Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 St. Clair Shores during CMS and state inspections, most recent first.
Delayed Call Light Response and Inadequate Night Shift Staffing: Residents reported long waits for call lights to be answered, especially on the night shift, with one resident stating staff sometimes turned off the light without addressing needs and another reporting waits of 30 minutes to an hour for assistance. A confidential group said night staff were slow to respond for toileting, brief changes, snacks, and repositioning, and CNAs described being assigned too many residents and struggling to meet care needs. The DON stated call lights should be answered within 20 minutes, but resident council notes showed the concern had been ongoing for months.
Failure to Treat a Resident with Dignity and Respect: A resident asked an LPN for two cups of ice at the nurse's station, but the LPN appeared annoyed, gave minimal eye contact, and responded in a curt, dismissive manner instead of assisting. The resident was cognitively intact, required partial to moderate assistance with some ADLs, and had diagnoses including Staphylococcal arthritis, adult T-cell lymphoma/leukemia, anemia, and DM; the care plan also called for fluids throughout the day due to risk for nutritional decline.
Failure to update care plans for two residents with complex medical needs. One resident had a PEG tube, dysphagia, malnutrition, and dialysis needs, but no care plan addressed PEG tube care and interventions. Another resident with MS, a nephrostomy tube, and a urostomy had repeated hospital transfers for tube or bag dislodgement, yet the care plan was not updated with interventions to prevent further dislodgement.
A resident with schizoaffective disorder, anxiety, and depression did not receive a monthly Abilify Maintena injection as ordered. MAR review and psychiatry notes showed missed doses, including a missed dose because the building did not have the medication available. Staff reported the injection was discarded after a nurse noticed a white substance in the syringe, and the guardian raised concerns about the resident not getting the shot on time.
Several residents with significant medical needs did not receive their prescribed narcotic pain medications as ordered, due to discrepancies between medication administration records and controlled substance logs. Staff interviews and documentation reviews revealed that narcotic doses were missing or unaccounted for, and concerns about drug diversion by nursing staff were identified. The facility failed to follow its own policies for medication administration and protection of resident property, resulting in the misappropriation of controlled substances.
A resident with multiple serious diagnoses was not scheduled for recommended follow-up appointments with an otolaryngologist and a urologist after admission. The staff member responsible for scheduling did not recall making the appointments and there was no documentation of any attempts. The DON confirmed the absence of documentation, and the facility could not provide a policy for appointment coordination.
A resident with multiple medical conditions and moderate cognitive impairment fell from their bed, sustaining bruising, due to inadequate assistance during a bed check. The care plan required two-person assistance and a mechanical lift for bed mobility, which was not followed, leading to the incident. The facility's policies on resident safety and fall management were not effectively implemented.
A facility failed to initiate a comprehensive care plan for a resident with an abdominal drainage tube within 48 hours of admission. The resident was observed with an ostomy bag and a drainage tube, but there was no physician order or care plan for the tube. The resident reported the drainage bag was not emptied until they did it themselves. The DON confirmed the expectation for a care plan, as per facility policy.
A resident with no cognitive deficit was not involved in their care planning meetings, despite facility policy requiring their participation. The resident was unaware of their care plan and had never attended care conferences. Attempts to contact the resident's guardian were unsuccessful, and the resident expressed concerns about their property and finances.
A resident with a left leg amputation experienced moisture-associated skin damage (MASD) due to the facility's failure to provide timely incontinence care. The resident was often left in a wet brief, and prescribed antifungal treatments were not consistently applied. Staff shortages and locked treatment carts contributed to the issue, resulting in the resident developing multiple open sores and satellite lesions.
The facility failed to monitor an accordion drainage device for a resident with an abdominal abscess and did not apply compression stockings or ace wraps for two residents with edema. One resident's drain was not emptied since hospital discharge, and two residents were observed without prescribed compression therapy, leading to unmanaged edema and discomfort.
A resident with a history of dementia and other conditions was found with an uncovered pressure ulcer on their right hip, despite care plans and treatment orders requiring regular dressing changes. The facility's failure to adhere to its skin management policy and treatment protocols led to this deficiency.
The facility failed to ensure the proper application of prafo boots for two residents, necessary for maintaining range of motion and preventing contractures. Observations showed the boots were often not worn, and documentation indicated infrequent application. Interviews revealed a lack of clarity and training among staff regarding responsibility for applying the boots, leading to inconsistent care.
A facility failed to label medications with resident identifiers or open dates on two medication carts. Two Trelegy Ellipta inhalers lacked resident identifiers, and a Breo inhaler and Humalog Insulin lacked open dates. An LPN and the DON confirmed the expectation for labeling, and the Medication Storage Guidance specifies dating requirements for these medications.
