This citation pertains to intake 2648348 and 2640731.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 6 residents (Resident #101) reviewed for medication administration resulting in an Immediate Jeopardy beginning on 10/9/25 at approximately 9:00 AM when Resident #101 received another resident's medications which were administered by an agency nurse and nursing student. Resident #101 was found approximately one hour later and was noted to be lethargic and was hospitalized from [DATE]-[DATE] where she was diagnosed with acute metabolic encephalopathy (significant decline in brain function due to an underlying metabolic disturbance) and iatrogenic polypharmacy (harm caused by the administration of multiple… …
F760 citations in Michigan
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F760 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F760 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 intake #3054443.Based on interview and record review, the facility failed to prevent significant medication errors in 1 of 1 resident (Resident #65) reviewed for medication errors, resulting in Resident #65 having an acute change of condition requiring hospitalization due to low blood sugar, decreased heart rate, low blood pressure, and admission to the ICU (intensive care unit). Findings include:Resident #65Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Bipolar (mental health condition that causes extreme shifts in mood, energy, activity levels and concentration), dementia (a decline in mental ability, memory loss, thinking difficulties and behavioral changes),… …
This citation is related to intake # 3107907 Based on interview and record review, the facility failed to follow the five rights of medication administration for one of three residents (Resident #3) reviewed for significant medication errors. Findings:Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of Diabetes Mellitus and chronic kidney disease. Review of a nursing Progress Note dated 07/21/26 reflected that R3 .was given the wrong insulin and bedtime medication pass .R3 went to the local acute care hospital for further assessment. Review of a Medication and Treatment Error form, dated 07/22/26, noted .the nurse was preparing R3's medication and got interrupted and gave the wrong insulin. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.87% | 0.78× |
| 2024 | 0.58% | 0.49× |
| 2025 | 0.93% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction