Regency At Jackson
Regency at Jackson in Jackson, MI — inspection on February 27, 2026.
Found 12 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
on his legs. LPN E stated earlier that day R106 was fine, around dinner time he was not fine, she got
room. LPN E stated R106's wife had left midafternoon, stated she called his wife. LPN E stated she
nursing progress notes, then stated she don't know if she had done that or not. LPN E then stated maybe they didn't send it, then stated it was kind of crazy at that time and it was the end of her shift.
Writer asked if she called the provider about this change in condition, stated she couldn't remember.
Writer asked if she had documented all the events that took place during this change in condition for R106, LPN E stated I think so and left at the end of her shift.
Record review of the nursing progress notes did not reflect that LPN E had called the primary provider nor the on call provider was notified of this emergency, prior to LPN E leaving at the end of her shift while EMS was still in house.
Nor did it reflect that R106 had been given the bed hold policy, transfer/discharge paperwork.During an interview on 02/20/26 at 3:10 PM, Social Worker H stated she thought she did some of those, unsure as she described an unplanned discharge and her role in those.
Social Worker H stated she did not see a progress note in his chart, then stated when she did the bed hold/transfer/discharge paperwork, she puts her progress note under regular progress note tab.
Writer asked if R106's wife was notified that he was being sent out to the hospital, and she stated it didn't look like it.
During an interview 02/24/2026 at 11:54 AM, prior Director of Nursing (DON) B stated R106's wife stopped her and told her she had concerns on his/R106's care.
Writer asked prior DON B if she was notified of the change in condition on R106 prior to sending him out to the hospital, prior DON B stated she didn't get an update until after they sent him out, after the fact.
Prior DON B stated they did talk to the nurse about the course of events that took place and what could they have done differently.
Writer asked prior DON B if the on-call provider had been notified of this change in condition needing to be sent out.
Prior DON B stated she wasn't sure as she found out about this after the fact.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
During an interview on 2/27/26 at 2:30 p.m., DON C reported 12 residents require assist of two with care needs.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
incident from the day shift. LPN U reported had just returned from break and CNA S reported that
move R104's room to another floor but police arrived and arrested R104 and removed from the facility.
neck and police officer had take photos. LPN U reported two staff were present on 2nd floor at the time of the incident, CNA S and LPN T. LPN U reported R103's Mother R arrived to facility shortly after being notified of incident and was very upset and wanted to confront R104 and verified staff did not allow.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
was dependent on staff for transfers, toileting and showers.During a telephone interview on 2/26/26
laid down entire night shift and grievance form was completed for resident and given to the NHA A.
morning when day shift arrived. CNA W reported R112 was heavily soiled with urine and stool and required shower after being left up in chair entire 12 hour night shift. CNA W' reported no CNA staff arrived during the night shift or were present on Sunday morning when she arrived. CNA W reported two nurses were present on Saturday night shift. CNA W reported when one CNA is scheduled cannot perform every 2 hour check and changes timely for all residents, not enough staff. CNA W reported potential allegations of abuse related to care concerns were reported to nursing staff on 2/22/26 around 7:00 a.m.
During an interview on 2/27/26 at 10:10 a.m., Licensed Practical Nurse (LPN) X verified no CNA staff worked Saturday 2/21/26 into 2/22/26 night shift on second floor. LPN X reported called on call manager, Prior Director of Nursing (PDON) B to inform and told to call Nurse Y to cover. LPN X reported Prior DON C never comes in to work if she is on call. LPN X reported CNA Z stayed over late 2/21/25 to get most residents to bed and left three residents up in chairs. LPN X reported same three residents remained up in chairs and with same clothing on upon return in morning for 7am day shift. LPN X reported management staff informed because potential allegation of neglect and resident care needs were not met. LPN X reported two nurses worked 2/21/26 into 2/22/26 night shift 7pm to 7am and second nurse was called in to work as CNA staff but was older and not physically able and was passing medications working as nurse.
