This citation pertains to intake number: 2640123Based on observation, interview, and record review, the facility failed to prevent the use of psychotropic medications without adequate indication for use and without resident monitoring in one (R102) of two residents reviewed for psychotropic medications, resulting in an immediate jeopardy when beginning on 9/16/25, R102 was prescribed psychotropic medications, who then experienced increased sedation, weight loss, and decreased ability to communicate. Findings include:Resident #102 (R102) was prescribed Haldol solution injection intramuscular (IM) daily as needed PRN and Olanzapine (Zyprexa) 5mg by mouth (PO) daily at night beginning 9/16/25. The Olanzapine was increased to 10 mg PO daily at night on 10/20/25. …
F605 citations in Michigan
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F605 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F605 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 citation pertains to intake: MI 657 Based on interview and record review the facility failed to ensure that R#926 was free of chemical restraints, effecting one resident (R#926) of three residents reviewed for chemical restraints, resulting in R#926 being discharged to hospital for evaluation of lethargy(unresponsiveness) after receiving medication given without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of face sheet documented that R#926 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Nursing Progress Note dated 7/21/21 at 17:21 (5:21 PM), R#926 had intact cognition and was a one person assist with transfers and ambulation. …
Based on interview and record review, the facility failed to adequately monitor laboratory values and ensure the resident representative was involved with treatment decisions for 3 residents (Residents #3, #31, and #54) out of 5 residents reviewed for unnecessary medication, resulting in the potential for medical complications for all 3 residents. Findings include:Review of the FDA prescribing information for Clozaril revealed, CLOZARIL treatment has caused severe neutropenia, defined as an absolute neutrophil count (ANC) less than 500/uL. …
What else Michigan surveyors cite →
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