Regency At Whitmore Lake

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure one out of three residents (Resident #12) received activities of daily living (ADL) care per the plan of care. Findings Included: Review of a Minimum Data Set (MDS) dated [DATE REDACTED] on page #21 under section GG revealed, Resident R12 was dependent on staff for Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed.The MDS defined dependent as, Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 12/23/2025 at 10:16 AM, Certified Nurse Aid (CNA) J was observed to perform catheter care for Resident #12 (Resident R12) while Resident R12 was in bed. Resident R12 was observed to be laying on the left side of the bed, Resident R12's left side and not in the middle of the bed, CNA J proceeded to tell Resident R12 to roll over to his left side, in which Resident R12 did. CNA J performed peri care and took out the old bedding from underneath Resident R12;

during that time Resident R12 was rolled to his left side Resident R12 stated to CNA J he was going to roll over the edge of

the bed. CNA J said OKAY, however did not roll Resident R12 immediately back onto his back, and continued to finish putting the new bedding and brief underneath Resident R12.During the observation Resident R12 was observed to be very close to the edge of the left side of the bed when he was rolled over to his left side. Furthermore, CNA J was observed to have rolled Resident R12 away from her and not towards her when she turned Resident R12 to his left and also to his right side while in the bed. There were not handrails for Resident R12 to hold onto or to possibly stop him from rolling out of the bed onto the floor.Review of Resident R12's care plans dated 11/12/2025, revealed a care plan was in place with a Focus of (Resident R12) has a functional ability deficit and requires assistance with self care/mobility . The care plan included an intervention that instructed staff for BED MOBILITY: (Resident R12) requires Dependent assist of two helpers with bed mobility. This is including rolling side to side, lying to sitting on side of bed and sitting to lying. The intervention was dated 11/12/2025. Review of Resident R12's Kardex (a residents documented plan of care for CNA to review and know how to care for a resident) revealed under BED MOBILITY: (Resident R12) requires Dependent assist of two helpers with bed mobility. This is including rolling side to side, lying to sitting on side of bed and sitting to lying. The intervention was dated 11/12/2025. In an

interview with CNA J on 12/23/25 at 10:39 AM, CNA J stated Resident R12 was a one person assist while in bed for bed mobility. CNA J was asked when the last time was that she had reviewed Resident R12's Kardex (plan pf care), CNA J stated about three days ago. In an interview on 12/23/2025 at 10:41 AM Director of Nursing (DON) B stated that Resident R12's care plans instruct staff to provide a two person assist for bed mobility and rolling side to side in bed, DON B said her expectation was that two staff members provided bed mobility care, including while rolling Resident R12 side to side in bed. DON B also stated that her expectation for any staff member rolling a resident in bed side to side with just a one-person assist was to roll the resident towards them and not away from them.

Residents Affected - Few

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

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If continuation sheet

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