Regency at Troy: Tracheostomy Care Failures - MI
The resident, identified in inspection records as R708, was admitted to Regency at Troy on West Maple Road sometime before November 20, 2025, when state inspectors arrived to investigate a complaint. What they found was a facility that had accepted a medically complex patient without verifying it had the staff or supplies to keep him alive.
The first nurse assigned to R708 told inspectors she was not comfortable caring for him and had no tracheostomy experience. She said the resident came with supplies but she wasn't sure which ones. When R708 communicated through his whiteboard that he needed suctioning, she told him she didn't know how to do it.
LPN H, a charge nurse who spoke with inspectors, described what happened next. The facility located a nurse on another floor who had tracheostomy experience and swapped assignments, putting that nurse with R708 for the duration of his stay. It was a solution improvised after the fact, after a patient who could not speak had already been left without someone who could suction his airway.
"It was a very scary situation because I wasn't comfortable," LPN H told inspectors.
R708 apparently agreed. He wrote on the communication board that he wasn't comfortable at the facility and that he was leaving the next day. He was transferred out the following day.
What LPN H described to inspectors also revealed a breakdown that started before the resident ever arrived. When LPN H notified the Director of Nursing about R708's admission, the DON's response was not to ask about his care needs or whether staff were prepared. The DON asked who had authorized the admission, because she hadn't.
That exchange captures the core of what inspectors cited: a facility that accepted a patient requiring specialized airway management without the clinical leadership knowing it was happening, without confirming trained staff were available, and without ensuring the necessary supplies were on hand and identifiable.
Tracheostomy suctioning is not an optional comfort measure. Secretions that accumulate in or around a tracheostomy tube can obstruct the airway. A patient who cannot clear his own airway and cannot speak to call for help depends entirely on whoever is assigned to his care knowing what to do and being willing to do it. R708 had a whiteboard. He used it. The nurse assigned to him said she didn't know how.
Inspectors cited the deficiency under F0684, which addresses the standard of care residents are entitled to receive. The harm level was recorded as minimal harm or potential for actual harm, affecting a few residents. The citation does not reflect what might have happened if R708 had not been alert enough to write his needs on a board, or if no experienced nurse had been found on another floor, or if the transfer had taken longer than one day.
Regency at Troy provided no further explanation or documentation before the survey concluded.
R708 left the facility on his own terms, in writing, the morning after he arrived. Whether he found a facility that knew how to care for him, the inspection record doesn't say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At Troy from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Regency at Troy in Troy, MI was cited for violations during a health inspection on November 20, 2025.
What they found was a facility that had accepted a medically complex patient without verifying it had the staff or supplies to keep him alive.
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.