This citation has 2 Deficient Practice Statements (DPS). DPS #1: Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to maintain safe and comfortable temperatures for the South Hall of the facility, when the South Hall's heating system failed on Friday, 01/10/20 and a heating contractor was not summoned to repair it until Monday, 01/13/20 at 2:30 PM, during which time temperatures in residents' rooms on the South Hall dropped significantly below 71 degrees Fahrenheit. The facility is also placed in Immediate Jeopardy for its failure to perform necessary and routine maintenance of the heating, ventilation and air conditioning (HVAC) system, including in residents' rooms. …
F584 citations in Michigan
Safe, clean, homelike environment · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F584 less often than its own record predicts
0.91 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F584.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F584 findings written in Michigan, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
This deficiency pertains to Intakes #MI00153229 and #MI00152446 Based on observation, interview, and record review, the facility failed to prevent one Resident (#3) of eight residents reviewed for homelike environment related to personal property from entering the rooms and taking personal possessions of other residents. This deficient practice resulted in Residents #2, #4, & #5 experiencing fear of continued resident to resident abuse, frustration, and emotional distress and items being taken from #7 and #8. Findings include: On 6/4/25 at 10:15 AM, the doorways to residents' room were observed with mesh-type barriers with stop sign notifications on the barriers. The barriers extended across the doorways and were secured with Velcro on each end to the doorframes. …
Based on observation, interview, and record review, the facility failed to maintain a homelike environment affecting one resident (R9) of two residents reviewed for environment. Findings include:On 8/11/26 at 10:05 AM, R9 was observed lying in bed watching television and was able to answer simple questions. A large (about the size of a tennis ball) brown stain was observed on the privacy curtain near their bed. When asked about the curtain, R9 stated, that looks nasty and should be cleaned. R9 was unsure how long the stain had been there.On 8/11/26 at 2:10 PM, R9 was observed lying in bed looking out the window. The brown stain on the privacy curtain was clearly visible from the hallway.On 8/12/26 at 10:02 AM, R9 was observed lying in bed watching television. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 1.38% | 0.62× |
| 2024 | 1.52% | 0.71× |
| 2025 | 1.91% | 0.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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