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Complaint Investigation

Regency At Whitmore Lake

August 28, 2025 · Whitmore Lake, MI · 8633 N Main Street
Citations 2
CMS Rating 1/5
Beds 131
Provider ID 235545
Healthcare Facility
Regency At Whitmore Lake
Whitmore Lake, MI  ·  View full profile →
Inspection Summary

Regency at Whitmore Lake in Whitmore Lake, MI — inspection on August 28, 2025.

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.

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Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

have anything more to do with that incident.During an observation and interview on 08/27/2025 at 3:35 PM, R1 was observed leaving his room and stopped in the hallway. R1 stated R2 continued to walk down his hall which was hall 200 and not the hall R2 resided on. R1 stated R2 continues to attempt to always sit be him during activities. R1 stated it pissed him off, he got mad about it, and it upset him. R1 state R2 goes into activities and other events to be near him, and he didn't like it. R1 stated again, it really pissed him off.

During an interview on 08/28/2025 at 10:05 AM, Licensed Nursing Home Administrator (LNA) A stated that after the incident on 3/30/2025, R2 was transfer to the 100 hall and out of the memory care unit. LNA A stated R2 had kissed R1 and R3 outside of the memory unit. LNA A stated that R2 is now more involved in activities and eating in the dining room. LNA A added if nursing feels R2 needed one on one supervision, they would pull a CNA off the floor from providing care to be with R2 however, LNA A did not state what would cause nursing to feel R2 needed the one-on-one supervision. LNA A stated she didn't see R2 kissing R1 and R3 as inappropriate behavior, because R2 did not latch onto him but more of an affectionate thing.This writer asked LNA A if other residents and staff were interviewed that live or work on that hall.

LNA A stated no. LNA A stated she did not interview the residents that live on that hall, she would have had to interview all residents because R2 walks throughout the whole facility.

Writer asked LNA A if the staff working in that area on the dates that this took place were interviewed, LNA A stated no.This writer asked LNA A if IDT meetings were held and documented any follow up from these incidents. LNA A stated they discussed it during IDT meetings, but it is not documented anywhere.LNA A stated that I & A is a risk management report where the nurses document the event that accrued, notifies the LNA, family, DON, provider, describes the event, immediate action to take place, removed R2 from the memory care unit, SW H to follow up.

Looked for any predisposition factors, SW H wrote what they did, referred to psychiatric services, SW H became the key person to oversee this.

Could have had a telehealth visit made with the provider, LNA A and DON B discuss what should be done until they write up the 5-day report. LNA A stated they look at QA based on the audits, education to staff if there was a break in the process. LNA A stated they would put in new interventions if the current ones didn't work. LNA A stated they didn't have anything else to add.

Stated they went back to the care plan and added one-on-one supervision based off her behavior. R2 is more involved with activities.

Asked why she didn't change or add new interventions, because they were already doing everything, they said they were already in place and because it was working.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Whitmore Lake

8633 N Main Street Whitmore Lake, MI 48189

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/28/2025 at 10:05 AM, Licensed Nursing Home Administrator (LNA) A stated that after the incident on 3/30/2025, R2 was transfer to the 100 hall and out of the memory care unit. LNA A stated R2 had kissed R1 and R3 outside of the memory unit. LNA A stated that R2 is now more involved in activities and eating in the dining room. LNA A added if nursing feels R2 needed one on one supervision, they would pull a CNA off the floor from providing care to be with R2 however, LNA A did not state what would cause nursing to feel R2 needed the one-on-one supervision.

LNA A stated she didn't see R2 kissing R1 and R3 as inappropriate behavior, because R2 did not latch onto him but more of an affectionate thing.This writer asked LNA A if other residents and staff were interviewed that live or work on that hall. LNA A stated no. LNA A stated she did not interview the residents that live on that hall, she would have had to interview all residents because R2 walks throughout the whole facility.

Writer asked LNA A if the staff working in that area on the dates that this took place were interviewed, LNA A stated no.This writer asked LNA A if IDT meetings were held and documented any follow up from these incidents. LNA A stated they discussed it during IDT meetings, but it is not documented anywhere.LNA A stated that I & A is a risk management report where the nurses document the event that accrued, notifies the LNA, family, DON, provider, describes the event, immediate action to take place, removed R2 from the memory care unit, SW H to follow up.

Looked for any predisposition factors, SW H wrote what they did, referred to psychiatric services, SW H became the key person to oversee this.

Could have had a telehealth visit made with the provider, LNA A and DON B discuss what should be done until they write up the 5-day report. LNA A stated they look at QA based on the audits, education to staff if there was a break in the process. LNA A stated they would put in new interventions if the current ones didn't work. LNA A stated they didn't have anything else to add.

Stated they went back to the care plan and added one-on-one supervision based off her behavior. R2 is more involved with activities.

Asked why she didn't change or add new interventions, because they were already doing everything, they said they were already in place and because it was working.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Whitmore Lake, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Regency at Whitmore Lake or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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