During an interview on 2/27/26 at 10:58 am NHA reported did not have any concern forms for R105 and verified no care concern forms for R110, R111, R112, or R113 in past 30 days and no additional allegations of abuse over the weekend.
During an interview on 2/27/26 at 11:10 NHA A reported no knowledge of three resident who remained up all shift on night shift 2/21/26 into 2/22/26. NHA A reported would expect staff to report concerns to management staff including allegations abuse/neglect immediately to NHA A or DON and complete grievance forms for residents if necessary.During a telephone interview on 2/27/26 at 12:48 p.m., facility Scheduler BB reported no longer worked at the facility as of today.
Scheduler BB reported to NHA A that was unable to fill schedule at least every other weekend and up to 3 times weekly.
Scheduler BB reported attempted to have at least four to five CNA staff and 2 nurses on days on each floor and was told by NHA A to just add transportation staff CC and Medical Record staff DD to schedules and advise to get with Director of Nursing B who reported to call staff.
Scheduler BB reported DON B was informed after all attempts had been made to fill schedule including call staff and no one would come in with no support.
Scheduler BB reported often completed concern form related to care concerns not being met and staffing at least two times weekly and provide to NHA A and DON B.
Scheduler BB reported also report concern to management who shake heads and advise to speak with another manager.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
distress.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
documented all the events that took place during this change in condition for R106, LPN E stated I
prior to LPN E leaving at the end of her shift while EMS was still in house.
Nor did it reflect that R106
2:49 PM, Registered Nurse (RN)/Unit Manager F Stated the nurses send the bed hold policy, transfers/discharge paperwork with the resident, then stated they should be documenting it in the nursing progress notes, but obviously they didn't as she looked through the nursing progress notes the date and time he was sent out.
During an interview on 02/20/26 at 3:10 PM, Social Worker H stated she thought she did some of those, unsure as she described an unplanned discharge and her role in those.
Social Worker H stated she did not see a progress note in his chart, then stated when she did the bed hold/transfer/discharge paperwork, she puts her progress note under regular progress note tab.
Writer asked if R106's wife was notified that he was being sent out to the hospital, and she stated it didn't look like it.
During an interview 02/24/2026 at 11:54 AM, prior Director of Nursing (DON) B stated R106's wife stopped her and told her she had concerns on his/R106's care, transferring him to the bathroom, was given the call light, dropped the call light, CNA didn't realize he had dropped the call light, went in right away after that.
Prior DON B stated by the time the wife brought her the concerns, he was off the toilet and cleaned up.
Writer asked prior DON B if she had filled out a grievance form, stated she didn't fill out a grievance or concern form, but informed wife that she could fill one out.
Writer aske prior DON B about his call light being put in the dresser drawer out of his reach to use.
Prior DON B stated she assumed it was put in the drawer at some point, moved out of the way for care but doesn't really know, but didn't follow up so to speak.
Prior DON B stated she would stop in on rounds and didn't see where his call light was not available.
Writer asked prior DON B if she was notified of the change in condition on R106 prior to sending him out to the hospital, prior DON B stated she didn't get an update until after they sent him out, after the fact.
Prior DON B stated they did talk to the nurse about the course of events that took place and what could they have done differently.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
Review of R104's care plans revealed there was no care plan in place for R104's decision to leave the facility against medical advice (AMA) or go on leave of absence (LOA).
There was no documentation that R104 had participated in care planning related to his decision to go AMA or on a LOA.
Review of the most recent Interdisciplinary Team (IDT) meeting notes dated 10/23/2025 revealed no discussion related to R104's decision to go on LOA against medical advice and/or regarding the form he had signed.
There was no documented discussion of care planning. Resident #108 (R108):Per the facility face sheet Resident #108 (R108) was admitted to the facility on [DATE].
