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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 →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
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.

Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies

care unit. LNA A stated R2 had kissed R1 and R3 outside of the memory unit. LNA A stated that R2 is

LNA A did not state what would cause nursing to feel R2 needed the one-on-one supervision. LNA A

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.

235545 08/28/2025

Regency at Whitmore Lake 8633 N Main Street Whitmore Lake, MI 48189

During an interview on 08/28/2025 at 10:05 AM, Licensed Nursing Home

LNA A stated that R2 is now more involved in activities and eating in the dining room. LNA A added if

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.

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.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.