Based on interview and record review, the facility failed to ensure 3 Residents received base line care plans (R14, R 117 and R 164) of 3 residents reviewed for baseline care plans, resulting in the potential for residents' needs and care not being met. Findings include: R 117 Review of R 117's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His daughter was his responsible party. During a telephone interview with R 117's responsible party (RP) Z on 9/20/21 at 11:59 AM, Z said she came to the facility on [DATE] when he was admitted . Z said the facility staff did not attempt to see him or meet with him for 4 hours. After 4 hours she went to find staff to find out what was going on. …
F655 citations in Michigan
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F655 less often than its own record predicts
0.32 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F655 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 provide a written summary of the baseline care plan to one resident (#98) or residents representative out of 18 residents reviewed for baseline care plan.Findings included: Resident #98 (R98)Review of the medical record revealed R98 was admitted [DATE] with diagnoses that include stroke, atrial fibrillation, hyperlipidemia (high fat content in blood), respiratory failure, type 2 diabetes, aphasia (language disorder), right sided paralysis (loss of muscle function), dysphagia (difficulty swallowing), and insomnia. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/31/2026, revealed a BIMS score that was not assessed related to R98's medical condition. …
Based on interview and record review, the facility failed to develop a respiratory baseline care plan for 1 of 7 residents (Resident #59) reviewed for admissions, resulting in the potential for Resident #59 not receiving effective and person-centered care. Findings include: A review of Resident #59's admission record, dated 6/6/18, revealed Resident #59 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #59's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 5/21/18, revealed Resident #59 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 12 which revealed Resident #59 was moderately cognitively intact. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.51% | 0.64× |
| 2024 | 0.49% | 0.71× |
| 2025 | 0.21% | 0.32× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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