Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency At Shelby Township during CMS and state inspections, most recent first.
Delayed care and failure to implement care plans: A resident with a heel DTI was observed without the ordered PRAFO boot in place, another resident with hemiplegia and incontinence reported delayed response and being left in urine-soaked clothes, and a third resident with cancer-related pain reported waiting over 2 hours for PRN pain medication despite a care plan directing immediate response to pain complaints. Staff described a busy unit with high resident assignments and call-offs, and the DON acknowledged staffing shortages.
A resident with a wound order had the dressing left in place beyond the scheduled change and was later found with a soiled bandage still dated from several days earlier. Another resident with bilateral AKA stumps had an order to keep the stumps offloaded with pillows while in bed, but staff repeatedly observed the stumps resting on the mattress. A third resident had an order allowing limited ice chips and specifically stating not to leave a cup of ice at bedside, yet a cup of ice was repeatedly observed at the bedside and staff could not explain the order.
Failure to provide appropriate pressure ulcer care was identified for a resident with a stage 4 sacral PU and malnutrition. The resident had orders to use a wedge pillow and be repositioned every 2 hours as tolerated, but was observed in bed with the HOB flat and no positioning device in place, while the wedge was found in a chair or closet. The resident stated the wedge had not been used in a while except briefly for left shoulder pain, and the WCN confirmed the resident should be repositioned regularly and that the wedge order was in place.
Medication labeling and dating were not maintained in one medication cart. An RN found two insulin lispro vials without dates, including one for an active resident and one for a discharged resident, and a fluticasone-salmeterol inhaler without a resident identifier or date opened. The DON stated the nurse should label both the carton and the medication, and the facility policy required medications to be dated and discarded per manufacturer guidelines.
The facility failed to respond promptly to call lights, affecting two residents and two rooms. One resident reported wait times up to forty-five minutes, while another's call light was ignored by multiple staff members. The facility's policy requires timely responses, but staffing challenges and known issues with response times were noted.
The facility failed to follow proper infection control practices in a contact isolation room and did not store nebulizer and C-Pap masks correctly for several residents. A maintenance assistant entered a contact isolation room without PPE and did not perform hand hygiene. Additionally, nebulizer and C-Pap masks were observed on nightstands without barriers, contrary to the facility's cleaning and storage protocols.
A resident expressed discomfort with their bed due to obesity, as it provided little room for movement. Despite staff acknowledging the need for a bariatric bed, the resident continued to experience dissatisfaction. The facility's policy emphasized the importance of appropriate beds for obese residents, but the resident's needs were not met.
A resident with a lumbar fracture was observed without a medically ordered back brace due to its omission from the care plan and Kardex. Staff were unaware of the requirement, leading to a deficiency in care planning as confirmed by the DON.
A facility failed to update a care plan for a resident with Alzheimer's and other conditions, who exhibited wandering behaviors and entered other residents' rooms at night. Despite observations and resident complaints, the care plan lacked new interventions since its initiation. The Social Worker and DON acknowledged the need for updated interventions, contrary to the facility's care planning policy.
A resident experienced a decline in functional abilities due to the facility's failure to provide scheduled restorative services. Initially receiving therapy, the resident was referred to a restorative nursing program but only received services once in 12 weeks, contrary to the scheduled three times a week. This lack of care was confirmed by staff and the absence of documentation.
A resident with lung cancer and COPD was observed with a freestanding oxygen tank in their room, contrary to the facility's policy requiring tanks to be secured by a chain, cart, or stand. The resident, who had intact cognition, was receiving continuous oxygen therapy. A CNA acknowledged the issue and intended to address it immediately.
A facility failed to obtain physician orders for colostomy care for a resident with Chronic Respiratory Failure and Major Depressive Disorder. The resident, who had an intact cognition and required assistance with mobility, reported needing to remind staff to empty their colostomy bag. The Director of Nursing acknowledged the oversight, noting the resident's colostomy care orders were not reactivated after hospital readmissions. The facility's policy did not address the need for colostomy care orders.
