Regency on the Lake - Fort Gratiot

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed properly store, label, and date medications for one resident (R56) of four residents reviewed for medication administration. Findings include: On 06/30/25 at 10:08 AM, Licensed Practical Nurse (LPN A) was observed to retrieve an inhaler for R56 from the cart which was unlabeled and undated. LPN A was asked if there was a date opened on the inhaler and replied, No. A review of R56's physician's order revealed, Ventolin HFA Inhalation Aerosol Solution 108 (90Base) Microgram per actuation (MCG/ACT)(Albuterol Sulfate) 2 puff inhale orally four times a day for shortness of breath. A review of R56 medical record revealed R56 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's. A review of R56's most recent Minimum Data Set assessment (MDS) revealed R56 with impaired cognition and required assistance of activities of daily living including medication administration. On 07/01/25 at 9:19 AM, the Director of Nursing (DON) was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00151561. Based on interview and record review, the facility failed to document notification of family and physician for a change in condition for one resident (R901) of three reviewed for notice of condition change. Findings include: A review of the complaint noted R901 had been seen on 01/28/25 and the resident appeared to be doing fine. It was noted that they were called on 01/30/25 and told R901 had been sent to the hospital. The complainant reported R901 appeared very ill and the emergency room physician reported that R901 had vomited and had a large amount of stool upon diagnostic examination and had sepsis (a body system wide infection). A review of the record for R901 revealed R 901 was admitted into the facility on [DATE], discharged to the hospital on [DATE] after and fall with fracture and re-admitted [DATE]. R901 was treated for a urinary tract infection and low blood pressure. Diagnoses included Dementia, Chronic Obstructive Pulmonary Disease and Protein Calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to apply heel protector boots per physician orders for two residents (R5 and R24) out of two reviewed for skin conditions and apply positioning devices per physician orders for one resident (R1) out of two reviewed for positioning. Findings Include: R5 On 6/4/2024 at 9:15 AM, R5 was observed in their bed. Two heel protection boots were noted to be in a wheelchair. R5 was noted to have their heels resting on the mattress. R5 was asked if they wear heel boots while in bed. R5 said they sometimes do and sometimes don't. On 6/5/2024 at 9:16 AM, R5 was observed laying in bed. Two heel protection boots were noted to be in a wheelchair. R5 heels were noted to be resting on the mattress. A review of the medical record revealed that R5 admitted into the facility on 9/20/2022 with the following diagnoses, Difficulty in Walking and Restless Leg Syndrome. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R5 also required assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure smoking/vape pens for one sampled resident (R59) of two reviewed for accidents. Findings include: On 6/04/24 at 10:52 AM, R59 was observed lying in bed, when asked a question R59 stated, I don't feel well and I don't want to talk. Observed on R59's overbed table was one vape/smoking pen. On 6/06/24 at 9:04 AM, R59 was observed lying in bed, when asked a question R59 stated, I don't want to talk. R59 then asked to be left alone. Observed on R59's overbed table was one vape/smoking pen. On 6/06/24 at 9:18 AM, the Unit Manager and R59's assigned nurse was asked if R59 was allowed to have vape/smoking pens in their room. The Unit Manager and the nurse was observed to go to R59's room and reported, residents are not to have smoking/vape pens. The Unit Manager was observed to come out of R59's room with three unopened boxes and one open smoking/vape pen. A review of R59's medical record revealed, R59 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach of one resident (R1) out of one reviewed for call lights. Findings include: On 06/04/24 at 09:15 AM, R1 was observed in bed sleeping. The soft touch call light was hanging on the end of the bed out of reach of the resident. On 06/05/24 at 09:10 AM, R1 was observed in bed sleeping. The soft touch call light was on the floor past the end of the bed out of reach of the resident. A review of the medical record revealed that R1 admitted into the facility on 5/28/2014 with the following diagnoses, Weakness and Abnormal Posture. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 8/15 impaired cognition. R1 also required assistance with bed mobility and transfers. Further record review of R1's care plan listed having the call light within reach as an intervention for multiple care plan problems as follows: Ensure/provide a safe environment. Call light in reach. Keep (R1's) environment as safe as possible with: even floors free from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00139026. Based on interview and record review, the facility failed to implement adequately supervision for one sampled resident (R901) of three residents reviewed for falls, resulting in multiple falls, and two hospital transfers. Findings include: A review of R901's census information revealed that R901 was originally admitted into the facility on [DATE] with diagnoses that included Alzheimer's Disease, Heart Failure, Gout, and History of Falling. A review of the R901's 5-Day Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 8/15 indicating a moderately impaired cognition, and required extensive assistance of 2 persons for bed mobility, transfers, and toilet use. Further review of R901's admission fall risk assessment dated [DATE] categorized the resident as being at At Risk for falls with the following details noted: -Does the resident have a history of falls? Yes -Does the resident have a fear of falling,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review, the facility failed to develop a care plan for use of a right hand orthosis (hand held splint) for one (R26) of two residents reviewed for orthotics resulting in limited resident access to and application of the orthosis. Findings include: Review of the facility record for R26 revealed an initial admission date of 2/8/23 with diagnoses that included Cerebral