Regency At Westland

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on observation, interview, and record review, the facility failed to timely implement care plan interventions following falls for one resident (Resident R107) out of three reviewed for plans of care. Findings include:On 1/27/2026 at 6:30 AM, Resident R107 was observed lying in bed with their feet hanging off the side. Resident R107's bed was not observed in a low position, with a blanket and sling pad underneath them. Registered Nurse (RN) H reported Resident R107 had just returned from the hospital following a fall where they hit their head and was on a blood thinner.A review of the medical record revealed Resident R107 was admitted into the facility on 1/13/2026 with the following medical diagnoses, Muscle Wasting and Atrophy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 5/15 indicating an impaired cognition. Resident R107 also required staff assistance with bed mobility and transfers.

Further review of Incident and Accidents (IA) reports noted the following: Date:1/24/2026.Nursing Description: Resident observed on [their] right side on the floor in-front of wheelchair before bedtime.Immediate action taken: Description: ROM (Range of Motion) performed without difficulty. No apparent injuries observed. Date: 1/26/2026.Nursing Description: Resident A&O X 1 (Alert and Oriented x 1), observed on the floor with head down. Abrasion observed to right side of face. Residents appear more confused than usual, old bruise to L (left) ring finger, and R (right) thigh. Unable to follow simple directions.

Throwing self to the floor, and on the side of the bed several times with difficulty to redirect. Also, on Eliquis (Blood Thinner) Oral Tablet 5 MG twice a day.Immediate action taken: Description: On call provider.made aware. New order received to send resident to ER (Emergency Room) for eval and tmt (treatment) post fall.A review of Resident R107's fall care plan did not reveal any new fall prevention interventions on 1/24/2026 or 1/26/2026 after Resident R107's readmission back into the facility.On 1/29/2026 at 11:45 AM, an interview was conducted with RN K, they reported when a resident falls in the facility, they (facility staff) talk about the fall

in their interdisciplinary team (IDT) meeting and decide what should be put in as an intervention. RN K stated the floor nurse is responsible for putting in a timely intervention after a resident fall. On 1/29/2026 at 1:53 PM, an interview was conducted with the Director of Nursing (DON), they confirmed timely interventions should be put in after someone falls. The DON reported the floor nurse does have guidelines

they can follow to put in timely interventions until the IDT meeting occurs.A review of a facility policy titled, Fall Management revealed the following, .4. The licensed nurse will complete.Review and/or revise care plan and link to the resident Kardex (resident care guide).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Westland

2209 North Newburgh Rd Westland, MI 48185

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 0/15 indicating

an impaired cognition. Resident R122 also required staff assistance with bed mobility and transfers.

Further review of the physician orders revealed the following, Start: 1/8/2026.Status: Active.Order: TLSO (Thoracic, Lumber, Spinal, Orthopedic) Brace to be work when out of bed for back.

Start: 1/8/2026.Status: Active.Order: Brace should be applied prior to patient being weight bearing.

On 1/27/2026 at 12:10 PM, Resident R122 was observed eating in the dining room in their wheelchair. No back brace was applied.

On 1/28/2026 at 9:07 AM, Resident R122 was observed sitting in a stationary chair with their breakfast tray in front of them and their head down on their bedside table. No back brace applied.

On 1/28/2026 at 10:25 AM, 10:42 AM and 11:17 AM, Resident R122 was observed up in a stationary chair. No back brace was applied.

On 1/29/2026 at 9:58 AM and 11:17 AM, Resident R122 was observed in sitting up in their wheelchair. No back brace was applied.

A review of the care plan and progress notes did not note any refusals regarding the application for Resident R122's back brace.

On 1/29/2026 at 10:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) U. LPN U reported Resident R122 tends to take off their back brace when it is applied. LPN U reported they put the brace on

this morning and has not gone back to check and see if they still had it on. LPN U reported that it should be documented if Resident R122 removed the back brace or refused to wear it.

A review of a facility policy titled, Physician's Order revealed the following, .It is the responsibility of the licensed nurse to follow physician orders.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Westland

2209 North Newburgh Rd Westland, MI 48185

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

known, in the medical record.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Westland

2209 North Newburgh Rd Westland, MI 48185

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

This citation pertains to intake 2648023Based on observation, interview, and record review, the facility failed to complete colostomy (an opening on the abdomen connecting the large intestine to the outside of

the body) care for one resident (Resident R148) out of two reviewed for colostomy care. Findings include:On 1/28/2026 at 9:21 AM, Resident R148 was observed lying in bed. Resident R148 was noted to have a colostomy located in their left lower abdomen. Resident R148 reported they had a colostomy and sometimes the staff forgets to empty it. Resident R148 reported if they tell staff, then they will empty it or change it. The resident stated one time their colostomy bag was so full, staff had to take two trips to empty it and were surprised their colostomy bag did not burst.A review of the medical record revealed Resident R148 admitted into the facility on 1/24/2026 with the following medical diagnoses, Colostomy Status and Diverticulitis of Large Intestines. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 11/15 indicating an impaired cognition. Resident R148 also required staff assistance with bed mobility and transfers. A review of the physician's orders did not reveal any orders related to colostomy care. Further review of the Treatment Administration Record (TAR) did not reveal any documentation related to providing colostomy care to Resident R148.On 1/29/2026 at 9:21 AM, an interview was conducted with Unit Manager (UM) V. UM V reported when a new admit comes in, the admitting nurse should put in the orders for things like a colostomy. UM V reported they complete chart audits and will clean up orders or add missing orders. On 1/29/2026 at 1:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they were unsure why

the colostomy care orders were not entered on admission. The DON reported the unit managers do chart audits and double check the orders after new admissions.A review of a facility policy titled, Colostomy did not address colostomy care.

Event ID:

Facility ID:

If continuation sheet