An LPN in a facility failed to perform hand hygiene and sanitize equipment between residents during medication administration and vital sign monitoring. The LPN did not clean the insulin vial stopper before use and misunderstood the frequency of required hand hygiene. The facility's infection control protocols, as confirmed by the ICP and DON, were not followed, resulting in deficiencies.
The facility failed to post ombudsman contact information in an accessible area, affecting all 124 residents. During a resident council meeting, attendees were unaware of the ombudsman's identity or contact information. The Activities Director also did not know the ombudsman and had been using contact information from a previous job. The administrator indicated a poster with a general number was in the vestibule, but it was not prominently displayed. A staff member was seen posting contact information behind a nurses' station desk, which was not easily accessible.
Delayed Call Light Response and Inadequate Night Shift Staffing
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to have call lights answered in a timely manner for 11 residents reviewed. The acting DON stated the facility expectation was that call lights should be answered within 20 minutes, and the facility policy stated call lights would be placed within residents’ reach and answered in a timely manner. However, resident council meeting notes from March 2025 through July 2025 documented ongoing concerns about delayed call light response, and residents reported that the issue had been brought up at each meeting without change. R110 reported that the facility was short of help on nights, that no one checked on them all night once they were in bed, and that when they used the call light staff took a long time to come, turned it off, and left without addressing their needs. Another resident reported hearing R110 calling out early in the morning for an extended period before staff responded. During a confidential group meeting, seven residents stated that night shift call light response was slow and that they needed assistance with snacks, toileting, brief changes, bed repositioning, and other care needs during the night. CNA interviews confirmed staffing concerns on nights, including one CNA per unit for 13 to 15 residents, assignments of 16 to 17 residents, and difficulty meeting needs when two staff were required for assistance. R47 also reported long waits for evening and midnight care, stating they had waited 30 minutes to an hour for staff to answer the call light. R47’s record showed diagnoses of cellulitis, mild cognitive impairment, COPD, and depressive episodes, with a BIMS score of 12/15 indicating moderate cognitive impairment, and the resident required extensive assistance with activities of daily living. The NHA stated they were not aware of the concerns about long waits on the midnight shift, while the AD stated resident council concerns were brought to department heads at IDT meetings. The report documents that the facility did not respond to the repeated resident concerns and observed delays in call light response.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat one resident with dignity and respect when the resident asked an LPN for two cups of ice at the nurse's station. The resident was observed politely making the request while the LPN sat at the nurse's station looking at her phone, but the LPN appeared visibly annoyed, made barely any eye contact, and responded in a curt and dismissive manner by saying someone else would be around to get the request. The resident then rolled away and waited for another staff member to assist. The resident involved, R24, was admitted on 6/26/25 with diagnoses including Staphylococcal Arthritis of the left knee, Adult T-Cell Lymphoma/Leukemia, anemia, and diabetes. The record showed the resident was cognitively intact and required partial to moderate assistance for transfers, toileting, and personal hygiene. The resident's care plan included encouragement and provision of fluids throughout the day due to risk for nutritional decline related to uncontrolled DM and IV therapy. When questioned, the LPN stated her shift had ended at 7:00 AM and she was supposed to be off work but was documenting two resident falls from the prior night.
Failure to Update Care Plans for PEG Tube and Nephrostomy Tube Needs
Penalty
Summary
The facility failed to develop or revise care plans for two residents reviewed for care plans. One resident had a PEG tube visible under a t-shirt and stated it was not currently being used. The resident was admitted with diagnoses including myasthenia gravis, moderate protein calorie malnutrition, renal dialysis, dysphagia, and gastrostomy insertion, and had a BIMS score of 15/15 with intact cognition. The resident required supervision or touching assistance for ADLs and was independent with mobility using a walker, but the EMR care plans did not include a plan addressing the PEG tube care and interventions. Another resident with multiple sclerosis, obstructive and reflux uropathy, neuromuscular dysfunction of the bladder, an artificial opening of the urinary tract with nephrostomy tube, and urinary diversion with a urostomy was observed in bed and verbally requesting to get up, with nephrostomy tubes noted. The resident required substantial to maximal assistance for all ADLs and mobility. The record showed repeated hospital transfers related to nephrostomy tube problems, including dislodgement, a nephrostomy bag not attached, nephrostomy tube replacement, and the resident disconnecting the nephrostomy tube, yet the care plan was not updated with interventions to prevent dislodgement after these readmissions.