Infarction with Right Hemiplegia and indication of a history of falls. R26 was readmitted on [DATE] following a hospitalization with the new diagnosis of Encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R26 required supervision for eating and upper body dressing, set up for oral hygiene and primarily maximum assistance for self care tasks and transfers otherwise. On 4/2/23 at approximately 9:50 AM, R26 was observed laying in bed. It was noted that R26 appeared to have right upper extremity contractures at the elbow, wrist and hand. There were no splints or orthotics in place and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered per order for one resident (R38) of five reviewed for medications, resulting in the potential for the exacerbation of acute or chronic health conditions. Findings include: On 4/2/23 at 9:14 AM, R38 was observed sitting up in bed with their breakfast tray in front of them. R38 was unable to respond to interview questions and appeared to have some limited use of the left side of their body. A review of R38's record and Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on 3/10/23 with medical diagnoses of Altered Mental Status, Unspecified Convulsions, End Stage Renal Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Metabolic Encephalopathy, Dependence on Renal Dialysis, Other Seizures, Dysphagia, Oropharyngeal Phase, and Muscle Weakness. Further review revealed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to answer call lights in a timely manner, assist with brief changes and or failed to assist residents during meals for four residents (R1, R8, R62, R68) of seven residents reviewed for activities of daily living care (ADLs), resulting in dissatisfaction with care, dissatisfaction during meals, and the potential for compromised nutrition and weight loss. Findings include: Resident #1 (R1) On 4/2/23 at 9:00 AM, during an initial tour of the facility, R1 was interviewed about their level of satisfaction with the care that they were receiving at the facility. R1 indicated that they sometimes had to wait up to Two hours for a brief change. R1 stated, That's too long. On 4/2/23 at 10:00 AM, a review of R1's EMR revealed the following, R1 had diagnoses of Heart failure and Hemiplegia (Paralysis) affecting left non-dominate side. A review of R1's most recent quarterly MDS revealed that R1 had an intact cognition and required extensive assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. This citation pertains to Intake MI00135496. Deficient practice #1. Based on observation, interview and record review the facility failed to provide sufficient staff monitoring to prevent inappropriate wandering, for one (R109) of one sampled residents reviewed for wandering, resulting and multiple unwelcome entries into residents' rooms. Findings include: On 4/02/23 at 11:13 AM, R109 was observed in bed sleeping, in the room a staff person was observed sitting in a chair near R109's bed. The staff person was asked the reason for her in R109's room and stated, Last night [R109] tried to get in bed with another resident without any clothes on. On 4/03/23 at 9:15 AM, R109 was observed with one to one (1:1) supervision from a staff person. On 4/04/23 at 12:35 PM, R109's one to one Certified Nurse Assistant (CNA) R was asked about R109's behavior and stated, [R109] has been ok today. I was able to get [R109] to sit and watch a movie, but I didn't know [R109] was legally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide thickened liquids per diet order for one resident (R38) of three reviewed for nutrition, resulting in the potential for difficulty swallowing and aspiration. Findings include: On 4/2/23 at 9:14 AM, R38 was observed sitting up in bed with their breakfast tray in front of them. R38 was unable to respond to interview questions and appeared to have some limited use of the left side of their body. R38's tray included a glass of orange juice and a glass of milk, and their meal ticket indicated that the resident's liquids were supposed to be nectar thick consistency, and that the resident was under aspiration precautions. The orange juice and milk on the tray, along with two Styrofoam cups on the resident's bedside table (one with water, one with what appeared to be apple juice) were visibly regular consistency (thin liquid). R38 then picked up their glass of milk and took a drink. The milk, again observed to be regular consistency,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a 14-day stop date was ordered for an as-needed (PRN) psychotropic medication and failed to document attempted non-pharmacological interventions prior to administration for one resident (R271) of five reviewed for unnecessary medications, resulting in the potential for adverse reactions and the prolonged use of psychotropic medication. Findings include: A review of 271's record and Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on 3/24/23 with medical diagnoses of Displaced Bimalleolar Fracture Of Left Lower Leg, Subsequent Encounter For Closed Fracture With Delayed Healing, History Of Falling, Wedge Compression Fracture Of First Lumbar Vertebra, Subsequent Encounter For Fracture With Routine Healing, Generalized Anxiety Disorder, Major Depressive Disorder, and Nicotine Dependence, Unspecified, With Unspecified Nicotine-Induced Disorders. Further review revealed that the resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and maintain nebulizer masks in a sanitary manner, for two residents (R21 and R34), resulting in masks left hanging on the side of the bed, and the potential for contamination of equipment and transmission of bacteria leading to respiratory infections from contaminated equipment. Findings include: R21 On 4/02/23 at 11:22 PM, R21 was observed in bed. Observed on the side table was a nebulizer mask sitting on the top of the machine. The nebulizer mask was also observed in the above condition on 4/3/23 and 4/4/23. A review of R21's medical record noted, R21 was admitted to the facility on [DATE] and readmitted [DATE], with diagnosis Cardiorespiratory conditions. R34 On 4/02/23 at 8:57 AM, R34 was observed in bed. A nebulizer mask was observed to hang off the bed's assist bars. The nebulizer mask was also observed in the above condition on 4/3/23 and 4/4/23. A review of R34's medical record noted, R34 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.