This citation pertains to intake #MI00138565. Based on interview and record review, the facility failed to, 1) ensure a complete and accurate nursing assessment was done after a significant change involving 1 resident (Resident #701), and 2) ensure the facility had a policy to follow for assessment regarding signs/symptoms of infection (not feeling well, increased temp, tiredness, nausea), resulting in hospitalization with a diagnosis of urinary tract infection (UTI) and sepsis (extensive infection), antibiotic given, and the likelihood for serious injury. …
F637 citations in Michigan
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F637 less often than its own record predicts
0.66 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F637 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.
Based on observation, interview, and record review the facility failed to ensure that a significant change Minimum Data Set was completed timely in one (Resident 3) out of 19 reviewed for Significant Change Minimum Date Sets. Findings include. Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unsteadiness on feet, lack of coordination, vascular dementia, and displaced subtrochanteric fracture of right femur. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/26, reflected R3 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/26/25 at 9:12 AM, R3 was observed in a common area seated in a wheelchair. …
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner for 2 (Resident #10, 42) of 6 Residents reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: According to the Centers for Medicare and Medicaid Service's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, published in (MONTH) (YEAR), a significant change comprehensive assessment must be completed within 14 days when a terminally ill resident enrolls in hospice services. CMS stated that the assessment assists staff to gather definitive information about a resident's strengths and needs that are then used to develop care plans. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 0.49× |
| 2024 | 0.09% | 0.38× |
| 2025 | 0.16% | 0.66× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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