Delayed Psychotropic Injection Administration
Penalty
Summary
The facility failed to provide psychotropic medication in a timely manner for one resident with diagnoses including schizoaffective disorder, anxiety disorder, and other recurrent depressive disorders. The resident was cognitively intact and required supervision for ADLs. The resident had an active order for Abilify Maintena 400 mg IM monthly, first starting on 5/19/25 and later changed on 6/16/25 to be administered on the 2nd of each month. Review of the resident’s MAR showed the injectable medication was not administered as ordered. Documentation from psychiatry noted that the resident was not receiving the Abilify Maintena correctly, that the resident did not receive the injection in May, and that the injection was given on June 2 and July 2 but not in May. A later psychiatry note stated the resident did not receive the August 2 injection because the building did not have the medication available. Social services also documented concerns from the resident’s sister/legal guardian about auditory hallucinations of a sexual nature and about the resident not receiving the shot when expected. Interviews with staff showed the assigned nurse discarded the injection after noticing a white substance in the syringe and reordered it STAT, but the medication was not available when expected. The DON stated the medication was delivered after the order had already been discontinued and was unsure what occurred in May when the resident did not receive the injection. The facility policy stated that if unavailable medication does not become available within 8 hours of the scheduled administration time, the facility will be notified by the pharmacy and an alternate procurement method will be established.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medications for four residents, as evidenced by discrepancies between medication administration records (MARs) and controlled substance logs. Multiple residents, including those with severe pain following surgery, cognitive impairments, and significant assistance needs, did not receive their prescribed narcotic medications as ordered. For example, one resident reported not receiving pain medication for an extended period, and documentation showed inconsistencies in the number of pills received versus those administered. Record reviews revealed that the number of narcotic doses documented as administered did not match the number of doses dispensed or recorded on controlled substance forms. In several cases, residents' MARs showed fewer doses given than what was documented on the controlled drug logs. Staff interviews confirmed awareness of these discrepancies, and there were concerns about drug diversion involving specific nursing staff. One nurse in particular was identified as being involved in multiple incidents where narcotic counts did not reconcile, and their behavior was described as suspicious during the investigation. The facility's policies required accurate documentation of pain medication administration and protection of residents' property, including medications. However, the observed discrepancies and staff actions indicated a failure to follow these policies, resulting in the wrongful use and potential diversion of residents' narcotic medications. The events were substantiated through interviews, record reviews, and direct observation of documentation inconsistencies.
Failure to Coordinate and Document Follow-Up Medical Appointments
Penalty
Summary
The facility failed to schedule and coordinate follow-up medical appointments as recommended for a resident who was admitted with multiple serious diagnoses, including Malignant Otitis Externa, Acute Osteomyelitis, Cholesteatoma of the External Ear, COPD, and Heart Failure. Upon admission, the hospital discharge summary recommended follow-up with an otolaryngologist within 3-7 days and a urologist within one week. Record review and staff interviews revealed that the staff member responsible for scheduling appointments did not recall making the necessary ear specialist appointment and stated that there was no documentation of any attempt to schedule these follow-ups. Further interviews with the DON confirmed that the scheduler handles appointments based on information from admissions, but there was no documentation of appointments or follow-up for the resident. Additionally, when the facility's policy for coordination of appointments was requested, it was not provided by the end of the survey. The lack of documentation and failure to coordinate the recommended follow-up appointments led to the deficiency.
Resident Fall Due to Inadequate Assistance
Penalty
Summary
The facility failed to ensure resident safety, resulting in a fall with bruising for one resident, identified as R800. R800 was admitted with multiple medical diagnoses, including hypertension, stroke with left hemiparesis, and a history of falls. The resident had a moderate cognitive impairment and required substantial assistance for bed mobility and transfers, as documented in their care plan and Kardex. On the morning of the incident, a CNA was performing a bed check and attempted to turn R800, who subsequently fell from the bed, sustaining bruising to the head, ribs, and elbow. The resident was assessed by an RN and found to have stable vital signs, but reported hitting their head during the fall. The care plan for R800 specified the need for two-person assistance and the use of a mechanical lift for bed mobility and transfers. However, during the incident, it appears that the required assistance was not adequately provided, leading to the fall. The facility's policies on routine resident care and fall management emphasize the importance of ensuring resident safety and minimizing fall risks, but these were not effectively implemented in this case. The incident was reported to the Nurse Practitioner, Director of Nursing, and the resident's Patient Representative, highlighting a lapse in adherence to established care protocols.
