F609 in Michigan. Pick another state for the same tag.
Against expectation — 2025
Michigan cites F609 more often than its own record predicts
Versus expected share1.08×
1.08 times the share F609 takes of citations nationally.
Share of Michigan citations2.65%
Of every deficiency written in Michigan in 2025, this is the portion that was F609.
Michigan2.65%
National2.45%
Share of all citations that were F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F609 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.
J · Immediate jeopardy, isolatedJanuary 14, 2021
This citation pertains to MI 589
Based on observation, interview, and record review, the facility failed to ensure covered staff immediately report to administration, the State Agency, and local authorities, an allegation regarding the suspicious resident death of Resident #3 when there were allegations of a nurse, RN (Registered Nurse) E, intentionally removing oxygen from Resident #3 to hasten their death and resulting in an Immediate Jeopardy that began on [DATE] when the facility administration was then made aware of allegations surrounding another death of a different Resident (Resident #12) related to the same nurse, RN E, removing oxygen from Resident #12, hastening his death. …
Based on interview and record review, the failed to fully implement and operationalize its Abuse Program Policy and Procedure and immediately report to the State Agency allegations and actual resident to resident abuse for 9 Residents (Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103) from 13 residents reviewed for abuse, resulting in Resident #4 being involved in multiple incidents of resident to resident abuse, the potential for continued abuse and falls with major injury in the facility to go unrecognized, and Resident #4 grabbing on to the wrist of Resident #102, causing pain, fear and increased anxiety.Findings include:Resident #4 (R4)Review of an admission Record revealed R4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included:… …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
This deficient practice pertains to Intake #3120666.Based on interview and record review, the facility failed to ensure an unexpected death was reported to the State Agency (SA) for one Resident (#1) of four residents reviewed for accident and incident reporting.Findings include: Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male with initial admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke), aphasia (a neurological communication disorder that impairs the ability to speak and understand speech), vascular dementia, hemiplegia and hemiparesis affecting the right side (weakness and/or partial or total paralysis), and restlessness and agitation. …
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