A resident with anxiety disorder and depression expressed suicidal ideation and was not provided with ongoing behavioral health services. Despite the resident's significant mood changes and verbal distress, there was no recent psychiatric follow-up or intervention. The facility's social worker was aware of the resident's concerns but only provided limited support, and the care plan's guidelines for monitoring and consulting behavioral health services were not followed.
A resident with neuromuscular dysfunction of the bladder experienced a delay in catheterization after returning from a doctor's appointment, leading to feelings of sadness and a perceived lack of care. The resident had to wait two hours for assistance, contrary to the facility's policy on dignity and resident rights, which expects prompt attention to residents' needs.
A resident with a persistent rash did not receive a scheduled dermatology consultation as ordered by a physician. Despite the resident's complaints of itching and burning, facility staff were unaware of any follow-up appointments. Observations revealed the resident's back, arms, and lower back were covered with a rash. The resident had diagnoses including type 2 diabetes and hypertension, with mildly impaired cognition.
Delayed Care and Failure to Implement Care Plans
Penalty
Summary
The facility failed to ensure interventions were implemented and care was provided timely for three residents. For one resident with diagnoses including muscle wasting and atrophy, bacterial arthritis of the left knee, and chronic gout, the active physician order required cleansing and dressing of a left heel deep tissue injury and offloading with a heel lift boot every morning and as needed. On observation, the resident was lying in bed with the heels resting on the bed, and the PRAFO boot was on an armchair beside the bed. The resident reported needing help to put the boot on, that staff had not come in, and that the boot had not been applied that morning; later observation showed the heels and boot remained in the same position. For another resident with right-sided hemiplegia/hemiparesis, muscle wasting and atrophy, and gout, the care plan directed staff to assist with ADLs, mobility, repositioning, and to check every 2 hours and as needed for incontinence, with perineal care and clothing changes after incontinence. The resident reported staff were sometimes slow to respond to the call light, up to 30 minutes, and described an episode where they were left in urine-soaked clothes after an accident. The resident stated the nurse took a long time to come in, declined to help, and left the resident in wet clothes, causing the resident to clean themself up and spend over an hour addressing the situation. For a third resident with bladder cancer and heart failure, the care plan directed staff to anticipate the need for pain relief and respond immediately to any complaint of pain. The resident reported ringing for pain medication in the evening, waiting about 20 minutes before a CNA responded, ringing again, and then waiting until later that evening when the next shift’s nurse administered the medication. The resident stated staff said they were busy and questioned whether the pain medication was important. The EMAR showed hydrocodone-acetaminophen was administered later that night, and staff reported the unit had a high resident load and call-offs, with the DON acknowledging staffing shortages and managerial staff available to assist.
Failure to Follow Physician Orders for Wound Care, Offloading, and Ice Chip Restrictions
Penalty
Summary
The facility failed to follow physician orders for three residents. R56, admitted with moderate protein-calorie malnutrition and peripheral vascular disease and assessed with a BIMS score of 3/15, had an active order for wound care to the right lateral lower leg every Tuesday, Thursday, and Saturday and as needed if missing or soiled for a venous ulcer. On 9/20/2025, the EMAR documented that the dressing change could not be completed because the resident was with family celebrating a birthday. When R56 was observed on 9/23/2025, the same gauze wrap and bandage dated 9/18/2025 remained on the right lower extremity and was soiled. The dressing was not changed until later that day, and the LPN confirmed the bandage was still dated 9/18/2025 and was unsure why it had not been changed as ordered. R119, admitted with infection of the right lower extremity amputation stump and moderate protein-calorie malnutrition, had an order to offload bilateral AKA stumps with pillows at all times while in bed. The resident was observed multiple times lying in bed with the stumps resting on the mattress, and the resident stated staff sometimes placed the stumps on pillows and sometimes did not. WCN A later observed the stumps on the mattress and placed a pillow under them, stating physician orders should be followed as written. R117, who was cognitively intact and had diagnoses including acute respiratory failure with hypoxia and peripheral vascular disease, had an order allowing 1 to 2 ice chips as needed to moisten the oral cavity every 30 minutes to 1 hour as requested, and specifically directing staff not to leave a cup of ice at bedside. Despite this, the resident was repeatedly observed with a cup of ice at the bedside, and RN F could not explain why the order was written regarding leaving ice at the bedside. The DON stated physician orders were to be followed, and ST G noted a risk of aspiration if the resident had too many ice chips or liquids.
