Based on interview and record review, the facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program. Findings: During an interview on 3/5/2026 at 2:31 PM, Regional Nurse (RN) M reported that the parent organization of the facility has a corporate director of compliance. RN M said staff can report suspected violations to a hotline.During the interview on 3/5/2026 at 2:31 PM, the Nursing Home Administrator (NHA) said she did not recall having training on the facility Ethics and Compliance program, but thought the online training was scheduled yearly. …
F895 citations in Michigan
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Michigan cites F895 more often than its own record predicts
3.48 times the share F895 takes of citations nationally.
Of every deficiency written in Michigan in 2024, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F895 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.
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 1.74× |
| 2024 | 0.04% | 3.48× |
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