A list of the most recent deficiencies for Regency at Lansing West. 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 | 2023-10-31 | 2023-12-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-11 | 2023-10-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-15 | 2023-06-16 | 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 | 2023-05-15 | 2023-06-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-15 | 2023-06-07 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-05-15 | 2023-06-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-15 | 2023-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-15 | 2023-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-15 | 2023-06-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-15 | 2023-06-07 | 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 | 2023-05-15 | 2023-06-07 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-05-15 | 2023-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-15 | 2023-06-07 | N |
| 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 | 2023-05-15 | 2023-06-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-15 | 2023-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-15 | 2023-06-07 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-10 | 2023-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-10 | 2023-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-10 | 2023-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-10 | 2023-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-10 | 2023-06-07 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-01-18 | 2023-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-18 | 2023-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-06 | 2023-01-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-06 | 2023-01-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-24 | 2022-07-01 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-05-24 | 2022-07-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-24 | 2022-07-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-24 | 2022-07-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-24 | 2022-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-24 | 2022-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-24 | 2022-07-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-24 | 2022-07-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-24 | 2022-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-24 | 2022-07-01 | N |
| Post nurse staffing information every day. | Health | 2022-05-24 | 2022-07-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-24 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-24 | 2022-07-01 | N |
| Dispose of garbage and refuse properly. | Health | 2022-05-24 | 2022-07-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-24 | 2022-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-24 | 2022-07-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-24 | 2022-07-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-26 | 2022-02-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-26 | 2022-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-02-25 | Y |
| 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 | 2022-01-26 | 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 | 2022-01-26 | 2022-02-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-26 | 2022-02-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-14 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-29 | 2021-09-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-29 | 2021-09-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-29 | 2021-09-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-11 | 2021-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-11 | 2021-04-14 | 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 | 2021-03-11 | 2021-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-11 | 2021-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-11 | 2021-04-14 | 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 | 2021-03-11 | 2021-04-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-11 | 2021-04-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-11 | 2021-04-14 | 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 | 2021-03-11 | 2021-04-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-03-11 | 2021-04-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-03-11 | 2021-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-11 | 2021-04-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-10 | 2021-04-14 | N |
