Regency At Bluffs Park
Regency At Bluffs Park in Ann Arbor, MI — inspection on February 20, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of R200's Death Certificate revealed the following:date of death : November 30, 2025.
Immediate
of Injury: Nursing HomeA review of the facilities policy titled Fall Management, documented in part
needs.
Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.
235658 02/20/2026
Regency at Bluffs Park 355 Huronview Blvd Ann Arbor, MI 48103
CNA told the nurse that resident had been unconscious but was awake when the nurse arrived, he
bleed. DON reported that nursing staff should refer to the Care plan or Kardex to determine what level
the care plan was not followed and the resident should not have been ambulating with nursing staff due to weakness and immobility. DON reported that through their interviews it was determined that R200 had ambulated with nursing staff prior to this incident and that there was a walker at his bedside.
When asked if she knew why a set of orthostatic vital signs were completed on [DATE], she reported that she did not and would let me know if she was able to determine that (no additional information was provided prior to survey exit).
When asked if any new interventions were put in place for residents dizziness, lightheadedness and hypotension, DON reported that she would let me know if she found any documentation of new interventions (no additional information was provided prior to survey exit).
When asked what the expectation was for gait belt use, DON reported that a gait belt should be used for all transfers for anyone that requires any level of assistance.Review of R200's Death Certificate revealed the following: date of death : [DATE].
Immediate cause of death: Complications of blunt force head trauma and FallDate of injury: [DATE], Time of Injury: 0645 on or about, Describe how injury occurred: The decedent fell from standing height, Place of Injury: Nursing Home.A review of the facilities policy titled Fall Management, documented in part Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs.
Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.A review of the facilities policy titled Routine Resident Care, documented in part Staff members should observe the following safety precautions with all residents.Gait belts are used for transfers and ambulation, as indicated.R200's care plan, Kardex and Therapy to Nursing Communication sheet indicated resident should have been ambulated by therapy only.
The resident was ambulated by a single (non-therapy) staff member without a gait belt or use of sit to stand, despite documentation that resident had experienced lightheadedness/dizziness, episodes of hypotension and required substantial/maximal assistance which resulted in major injury (multiple skull fractures and brain bleed).