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Deficiency Records for Regency at Whitmore Lake
A list of the most recent deficiencies for Regency at Whitmore Lake. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Regency at Whitmore Lake. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | 2024-08-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-05 | 2024-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-05 | 2024-07-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-05 | 2024-07-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-28 | 2024-04-17 | N |
| Honor 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. | Health | 2024-03-05 | 2024-04-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-05 | 2024-04-14 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-05 | 2024-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-05 | 2024-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-05 | 2024-04-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-05 | 2024-04-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-05 | 2024-04-14 | N |
| Post nurse staffing information every day. | Health | 2024-03-05 | 2024-04-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-05 | 2024-04-14 | N |
| Ensure 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. | Health | 2024-03-05 | 2024-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-05 | 2024-04-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-05 | 2024-04-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-05 | 2024-04-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-05 | 2024-04-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-05 | 2024-04-14 | Y |
| Meet other general requirements. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-28 | 2024-04-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-13 | 2023-10-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-13 | 2023-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-02 | 2023-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-09-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-13 | 2023-03-06 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-13 | 2023-03-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-22 | 2023-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-22 | 2023-03-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-22 | 2023-03-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-22 | 2023-03-06 | Y |
| Honor 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. | Health | 2022-11-22 | 2023-03-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-22 | 2023-03-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-22 | 2023-03-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-22 | 2023-03-06 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-22 | 2022-12-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-22 | 2022-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-11-22 | 2022-12-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-22 | 2022-12-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-22 | 2022-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-22 | 2022-12-23 | N |
| Ensure 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. | Health | 2022-11-22 | 2022-12-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-22 | 2022-12-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-22 | 2022-12-23 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-11-22 | 2022-12-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-22 | 2022-12-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-22 | 2022-12-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-22 | 2022-12-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-12-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-12-23 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-22 | 2022-12-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-22 | 2022-12-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-22 | 2022-12-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-22 | 2022-12-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-22 | 2022-12-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-22 | 2022-12-23 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-11-22 | 2022-12-23 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-06 | 2022-08-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-25 | 2022-02-25 | Y |
| Honor 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. | Health | 2022-01-25 | 2022-02-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-25 | 2022-02-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-25 | 2022-02-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-25 | 2022-02-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-25 | 2022-02-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-25 | 2022-02-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-25 | 2022-02-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-25 | 2022-02-25 | Y |
| Post nurse staffing information every day. | Health | 2022-01-25 | 2022-02-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-14 | 2021-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-14 | 2021-09-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-14 | 2021-09-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-14 | 2021-08-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-14 | 2021-08-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-14 | 2021-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-14 | 2021-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-14 | 2021-08-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-14 | 2021-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-14 | 2021-08-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-14 | 2021-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-14 | 2021-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-14 | 2021-08-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-07 | 2021-08-09 | N |
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