Failure to Follow Pressure Ulcer Positioning Orders
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident with a stage 4 sacral pressure ulcer and moderate protein-calorie malnutrition. The resident was admitted with orders to verify that a wedge pillow was in use and to reposition every 2 hours as tolerated, with notification to the MD/WC of any changes. The resident’s MDS showed intact cognition and the resident required staff assistance with bed mobility and transfers. During observation, the resident was found lying in bed with the head of bed flat, on their back, with their feet hanging off the bed and no positioning devices in place, while the green positioning wedge was in a chair next to the bed. On later observations, the wedge was again found in the chair or closet rather than in use, and the resident stated it had not been used in a while except briefly for left shoulder pain. The WCN stated the resident should be repositioned every 1-3 hours as tolerated and that there was an order to verify the wedge was in place. The NHA stated that physician orders and interventions should be followed.
Medication Labeling and Dating Deficiency
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles in one of four medication carts. During observation of the Spring Hill medication cart with the RN, two insulin lispro vials were found without dates on the vials, including one for an active resident and one for a discharged resident. In the same cart, a 100-50 MCG/ACT fluticasone-salmeterol inhaler did not have a resident identifier or a date opened. The DON later stated the nurse should label both the carton and the actual medication in case the carton is lost or damaged. The facility policy stated medications are to be stored, dispensed, and destroyed safely and in accordance with state and federal laws, and that medications will be dated and discarded per manufacturer guidelines.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to respond to residents' call lights in a timely manner, as observed in the cases of two residents and two specific rooms. Resident R81 and their daughter reported that call light wait times could extend up to forty-five minutes, particularly during early mornings and weekends. R81, who required partial to moderate assistance with activities of daily living, experienced delays in receiving care. Interviews with CNAs revealed challenges in meeting resident care needs, especially when the facility was not fully staffed. In another instance, the call light for a room was observed to be activated for over twenty minutes before being answered by a CNA. Similarly, Resident R47's call light was ignored by multiple staff members, including therapy and activities staff, a CNA, and a nurse, until the Director of Nursing intervened. Despite the intervention, R47 reported that their needs were not addressed when the call light was turned off, leading them to call out for help. The facility's policy mandates timely responses to call lights, but the Nursing Home Administrator acknowledged that lengthy response times were a known issue.
Infection Control and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices in a contact isolation room and did not properly store nebulizer and C-Pap masks for several residents. Specifically, a maintenance assistant entered a contact isolation room without donning or doffing personal protective equipment (PPE) and did not perform hand hygiene upon exiting, despite the presence of a sign and PPE on the door. The Director of Nursing (DON) confirmed that all personnel entering such rooms should wear PPE and perform hand hygiene upon exiting, as per the facility's policy on contact precautions. Additionally, the facility did not properly store nebulizer and C-Pap masks for five residents, as these items were observed sitting on nightstands without any barrier. The DON stated that there are order sets for cleaning these masks, which should be placed on a paper towel to dry before being put away. However, the facility's policy on noninvasive positive-pressure ventilation did not mention storage practices, leading to improper storage of these respiratory devices.