Failure to Initiate Care Plan for Abdominal Drainage Tube
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident with an abdominal drainage tube was initiated within 48 hours of admission. The resident was observed with an ostomy bag and a drainage tube connected to a collection device, which was hanging on their walker. A record review revealed the absence of a physician order or a comprehensive care plan for the drainage tube. The resident reported that while the ostomy bag was changed, the drainage bag was not emptied until they did it themselves. An interview with the Director of Nursing confirmed the expectation that a care plan should have been in place to address the specific needs of the drainage tube. The facility's policy requires a person-centered Plan of Care to be developed within 48 hours of admission, identifying any immediate needs.
Resident Excluded from Care Planning Meetings
Penalty
Summary
The facility failed to ensure that a resident, identified as R20, was involved in their care planning meetings. R20 reported having a guardian they had never met and expressed unawareness of their plan of care or participation in care conferences. Despite having a BIMS score of 15/15, indicating no cognitive deficit, R20 was not included in care conferences held on three separate occasions. The facility's policy requires resident participation in care planning conferences, but R20 was neither invited nor attended these meetings. Additionally, attempts to contact R20's guardian were unsuccessful, with voicemails left and no responses received. R20's medical record indicated diagnoses of unspecified dementia, polyosteoarthritis, muscle wasting and atrophy, and foot drop. The resident expressed concerns about their property and belongings, as well as a lack of access to their finances. The social worker confirmed that R20 had repeatedly inquired about these issues and had attempted to contact the guardian without success. The facility's policy mandates efforts to increase resident participation in care planning, but these were not effectively implemented for R20, leading to the deficiency noted in the report.
Failure to Provide Timely Incontinence Care Leads to Skin Damage
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, resulting in moisture-associated skin damage (MASD). The resident, who had a left leg amputation and was unable to walk, reported being left wet for extended periods, leading to a fungal rash on their buttocks. Despite having a prescription for antifungal powder and cream, the resident stated that staff could not find these items, and they had to purchase their own cream. Observations confirmed that the resident was often left in a wet brief, and the prescribed treatments were not consistently applied. On multiple occasions, the resident was observed in a wet brief, and staff did not apply the necessary cream and powder as ordered. The wound care nurse confirmed that the treatment items were kept in a locked treatment cart, making it difficult for aides to use them with each episode of pericare. The resident expressed discomfort and pain from the MASD, which had progressed to multiple open sores and satellite lesions. Interviews with staff revealed that the midnight shift was often short-staffed, leading to residents being left wet until the day shift began. The resident's care plan indicated the need for incontinence care with each episode and the application of a moisture barrier cream. However, there were no progress notes indicating any refusal of care by the resident. The Director of Nursing stated that it was the resident's preference to wear a brief in bed, but the resident reported that they were not allowed to go without one due to being on a water pill. The lack of timely and appropriate incontinence care contributed to the worsening of the resident's skin condition.
Failure to Monitor Medical Devices and Apply Compression Therapy
Penalty
Summary
The facility failed to initiate care orders and monitor an accordion drainage device for a resident who was admitted with a vesicointestinal fistula, abdominal abscess with drain, and a temporary ostomy. Upon observation, the resident was found with an ostomy bag and a drain connected to an accordion drainage system, which had not been emptied since leaving the hospital. The resident confirmed that no one had attended to the drain, which contained 40 ml of medium brown, nectar-thick liquid. A review of the resident's medical records confirmed the presence of a drain, and the Director of Nursing stated that medical devices should have a physician's order to initiate care. The facility also failed to apply compression stockings and ace wraps for two residents reviewed for edema. One resident, who was supposed to wear compression stockings, was observed multiple times without them, despite having a diagnosis of congestive heart failure and a history of venous thrombosis. The resident reported that the stockings were too small, and no one could put them on. The resident's care plan included minimizing risk factors for cardiovascular distress, but the compression stockings were not applied as ordered. Another resident, who preferred ace wraps over compression stockings, was observed without ace wraps and with bilateral lower extremity edema. The resident reported pain and difficulty managing the swelling, and they did not have leg rests for their wheelchair to elevate their legs. The resident's medical records included an active physician's order to apply ace wraps daily, but this was not done, leading to continued edema and discomfort.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as R44, who was observed with an uncovered wound on their right hip. Despite the care plan indicating the need for wound treatment and dressing, the wound was found without any dressing or treatment during an observation. The resident's medical records showed a history of dementia, Alzheimer's disease, and other conditions that increased their risk for skin integrity issues. The care plan included interventions for repositioning and incontinence care, but these were not adequately followed, as evidenced by the uncovered wound. The resident's treatment administration record indicated a change in the wound care protocol, which required cleansing and dressing the wound every other day. However, the observation of the uncovered wound suggests a lapse in following these orders. The facility's policy on skin management emphasized the need for identifying and implementing interventions to prevent pressure injuries, but the failure to cover the wound indicates a deficiency in adhering to this policy. The concern was raised by a concerned party, who noted that the wound care treatments were not being performed as ordered.
