A list of the most recent deficiencies for Regency at Livonia. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-11 | 2023-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-11 | 2023-11-20 | N |
| Provide appropriate foot care. | Health | 2023-10-11 | 2023-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-11 | 2023-11-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-11 | 2023-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-11 | 2023-11-20 | 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 | 2023-10-11 | 2023-11-20 | Y |
| 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 | 2023-10-11 | 2023-11-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-11 | 2023-11-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-11 | 2023-11-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-11 | 2023-11-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-11 | 2023-11-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-07 | 2023-03-28 | Y |
| 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 | 2022-08-11 | 2022-09-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-11 | 2022-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-11 | 2022-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-08 | Y |
| Educate 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. | Health | 2022-08-11 | 2022-09-08 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-09 | 2022-09-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-16 | 2021-11-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-25 | 2021-09-17 | 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 | 2021-04-21 | 2021-05-17 | Y |
| 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 | 2021-04-21 | 2021-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-21 | 2021-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-21 | 2021-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-21 | 2021-05-17 | 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 | 2021-04-21 | 2021-05-17 | N |
| Post nurse staffing information every day. | Health | 2021-04-21 | 2021-05-17 | 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 | 2021-04-21 | 2021-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-21 | 2021-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-05-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-21 | 2021-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-21 | 2021-05-17 | N |