Failure to Provide Adequate Bed for Obese Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R56, who expressed discomfort and dissatisfaction with their bed. Observations revealed that R56, who is obese, had very little room in their bed, leading to discomfort. R56 repeatedly expressed their desire for a more comfortable bed, indicating they could not move once placed in bed. Interviews with staff, including a CNA and a nurse, acknowledged the need for better beds, with the nurse suggesting that R56 should have a bariatric bed. However, the Unit Nurse Manager believed R56 already had a bariatric bed, which was contradicted by the Environmental Services Director upon inspection. The facility's administrator indicated that all beds were considered bariatric based on weight, not dimension, and mentioned a discussion about a positioning bar for R56. Despite this, the resident's discomfort persisted. R56's medical records showed a diagnosis of morbid obesity and muscle weakness, with a weight of 384 pounds. The facility's policy on bariatric bed use highlighted the importance of providing beds that accommodate larger body sizes for comfort and self-esteem, yet R56's bed did not meet these criteria.
Failure to Document Back Brace in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R103, who was observed multiple times without a back brace that was medically ordered. The resident was admitted with a diagnosis of a wedge compression fracture of the fifth lumbar vertebra and had an active physician order to wear a lumbar brace when out of bed, with skin integrity checks every shift. Despite this, the care plan and Kardex did not document the requirement for the back brace, leading to confusion among staff about the resident's care needs. Observations and interviews revealed that the Certified Nurse Assistant (CNA) and Licensed Practical Nurse (LPN) were unaware of the back brace requirement due to its absence in the care plan. The Director of Nursing (DON) confirmed the oversight after reviewing the resident's orders and care plan. The facility's policy mandates that every resident should have a person-centered care plan developed by an interdisciplinary team, which was not adhered to in this case, resulting in a deficiency in the resident's care planning.
Failure to Revise Care Plan for Wandering Behaviors
Penalty
Summary
The facility failed to revise a care plan to address wandering behaviors for a resident diagnosed with Alzheimer's Disease, Dementia, Hyperlipidemia, Catatonic Schizophrenia, and Depressive disorder. The resident, who was admitted on 02/05/24, was observed to have severely impaired cognition with a Brief Interview Mental Status assessment score of 00. Despite these conditions, the care plan for the resident's risk of elopement and wandering, initiated on 02/05/24 and revised on 08/23/24, did not include new interventions since the initial date. Additionally, the care plan addressing cognitive decline and impaired thought processes, initiated on 02/07/24 and last revised on 03/07/24, failed to reflect the resident's intrusive behaviors. Observations and interviews revealed that the resident exhibited wandering behaviors, entering other residents' rooms at night, and was difficult with staff. During a confidential resident council, other residents expressed concerns about the resident's behavior, indicating that the resident did not heed 'stop signs' on doors and required staff intervention. The Social Worker and Director of Nursing acknowledged that the interventions should be updated to effectively address the resident's behaviors. The facility's policy on care planning, revised on 6/24/21, mandates that care plans be person-centered and based on comprehensive assessments, which was not adhered to in this case.
Failure to Provide Scheduled Restorative Services
Penalty
Summary
The facility failed to provide necessary restorative services to maintain the functional abilities of a resident, identified as R70. R70 was observed to have a decline in their ability to perform activities of daily living, such as bathing, due to a lack of restorative care. Initially, R70 was receiving occupational and physical therapy, which was discontinued on 7/17/24, with a referral to the restorative nursing program. However, R70 reported not receiving the restorative care as planned, which was confirmed by the absence of documentation in their electronic medical record. Further investigation revealed that R70 was scheduled to receive restorative services three times a week, but only received it once during a 12-week period. The facility's policy on restorative nursing indicates that services should be available up to 6-7 times per week, with documentation required for each session. The failure to provide the scheduled restorative services and the lack of documentation contributed to the resident's decline in functional abilities, as observed and reported by the resident and confirmed by staff interviews.
Improper Storage of Oxygen Tank
Penalty
Summary
The facility failed to properly store an oxygen tank for a resident, identified as R221, who was receiving continuous oxygen therapy via a nasal cannula. On the specified date, R221 was observed in their room with a freestanding oxygen tank, which was not secured by a stand or cart as required by the facility's policy on oxygen storage and assembly. R221 had recently been admitted to the facility with medical diagnoses of lung cancer and chronic obstructive pulmonary disease (COPD), and their cognitive status was intact, as indicated by a perfect score on the Brief Interview for Mental Status. A Certified Nursing Assistant (CNA) acknowledged the absence of a stand for the oxygen tank and stated they would obtain one immediately. The facility's policy mandates that each oxygen tank be stored individually, secured by a chain, on a cart, or on a stand.
