Based on observation, interview and record review the facility failed to ensure residents received care by qualified persons in 1 of 5 residents (Resident #13) reviewed for psychotropic medications, when nursing staff completed Resident #13's Psychotropic Medication Review for GDR (Gradual Dose Reduction) assessment without involvement from the physician or nurse practitioner, resulting in an incomplete GDR assessment for Resident #13.Findings include: According to the facility's policy Psychotropic Medication Use dated 1/10/24 revealed, .Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in efforts to discontinue the medication when appropriate.For any resident who is receiving a psychotropic medication to treat a disorder… …
F659 citations in Michigan
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F659 more often than its own record predicts
1.37 times the share F659 takes of citations nationally.
Of every deficiency written in Michigan in 2025, this is the portion that was F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F659 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.
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 0.78× |
| 2024 | 0.02% | 0.72× |
| 2025 | 0.05% | 1.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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