This citation pertains to complaint intake MI 859. Based on interview and record review, the facility failed to ensure proper food consistency and appropriate monitoring during meals for 1 (Resident #2) of 3 total sampled residents reviewed for assistance with and mechanically altered meals, resulting in immediate jeopardy which began on [DATE] when Resident #2, who required 1 to 1 assistance with meals and a mechanically altered meal texture of pureed foods, ate solid foods, unsupervised, choked on the food that was provided to him by the facility, resulting in Resident #2 choking on the food, becoming unresponsive, and death. …
F808 citations in Michigan
Nutrition and Dietary Deficiencies
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F808 less often than its own record predicts
0.55 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F808.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F808 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 ensure residents received diets as prescribed by a physician and in accordance with the plan of care for four Residents (#1, #17, #28 and #34) of five residents reviewed for therapeutic diets. Findings include:Resident #28 (R28)During breakfast meal rounds on 3/2/2026 at 8:05 AM, R28 was noted to have scrambled eggs and sausage with gravy served. R28's meal tray card indicated Diet: 2gm (gram) Na+ (Sodium).During an interview on 3/2/2026 at 8:35 AM, the Certified Food Service Manager (CFM) T was asked about the diet and she stated, We are out of low sodium gravy right now.The medical record for R28 indicated a physician diet order dated 9/4/2025 of No Added Salt (NAS), Low fat. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.09% | 0.45× |
| 2024 | 0.21% | 1.27× |
| 2025 | 0.08% | 0.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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