CMS · Michigan LARA publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity GHarm
Care planningRecords
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-09-17Record 235366-20240717-F658
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-08-09Record 235366-20240717-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-09Record 235366-20240717-F689
F760Ensure that residents are free from significant medication errors.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-09Record 235366-20240717-F760
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F550
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F600
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F602
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F677
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F679
F680Ensure the activities program is directed by a qualified professional.Scope/severity FStandard
Care planning
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F680
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F686
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F695
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F699
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F726
F730Observe each nurse aide's job performance and give regular training.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F730
F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F742
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F756
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F812
F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F813
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-17Record 235366-20240717-F883
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F887
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F919
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-09Record 235366-20240717-F940
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F550
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F658
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F676
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F689
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-03-19Record 235366-20240221-F725
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F554
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F558
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F561
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F585
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F689
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F695
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F804
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-09Record 235366-20230607-F880