A list of the most recent deficiencies for Regency On The Lake - Fort Gratiot. 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 | 2023-09-05 | 2023-09-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-04 | 2023-04-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-04 | 2023-04-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-04 | 2023-04-25 | 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 | 2023-04-04 | 2023-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-04 | 2023-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-04 | 2023-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-04 | 2023-04-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-03 | 2023-04-25 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-11 | 2022-09-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-11 | 2022-09-05 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-01-26 | 2022-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-02-18 | N |
| 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 | 2022-01-24 | 2022-02-18 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-01-24 | 2022-02-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-24 | 2022-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-24 | 2022-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-24 | 2022-02-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-24 | 2022-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-04 | 2021-05-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-02-03 | 2021-03-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-02-03 | 2021-03-05 | 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 | 2021-02-03 | 2021-03-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-03 | 2021-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-03 | 2021-03-05 | 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 | 2021-02-04 | 2021-03-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-02-04 | 2021-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-04 | 2021-03-05 | N |