Failure to Obtain Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to obtain physician orders for colostomy care for a resident who required such services. The resident, who had a colostomy for some time, was observed needing assistance with emptying the colostomy bag and reported having to remind staff to perform this task. The resident was admitted with diagnoses of Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder and had an intact cognition score of 13/15. Despite requiring staff assistance with bed mobility and transfers, the medical record review revealed no physician orders for colostomy care, including changing. The Director of Nursing confirmed the oversight, noting that the resident's colostomy care orders were not reactivated after hospital readmissions. Additionally, the facility's policy on colostomy and ileostomy care did not address the need for colostomy care orders and tasks.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide ongoing behavioral health services for a resident, identified as R27, who was experiencing significant mood changes and expressing suicidal ideation. R27, who had a diagnosis of anxiety disorder and a history of depression, was observed to be in bed, expressing a lack of desire to get up due to concerns about their son's financial situation. Despite these observations and R27's verbal expressions of distress and a wish to die, there was no evidence of recent psychiatric follow-up or intervention since a psychiatry note dated two months prior, which had indicated depression but denied suicidal ideation at that time. The facility's social worker was aware of R27's concerns but only provided limited support by contacting R27's older son and providing a church contact. The care plan for R27 included monitoring for mood changes and consulting behavioral health services as needed, but there was no documentation of any recent psychiatric or psychological referrals or interventions. The facility's policies on behavior management and social services referrals were not adequately followed, as there was no evidence of a behavior management meeting or appropriate follow-up to address R27's worsening mood and expressed suicidal thoughts.
Failure to Timely Catheterize Resident
Penalty
Summary
The facility failed to ensure timely catheterization for a resident, resulting in a deficiency related to dignity and resident rights. The resident, who has a diagnosis of neuromuscular dysfunction of the bladder, reported being catheterized early in the morning for a doctor's appointment. Upon returning from the appointment, the resident requested to be catheterized again due to discomfort but had to wait two hours for assistance. This delay caused the resident to feel upset and sad, as they perceived a lack of care from the nursing staff. The Director of Nursing confirmed that the expectation is for residents' needs to be addressed promptly when assistance is requested. The facility's policy emphasizes treating residents with respect and dignity, promoting their quality of life, and protecting their rights.
Failure to Schedule Dermatology Consultation for Resident
Penalty
Summary
The facility failed to follow up on a physician's order to schedule a dermatology consultation for a resident who had been experiencing a persistent rash. The resident, who was observed sitting on the side of his bed, expressed concerns about not having seen the wound doctor for his old sore and a rash that itches and burns. A review of the resident's medical record revealed a physician's note from late August requesting a dermatology consult for a rash on the resident's back and groin, which was described as round and raised but not scaly or dry. The resident reported that the rash was itchy, sore, and sometimes burned, and that hydrocortisone cream had not been effective. Interviews with facility staff, including a charge nurse and a wound care nurse, revealed that they were unaware of any follow-up appointments for the resident. An observation of the affected area with the wound care nurse showed that the resident's back, arms, and lower back were covered with a rash and several scaly areas. The resident was admitted to the facility with diagnoses including orthopedic aftercare, type 2 diabetes, hypertension, and sleep apnea, and had a mildly impaired cognition score. The Director of Nursing stated that the expectation would be for the appointment to be made by the appropriate party and for the resident's care to be followed up on.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shelby Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Manor Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 9 | 0 |
| Shelby Crossing Health Campus | 2.7 mi | ★★★★★ | 0 | 0 |
| Shelby Health And Rehabilitation Center | 2.7 mi | ★★★★★ | 10 | 0 |
| Lakeside Manor Nursing And Rehabilitation Center | 3.5 mi | — | 12 | 0 |
| Medilodge Of Shoreline | 4.2 mi | ★★★★★ | 8 | 0 |
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