Record review of a Minimum Data Set (MDS) dated [DATE], revealed R108 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated R108 cognition was intact.Review of LOA sign out sheets revealed R108 frequently left the faciity on LOA.
Review of IDT notes dated 12/29/2025 revealed no discussion regarding R108 going on LOA and evaluation of safety.Review of R108's care plans revealed no care plan in place that addressed R108's LOA and safety interventions and assessments. In an interview on 2/25/2026 at 2:10 PM, Director of Nursing (DON) C stated she did not find an evaluation for R108's ability to go on LOA and said she did not find any documentation from IDT for R108's LOA ability. DON C stated that her expectation was that an evaluation and care planning be completed for a resident who goes LOA.
Review of the facility's policy and procedure dated 11/16/2022; revealed, A corresponding care plan shall also be developed and initiated.
The care plan shall address any applicable clinical issues such as the Resident's possible need for medication(s) during leaves, education related to the administration of such medication, and possible dietary issues during leaves.
Any other potential concerns or problems should also be addressed.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
Review of the medical record reflected that R106 was admitted to the facility on [DATE].
Diagnoses
related ulcers in the lower extremities, Dementia and peripheral vascular disease.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2026 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of
- Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial
assistance with showering and personal care. R106 was dependent on toileting and perineal hygiene.
During an interview on 02/20/2026 at 2:40 PM, Certified Nursing Assistance (CNA) G stated they serve water to the residents when they ask or during each shift, there should be dates and times on the foam cups.
Writer asked CNA G if they had enough staff to provide the care to those residents.
CNA G stated all they can do it go one room at a time, and she had to decide if she was going to pass lunch trays or care for residents.
During an interview on 02/24/2026 at 10:15 AM, R106's family member M stated R106 was only at this facility three weeks. R106's family member M stated R106 had not received showers but one time during his stay. He had a pull up on and would pull on the side of it so he could pee in the urinal.
He/R106 would ask to go poop, and he couldn't go on a bed pan, she told them he would go on a commode, so they didn't, they brought him the bed pan.
R106's family member H added that they finely took him into the bathroom to sit on the toilet, his call light was behind him and he couldn't reach it. He sat on the toilet and yelled for someone to come in help him.
Staff told him to use the call light, but he couldn't reach the light, so he had to yell out for help.
Finally, someone came in to help him get off the toilet.
Record review revealed R106 was scheduled to receive showers every Wednesday and Saturday morning.
The completed task sheet revealed R106 did not receive a shower on 01/07/2026 with no reason given for not providing this shower.
Record revealed R106 refused a shower on 01/10/2026 but did not provide an explanation or any additional attempts to shower him that day.
The completed task sheet revealed R106 did not receive a shower on 01/14/2026, with no reason given for not providing this shower.
The completed task sheet revealed R106 received a shower on 01/21/2026.
R106 was not offered a shower on 01/17/2026 or on 01/24/2026. R106 received one shower during his three weeks stay at the facility.
During an interview on 02/24/2026 at 2:30 PM, Director of Nursing (DON) B stated her expectations would be that the CNAs ask the residents once, if they decline or refuse, have another CNA go in and ask if they could give him a shower, it they still say no, then let the nurse know.
Record review did not reveal any documentation as to why the showers were not given, no documentation to support they had asked more than once, nor supporting documentation supporting the CNAs told the nurse they were not able to shower R106 on one of his scheduled days.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
(R108) an evaluation was completed to determine ability for leave of absence (LOA).Findings
[DATE].
Record review of a Minimum Data Set (MDS) dated [DATE], revealed R108 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated R108 cognition was intact.
During an interview with R108 on 2/25/2026 at 12:02 PM, R108 was observed lying in bed and answered all questions appropriately.Per progress notes dated 2/11/2026, R108 had signed out LOA with another resident, and upon returning to the facility R108 did not use the crossed walk to cross back over the street.
Upon crossing the street, R108 was struck by a vehicle that was aggressively driving over the speed limit. R108 was found to have fractured spleen, rib, and laceration of the scalp.
