This citation pertains to intake # MI 663 Based on interview and record review, the facility Administrator failed to follow established risk management and abuse/neglect prevention policies and procedures, resulting in an Immediate Jeopardy when beginning on [DATE], the Administrator did not (a) report and investigate the sudden and unexpected death of Resident #800 and (b) report and investigate an allegation of neglect that resulted in the death of Resident #800. This deficient practice resulted in the potential for the Administrator to continue to arbitrarily not report allegations of abuse and neglect and not follow established risk management guidelines for sudden and unexpected deaths and policies and procedures for reporting and investigating allegations of Abuse/Neglect and… …
F835 citations in Michigan
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F835 less often than its own record predicts
0.54 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F835 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 administer resources effectively and efficiently to maintain the residents highest practicable physical, mental, and psychosocial well-being, resulting in a repeat immediate jeopardy for water temperatures, and immediate jeopardy for infection control, most deficiencies that were on the last annual survey were repeated and no active quality assurance program in place to resolve facility issues. Findings include: During the quality assurance review on 2/7/22 at 2:36 PM, the Nursing Home Administrator (NHA) said he has been the administrator since September 2021. The NHA said the former Director of Nursing (DON) ran the Quality Assurance (QA) meetings. …
Based on observation, interview, and record review the facility failed to adequately address one resident (R59) of one resident identified to possess smoking paraphernalia, resulting in the potential for unidentified and unsafe smoking practices within the facility that did not comply with the facility's smoking policy.Findings include:On 6/23/26 at 6:51 p.m. during the entrance conference, it was confirmed with the Nursing Home Administrator (NHA) that the facility was non-smoking. On 6/23/2026 at 9:39 p.m. R59 was observed walking independently in the halls of the unit ([NAME]). R59 appeared alert, oriented to person, place, and situation. R59 did not voice any concerns regarding care. On 6/25/26 at 12:37 p.m. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 0.42× |
| 2024 | 0.15% | 0.46× |
| 2025 | 0.16% | 0.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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