Failure to Apply Prafo Boots for Residents
Penalty
Summary
The facility failed to ensure the proper application of prafo boots for two residents, R77 and R20, which are necessary to maintain or improve their range of motion and prevent further contracture deformities. Observations revealed that R77's prafo boots were consistently found on the floor next to the dresser rather than being worn, and R77 reported that the staff only applied the boots several times per month. Documentation showed that the boots were applied only five times in the last 30 days, with three refusals noted. R77's care plan and medical records indicated a need for the boots to be worn 4-5 hours daily to manage bilateral foot drop contracture deformity, but this was not consistently followed. Similarly, R20's prafo boots were observed on top of a pile of belongings or on the floor, and R20 reported that the staff no longer applied the boots as frequently as before. The medical records for R20 indicated a need for the boots to be worn up to 6 hours daily to manage foot drop and reduce the risk of further contracture deformity. However, documentation showed the boots were applied only seven times in the last 30 days, with one refusal noted. Interviews with staff revealed a lack of clarity and training regarding who was responsible for applying the boots, contributing to the inconsistency in care. The facility's policy on contracture prevention and management states that restorative programs, including splint/brace assistance, should be provided by trained nursing assistants or licensed nurses. However, interviews with staff, including the Director of Nursing, indicated that there was no specific assignment of responsibility for applying the prafo boots, leading to a failure in ensuring that the residents received the necessary care to maintain their mobility and prevent further decline.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to properly label medications with resident identifiers or open dates on two of four medication carts. During an observation, two Trelegy Ellipta inhalers were found without resident identifiers on the Superior Wing medication cart. An LPN stated that they label inhalers with the resident's name and the date opened. Additionally, on the C200 wing medication cart, a Breo inhaler was labeled with a resident's name but lacked an open date, and a bottle of Humalog Insulin did not have an open date on the vial or box. The Director of Nursing confirmed that the expectation is for medication open dates to be on the medication container. The Medication Storage Guidance specifies that multiple-dose vials for injection should be dated when opened and discarded after 28 days, and inhaled medications like Breo Ellipta and Trelegy Ellipta should be dated when the foil tray is opened and discarded after six weeks.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to maintain infection control standards during medication administration and vital sign monitoring. On two separate occasions, an LPN was observed preparing and administering medications, including insulin, without performing necessary hand hygiene. The LPN did not sanitize the glucometer, blood pressure machine, or pulse oximeter between resident uses. Additionally, the LPN did not clean the rubber stopper of the insulin vial before drawing up insulin. When questioned, the LPN indicated a misunderstanding of when hand hygiene and equipment sanitization were required, believing hand hygiene was only necessary after every third resident. The Infection Control Practitioner and the Director of Nursing confirmed the facility's expectations for hand hygiene and equipment sanitization. Hand hygiene should be performed before and after medication preparation, before and after giving medication to residents, and before and after donning and doffing gloves. Equipment should be sanitized between residents using appropriate cleaning agents. The LPN's actions did not align with these established protocols, leading to the observed deficiencies in infection control practices.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post ombudsman contact information in an accessible area, affecting all 124 residents. During a resident council meeting, attendees were asked if they knew who their ombudsman was and how to contact them. None of the attendees were aware of the ombudsman's identity or contact information, and they denied seeing any postings of this information within the facility. This indicates a lack of accessible information regarding the ombudsman for the residents. Further interviews revealed that the Activities Director (AD O) did not know who the ombudsman was and had never seen the contact information posted in the facility. AD O had been providing residents with ombudsman contact information from a previous place of employment. The facility's administrator (NHA) pointed to a poster in the vestibule that contained a general number for the ombudsman program, but it was not prominently displayed. Additionally, an unidentified staff member was observed posting a framed poster with various contact numbers, including the ombudsman program, behind a nurses' station desk, which was not easily accessible to residents.
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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 St. Clair Shores
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Grosse Pointe | 0.8 mi | ★★★★★ | 1 | 0 |
| Shorepointe Nursing Center | 1.7 mi | ★★★★★ | 1 | 0 |
| The Orchards At Roseville | 2.1 mi | ★★★★★ | 3 | 0 |
| The Orchards At Harper Woods | 2.1 mi | ★★★★★ | 11 | 0 |
| The Rivers Health & Rehabilitation Center Of Gross | 2.7 mi | ★★★★★ | 9 | 0 |
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