F657 in Michigan. Pick another state for the same tag.
Against expectation — 2025
Michigan cites F657 more often than its own record predicts
Versus expected share1.12×
1.12 times the share F657 takes of citations nationally.
Share of Michigan citations2.09%
Of every deficiency written in Michigan in 2025, this is the portion that was F657.
Michigan2.09%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F657 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, isolatedOctober 17, 2018
Based on observation, interview, and record review, the facility was placed in Immediate Jeopardy due to their failure update Behavior Care Plans for two Residents (#1 and #2) to prevent resident to resident abuse when on 9/12/18, Resident #2 threatened to kill Resident #1 and then on 9/30/18, was found in the hall by facility staff attempting to suffocate Resident #1. This deficient practice resulted in the potential to cause death. The Immediate Jeopardy had the potential to affect all residents in the facility. …
Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for one resident (Resident #8) out of 13 residents reviewed for quality care, resulting in hospitalization for a fracture sustained after a fall from staff use of the incorrect lift device.
Findings:
Resident #8 (R8)
Review of an Admission Record reflected R8 admitted to the facility with diagnoses that included generalized osteoarthritis, hemiplegia and hemiparesis (weakness and partial paralysis) of the left non-dominant side following a stroke, history of traumatic brain injury and muscle weakness. …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
This citation refers in part to intake 3072219. Based on observation, interview, and record review, the facility failed to ensure the care plan was revised to reflect the current needs of the resident for three residents (R154, R35, R147) of five reviewed for individualized care plans. Findings include: R154 On 08/25/2026 at 10:35 AM, R154 was observed dressed and seated in a wheelchair on the door side of the bed. R154 had a hinged support brace on the right leg which extended from the thigh to the calf. the hinge of the brace was below the level of the knee joint. The resident was asked about the position of the leg brace and commented the hinge should be at the knee joint, R154 attempted to pull the brace up. The position of the brace did not change. …
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