This citation pertains to intake #2808946.Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards in 3 residents (Resident #101, #103 & #106) of 6 residents reviewed for quality of care, resulting in an immediate jeopardy for 1 resident (Resident #101) when, beginning on 2/28/26 at approximately 8:00 AM, Resident #101 had an acute change of condition and staff failed to accurately assess, monitor and notify the physician, resulting in Resident #101 being transported to the hospital on 3/1/26 (approximately 24 hours later) due to unresponsiveness, hypertensive (high blood pressure) and fever. …
F684 citations in Michigan
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F684 more often than its own record predicts
1.53 times the share F684 takes of citations nationally.
Of every deficiency written in Michigan in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F684 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 care and services in accordance with professional standards of practice and the residents' assessed needs for three Residents (#5, #6, #7) of three reviewed for quality of care, resulting in actual harm to Resident #5 after an infection in the toe required amputation.Findings include:Resident #5 (R5)Record review indicated R5 was admitted on [DATE] with diagnoses including multiple sclerosis (MS), congestive heart failure, osteoarthritis, thrombophilia, atrial fibrillation, hyperlipidemia, and quadriplegia.During a phone interview on 8/18/26 at 11:55 AM, complainant B stated R5 has chronic issues with his feet due to MS and toe curvature. …
This Citation Pertains to Intake 3171112.Based on interview and record review, the facility failed to ensure the facility provided updated communication to the physician provider related to a change in condition following failed interventions for one Resident (#701) of three residents reviewed. Findings include:Review of intake documentation revealed a concern that, on [DATE], Resident #701 fell out of their bed and was found unresponsive and required Cardiopulmonary Resuscitation (CPR). Resident #701 was subsequently transferred to the hospital and passed away. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 4.79% | 1.32× |
| 2024 | 4.97% | 1.25× |
| 2025 | 6.58% | 1.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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