Regency at Whitmore Lake: Care Plan Failures After Kisses - MI
The inspection at Regency at Whitmore Lake, completed August 28, 2025, stemmed from a complaint. It centered on an incident that took place March 30, 2025, when a resident identified in the report as R2 kissed two other residents, identified as R1 and R3, outside the memory care unit. A receptionist separated the residents and notified the Director of Nursing and the Licensed Nursing Home Administrator. The receptionist told the inspector she helped fill out the required form and was told it would be submitted to the state. After that, she said, she had nothing more to do with it.
What followed, according to the administrator's own account five months later, was an investigation that interviewed nobody.
Licensed Nursing Home Administrator A told the inspector that after the March incident, R2 was transferred out of the memory care unit to the 100 hall and became more involved in activities and dining. She said that if nursing felt R2 needed one-on-one supervision, they would pull a certified nursing assistant off the floor to provide it. She did not describe what would trigger that decision.
When the inspector asked whether residents or staff who lived or worked on that hall had been interviewed, the administrator said no. She said she would have had to interview all residents because R2 walked throughout the whole facility. When asked whether staff working in the area on the dates of the incidents had been interviewed, she said no again.
When asked whether the interdisciplinary team meetings held afterward had been documented, she said they had discussed it in those meetings, but it was not documented anywhere.
The administrator described the facility's incident and analysis process, walking through the steps: nurses document the event, notify the administrator, the director of nursing, the family, and the provider; a social worker follows up; psychiatric services were referenced; the social worker became the key person overseeing R2's situation. She said the care plan was updated to add one-on-one supervision based on R2's behavior. She said they look at quality assurance through audits and provide staff education if there's a break in the process.
Then she said they didn't have anything else to add, because they were already doing everything, and because it was working.
R1, observed in the hallway the day before that interview, told the inspector a different story. He said R2 continued to come down his hall, which was not the hall R2 lived on. He said R2 kept trying to sit near him during activities. He said it pissed him off, that he got mad about it, that it upset him. He said R2 goes into activities and other events specifically to be near him, and he didn't like it. He said again: it really pissed him off.
The administrator told the inspector she did not see the kissing as inappropriate, describing it as more of an affectionate thing, because R2 had not latched on.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a few residents. It falls under the federal tag governing care planning, specifically the requirement that facilities develop and update care plans that reflect each resident's needs and the interventions meant to address them.
What the inspection documents is a gap between the process the administrator described and what was actually done. Discussions happened but weren't written down. Interventions were listed as already in place. No one who witnessed the incidents or worked near them was asked what they saw. The care plan was updated. The situation, the administrator said, was being handled.
R1, five months after the incident that prompted all of this, was still watching R2 come down his hallway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At Whitmore Lake from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
Regency at Whitmore Lake in Whitmore Lake, MI was cited for violations during a health inspection on August 28, 2025.
The inspection at Regency at Whitmore Lake, completed August 28, 2025, stemmed from a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.