Record review of a care plan dated 10/25/2026, revealed a care plan was in place that identified R108's impaired visual function, related to visual changes as result from stroke.
The care plan did not have any interventions that addressed R108's LOA for safety with visual impairment.Per the facility policy and procedure dated 11/16/2022 and titled, Resident Leave of Absence Policy, .The nature of the environment and individual associations related to the leave should also be considered.
Affected Residents should be evaluated regarding such abilities at admission, quarterly, upon a significant change in condition, and following any new developments that may warrant a change in the findings of the evaluation.In an interview on 2/25/2026 12:20 PM, Social Worker N (SW) stated that she had heard that staff had to know if a resident was safe to go out on LOA as their own responsible person.
SW N said she would imagine that there was an assessment form that was used. SW N said she had never seen an assessment form, nor had she ever performed an assessment on a resident.
Record review of R108's electronic medical record (EMR) revealed there was one Interdisciplinary Team (IDT) meeting on 11/11/2025, however the meeting notes did not address R108's LOA and did not evaluate R108's ability to go on an LOA safely.In an interview on 2/25/2026 at 2:10 PM, DON B upon review of R108's EMR, stated that she was not able to find an evaluation for LOA ability for R108. DON B stated that it was her expectation that the policy be followed, and an IDT meeting be held where an evaluation for LOA ability was completed.No IDT meeting or evaluation for R108's LOA ability was conducted or found in R108's EMR after the 2/11/2026 accident.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
During an interview on 2/27/26 at 2:30 p.m., DON C reported 12 residents require assist of two with care needs.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
refrigeration.
jeopardy to resident health or 2/19/26 Electrician notified to inspect for correct plug for steamer to be used in temporary kitchen. safety They rewired to accommodate the steamer in the temporary kitchen and passed to use now in the temporary kitchen.
2/19/26 Steam table disinfected once it was removed from construction zone. 2/19/26 Hand washing station was delivered and is set up in the temporary kitchen While the Immediate Jeopardy was removed on 2/19/2026, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy at scope and severity of widespread, due to the fact that sustained compliance has not been verified by the state agency.
235016 02/27/2026
Regency at Jackson 434 W North Street Jackson, MI 49202
ensure immunizations were administered for one out of three residents (Resident #108) who
vaccinations.Findings Included:Per the facility face sheet Resident #108 was admitted originally admitted to the facility on [DATE]; with a most recent admission date of 2/14/2026.Review of a consent form revealed R108 had signed the consent on 10/28/2025 to receive the vaccination.Review of a consent form revealed R108 had signed a consent on 10/28/2026 to receive the vaccination.Review of R108's electronic medical record (EMR) revealed under immunizations that the RSV and PCV20 immunizations were pending immunization with a confirmation date of 10/28/2025.
Record review of R108's Physician orders for the month of October 2025 through 2/26/2026 revealed no Physician's order was ever written for either of the vaccinations to be administered.Review of Medication Administration Records (MARS) for the months of October through December 2025, and January and February 2026 revealed neither the PCV nor RSV vaccinations were documented on the MARS as administered to R108.In an interview on 2/26/2026 at 2:25 PM, Director of Nursing (DON) B stated that R108 did sign the consent forms for the RSV and PSV20 vaccinations, but after reviewing the October ad November 2025 MARS DON B said R108 never received the two vaccinations. DON B also reviewed R108's progress notes for the months of October and November 2025 and stated that there was no documentation of R108 receiving the two vaccinations, nor a note of the reason why R108 did not receive the two vaccinations.On 2/26/2026 at 3:23 PM, DON B stated that she was able to look into R108's 10/28/2025 consent for the PSV20 and RSV vaccination, and found the consents were signed by R108 on 10/28/2026, but the vaccinations were never administered. DON B said the vaccinations should have been administered to R108 because R108 requested them and signed consent.