This citation pertains to intake: MI 908. Based on interview, and record review, the facility failed to assess for a removal of a catheter and provide necessary treatment and services to six residents (R701, 708, 709, 710, 711 & 712) of six residents reviewed who required care for indwelling catheters, resulting in an immediate jeopardy when R701 developed a Urinary Tract Infection ([CONDITION(S)]) which caused septic shock, admission into the Intensive Care Unit (ICU) and expired two days after being hospitalized . This deficient practice resulted in R701's death and the potential for serious injury, infection, harm, and/or death to all facility residents with urinary catheters. The Immediate Jeopardy (IJ) started on [DATE]. …
F690 citations in Michigan
Incontinence and catheter care · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F690 more often than its own record predicts
1.25 times the share F690 takes of citations nationally.
Of every deficiency written in Michigan in 2025, this is the portion that was F690.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F690 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.
This citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to timely identify signs/symptoms of a urinary tract infection (uti), failed to consistently inform the Physician/NP (nurse practitioner) of identified signs/symptom, and failed to timely treat a uti for one (R202) of three residents reviewed for a change of condition, resulting in the resident to be hospitalized in the intensive care unit for urosepsis (urinary tract infection spreads to the bloodstream) and ultimately admitted into hospice care. Findings include:A review of a hospital Emergency Medicine consult dated 8/19/25 at 11:55 AM, documented in part . present to the Emergency. for altered mental status and hypotension. they <sic> she is acting worse than baseline. …
Based on interview and record review, the facility failed to prevent the development of a facility-acquired Urinary Tract Infection (UTI) for one resident (Resident #52) of two residents reviewed, resulting in verbalized discomfort by Resident #52, antibiotic therapy and prolonged illness. Findings include: Resident #52:In an interview on 08/03/2026 at 10:47 AM, Resident #52's family member revealed that the resident she developed a Urinary Tract Infection (UTI) the prior week while residing in the facility. The facility staff started Resident #52 on intravenous (IV) antibiotics and got a urine culture. The family member stated that the resident could not self-ambulate and needed staff assistance to get to the restroom. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 2.40% | 1.48× |
| 2024 | 1.56% | 1.04× |
| 2025 | 1.70% | 1.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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