This Citation Pertains to Intake Number MI 237 Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to the facility's systemic failure to account for narcotics and controlled substances on a daily basis and resolve discrepancies, including the theft of 41 narcotic tablets/capsules and a vial of [MEDICATION(S)], leading to the likelihood of a serious adverse outcome, including harm and untreated pain and continued diversion. Immediate Jeopardy: On 12/20/21, the Director of Nursing was notified by the pharmacy at 7:13 AM and at 2:39 PM that none of the narcotics sent to the facility on [DATE] for placement into the back-up medication dispensary system (Omnicell) were placed into the back-up system including 41 doses of narcotic medications:… …
F755 citations in Michigan
Pharmacy services · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F755 less often than its own record predicts
0.45 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F755.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F755 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 implement and operationalize processes and procedures to ensure monitoring, accountability, and pharmacological oversight of controlled medications in the Med-bridge and North Hall of the facility per professional standards of practice. This deficient practice resulting in lack of appropriate storage, securement, reconciliation, administration, and disposal and/or return of controlled medications including lack of accurate comprehensive documentation and reconciliation of Methadone (prescription opioid medication frequently used to treat individuals with opioid dependence) brought into the facility, and the likelihood for inappropriate medication use and administration, accidental exposure, and diversion which has… …
This citation pertains to Intake #3063059. Based on observation, interview, and record review, the facility failed to ensure routine medications were ordered, received and administered in 2 residents (Resident #38 & #17) of 20 residents reviewed, resulting in residents not having a sufficient supply of physician ordered medications and a delay in treatment for medical conditions. Findings include:Resident #38 (R38)Review of a Face Sheet revealed R38 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pulmonary hypertension (a type of high blood pressure that affects the lungs and heart).Review of a Minimum Data Set (MDS) assessment for R38, with a reference date of 8/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total… …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 1.17% | 0.55× |
| 2024 | 1.28% | 0.60× |
| 2025 | 1.06% | 0.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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