Regency on the Lake - Fort Gratiot

In the surveyor’s words

From the most serious findings on record at Regency on the Lake - Fort Gratiot, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Feb 3, 2021

  Based on interview and record review, the facility failed to perform and maintain documentation of ongoing infection control surveillance, monitoring, and tracking in the resident population in a timely manner for all residents residing in the facility, resulting in the potential for unidentified trends of infections within the facility. Findings include: On 2/2/2021 at 10:14 AM, the Infection Control Nurse provided all of the facility's Infection Control documentation including surveillance, line listings and policies. At that time, she explained that she had not fully documented surveillance for any other infections within the facility aside from COVID-19. […]

• No harm, potential for more than minimal, isolatedF761Jul 2, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF580Apr 2, 2025

  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). […]

• No harm, potential for more than minimal, isolatedF684Jun 6, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF689Jun 6, 2024

  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. […]