Regency At Westland
Regency at Westland in Westland, MI — inspection on January 29, 2026.
Found 4 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
actions that can be measured.
interventions following falls for one resident (R107) out of three reviewed for plans of care.
Findings
R107's bed was not observed in a low position, with a blanket and sling pad underneath them.
Registered Nurse (RN) H reported 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 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. 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 R107's fall care plan did not reveal any new fall prevention interventions on 1/24/2026 or 1/26/2026 after 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
235655 01/29/2026
Regency at Westland 2209 North Newburgh Rd Westland, MI 48185
recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 0/15
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, R122 was observed eating in the dining room in their wheelchair. No back brace was applied.
On 1/28/2026 at 9:07 AM, 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, 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, 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 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 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 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.
235655 01/29/2026
Regency at Westland 2209 North Newburgh Rd Westland, MI 48185
smoke.
generally went out at the same time and about the same number of times each day.
On 01/29/2026 at 12:08 PM, the Director of Nursing (DON) was aware R17 would go on LOA, and the nurse should be informed of a resident's departure, even when accompanied by a CNA.
On 01/29/2026 at 12:48 PM, Social Worker (SW) G was asked about R17 and reported they had known of R17 since their admission and R17 had consistent LOAs due to the resident ear appointments.
R17's care conferences and mental status were reviewed, and it was noted that all Minimum Data Set (MDS) assessments since admission had documented R17 as cognitively intact with a 15/15 Brief Interview for Mental Status (BIMS) score. It was confirmed the last care conference had been held on 02/25/25 and a care plan entry for an LOA was not routinely completed unless there had been a problem. A review of the elopement risk documentation indicated R17 was at No risk. 01/29/2026 2:59 PM, Physician F reported 'leave of absence with medications' orders are only given when residents have capacity (deemed competent).
A review of the record for R17 they were admitted into the facility on [DATE] and readmitted [DATE], 01/26/25 and 03/19/25.
Diagnoses included Nicotine dependence, Alcohol Dependence, Falls, Stroke and Syncope (Fainting).
The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 BIMs score and R17 was independent for all activities of daily living which included walking without an assistive device. A review of the progress notes revealed no indication staff were aware R17 was not signing out or back in following smoke breaks or appointments. A review of the care plan revealed R17 was at risk for falls. It was confirmed by the Administrator on 01/29/26 at 2:25 PM via email that no care plan for the LOA had been completed.
A review of the facility policy titled, Care Planning effective 03/03/25 revealed, .The care plan must be specific, resident centered, individualized and unique to each resident .
A review of the policy titled Resident Leave of Absence Policy, dated as last approved on 3/7/2023 revealed the following: Specifically, the IDT shall evaluate whether it is clinically appropriate for the Resident to leave and/or discharge from the Facility without supervision, and/or whether there are any other concerns related to such leaves or discharges whether they be supervised or unsupervised.
Such concerns may include, but are not limited to, the Resident's possible use and/or possession of drugs or alcohol, and behaviors involving the possible participation in illegal activities.
Further review of the facility policy titled, Resident Leave of Absence Policy dated as last approved on 3/7/2023, .IV. LEAVE PROCEDURE: .2.If the Resident has been approved for a Leave of Absence or is Leaving the Facility Against Medical Advice, the Resident and/or Responsible Party shall make an effort to notify the Facility in advance regarding the date, time location and expected length of a planned leave of absence from the Facility. 3.
Residents and/or Responsible Parties shall Sign Out before leaving the Facility for a Leave of Absence by indicating the time of the leave, any family or friends accompanying the Resident during the leave, applicable contact information and the proposed location and estimated length for the leave.
Residents or Responsible Parties shall also 'Sign In upon returning to the Facility following a Leave of Absence. If the Resident refuses or fails to Sign In or Out relative to a Leave of Absence, Facility staff should document such information, if known, in the medical record.
235655 01/29/2026
Regency at Westland 2209 North Newburgh Rd Westland, MI 48185
such services.
facility failed to complete colostomy (an opening on the abdomen connecting the large intestine to the
include:On 1/28/2026 at 9:21 AM, R148 was observed lying in bed. R148 was noted to have a colostomy located in their left lower abdomen. R148 reported they had a colostomy and sometimes the staff forgets to empty it. 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 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. 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 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.