This citation pertains to MI 589 and M 6435. Based on interview and record review, the facility failed to implement its established Abuse Prevention Program when it was alleged two Residents (Resident #3 and Resident #12) passed away after alleged nursing misconduct, abuse and neglect (intentionally removing physician ordered oxygen for extended periods of time and over-medicating with narcotics) while under the care of a Registered Nurse (RN E) resulting in an Immediate Jeopardy (IJ) that began on [DATE] when a Certified Nurse Aide (CNA) and other licensed nursing staff aware of the situation failed to immediately report alleged abuse to facility administration and when local police detectives made the facility Administration aware of an open investigation into a report of suspicious… …
F607 citations in Michigan
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F607 less often than its own record predicts
0.77 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F607 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: MI00150544. Based on interview, and record review, the facility failed to protect one resident (R901) during an abuse investigation out of four residents reviewed for abuse resulting in fear of retaliation and feeling scared. Findings include: A review of a facility reported incident (FRI) submitted 2/13/25 to the State Agency revealed, It was alleged the facility staff misappropriated resident funds. On 2/25/25 at 10:00 AM, R901 explained back in October (2024) they wanted to open a bank account to deposit their check from social security. They had asked their family to assist but they were taking too long. …
This citation pertains to intake #3095854Based on interview and record review, the facility failed to implement the abuse policy for reporting and response to allegations of abuse and prevent the potential for further allegations of abuse to be unreported in 1 of 5 residents (Resident #6) reviewed for abuse.Findings include: Resident #6 (R6)Review of an admission Record for R6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks), and psychotic disorder with delusions (mental health disorder in which a person has fixed, false beliefs).Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, revealed a Brief… …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.48% | 0.64× |
| 2024 | 0.19% | 0.26× |
| 2025 | 0.50% | 0.77× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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