentation of such a preference or any assessment supporting its safety for this resident. Interviews with nursing and therapy staff further revealed that CNAs typically used whatever sling was in the resident’s room and that the resident’s care plan did not specify the type of sling to be used for transfers. There was no documented assessment by therapy or nursing indicating that the resident had the necessary upper body strength and core stability to safely use a hygiene sling for non-toileting transfers. As a result, the resident, who had dementia and Alzheimer’s disease and was dependent for transfers, was transferred with a sling that did not provide adequate support for her condition, directly leading to her fall and head injury during the Hoyer lift transfer.
Removal Plan
- Review elopement and missing person policies and procedures.
- Modify the elopement assessment tool scoring to enhance identification of safety risks.
- Reassess all residents for elopement risk.
- Initiate wander guards for residents identified as elopement risks based on the updated elopement assessment tool.
- Check all wander guards and alarms for functionality.
- Provide comprehensive education on elopement prevention, including ongoing assessments, definitions, exit-seeking behaviors, and role expectations, to all licensed nursing staff and certified nursing assistants.
- Provide education to remaining employees prior to the start of their next working shift.
- Review education material and completion quarterly at the QAPI meeting.
- Perform weekly audits of new admissions for 4 weeks to ensure elopement assessments are completed on admission, kept up to date, and that a care plan addresses any identified risk.
- Create a workstation at the main entrance and schedule staff to monitor traffic in and out of the building.
- Install a Red Box Audible Alarm at the main entrance.
- Maintain the alarm by the entrance attendant.
- Activate the alarm any time the door is opened.
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