Based on observation, interview, and record review, the facility failed to ensure eight residents (Resident #14, #15, #23, #27, #31, #36, #39, and #47) received skilled nursing services including medication administration and assessments by a licensed nurse, resulting in Immediate Jeopardy when an unlicensed staff member administered medications, performed assessments, and falsified medical records to reflect the skilled nursing services were performed by a Registered Nurse (RN). Findings include: Review of the facility staff list revealed Staff Member J was a Nurse Grad. In an interview on 03/15/23 at 1:43 PM, Staff Member J self reported she was the facility's scheduler and wound nurse. Staff Member J identified herself as a Registered Nurse. …
F839 citations in Michigan
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Michigan cites F839 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F839 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 3055356. Based on observation, interview and record review, the facility failed to ensure staff who identified themselves as a Social Worker had the required credentials, according to State Law, for two (R2 and R5) of two reviewed. Findings include:Review of a complaint intake, received by the State Agency, reflected, .Facility worker [Staff Member (SM) F] incorrectly and fraudulently identifies herself as a licensed social worker to both other professionals, families, and patients/residents at facility. [SM F] does not have any social work degree or license. Identifying oneself or their work as social work without a degree and license is illegal . …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 0.76× |
| 2024 | 0.06% | 1.13× |
| 2025 | 0.05% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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