Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Westland during CMS and state inspections, most recent first.
A resident with muscle wasting, impaired cognition, and dependence for bed mobility and transfers experienced multiple falls, including being found on the floor near a wheelchair and later on the floor with a facial abrasion, bruising, increased confusion, and episodes of throwing themself to the floor while on Eliquis. Observation also found the resident in bed with feet hanging off the side and the bed not in a low position. Despite these events, review of the fall care plan showed no new fall-prevention interventions were added after the falls or after readmission, even though staff and facility policy indicated that the floor nurse is responsible for timely care plan review and revision after a fall.
Surveyors found that the facility did not follow physician and hospital orders for two residents: one had staples from a below-knee amputation stump removed early at the facility instead of according to the hospital After Visit Summary and scheduled vascular surgery follow-up, and another, with a T9–T10 vertebral fracture and severe cognitive impairment, was repeatedly observed out of bed in a wheelchair or chair without the ordered TLSO back brace applied, with no documented refusals despite staff reporting the resident often removed the brace.
Two residents exited the facility without staff awareness or proper LOA documentation, despite established procedures requiring residents to sign out and notify nursing staff. One cognitively impaired resident with a history of alcohol and opioid dependence and frequent falls walked out the front door unchallenged by front-desk staff, went off property to obtain snacks, fell outdoors, and returned with a knee abrasion and skin tear. Another cognitively intact resident who routinely left the building to smoke also departed without signing out, even though reception staff, the DON, and the social worker were aware of the resident’s frequent LOAs and expected that all exits be logged at the nurse station. Staff on the affected unit reported being short-staffed relative to expected nurse and CNA coverage.
A resident with a colostomy and impaired cognition reported that staff sometimes forgot to empty the colostomy bag, including one episode when the bag became extremely full and required two trips to empty. Review of the record showed no physician orders or TAR documentation for colostomy care despite the resident’s colostomy status and need for staff assistance with mobility and transfers. The UM stated that admitting nurses should enter such orders and that chart audits are used to identify missing orders, while the DON was unsure why colostomy care orders were not entered; the facility’s colostomy policy did not address colostomy care.
The facility failed to complete an annual PASARR for a resident with Bipolar Disorder, Depressive Disorder, and Vascular Dementia. The resident was observed awake in bed and repeatedly asking for hearing aid batteries to be changed. Record review showed the last annual PASARR had been completed previously, and the SW stated the form was missed when the resident was readmitted; the NHA confirmed PASARRs should be completed on admission and annually.
A resident with vascular dementia and Alzheimer dementia was observed in bed with an over-bed table holding a cup containing five unidentified pills and water. The resident said the pills were their morning medication but stated they were no longer taking them because they made them sick. The record did not show a self-administration assessment, and the DON stated that unless a resident has an order to self-administer, the nurse must stand and watch the resident take the medication.
A resident with impaired cognition and malnutrition was admitted with a sacral wound, but a wound care order was not initiated until three days later. The DON confirmed that the nurse did not promptly request a treatment order despite facility policy requiring immediate intervention and documentation for skin impairments.
The facility failed to maintain proper food safety and hygiene practices, with issues such as moldy and undated food items, dust buildup, and unclean utensils found during an inspection. These deficiencies potentially affected all 115 residents, as the facility did not adhere to its food purchasing and storage policy.
A resident was found self-administering eye drops without a documented assessment or care plan. Despite having intact cognition, the facility did not complete the necessary documentation for self-administration upon admission. The DON acknowledged the oversight, noting that the required documentation was completed only after the resident was observed with the medication at bedside.
The facility failed to complete and submit PASARR Level I screenings for two residents with mental illness or intellectual disabilities. One resident, a veteran with nightmares and impaired cognition, and another with severe cognitive impairment and multiple psychiatric diagnoses, did not have the required screenings completed, as confirmed by a social worker. The facility's policy mandates annual screenings, which were not conducted in these cases.
The facility failed to follow a physician's order for a urology consult for a resident experiencing painful urination, and also failed to ensure transportation for another resident to outside medical appointments. The first resident's urology consult was not completed despite a physician's order, and the second resident missed multiple appointments due to transportation errors, including the need for a stretcher for transport.
The facility failed to document and provide restorative care and splint application for three residents. One resident was observed without a necessary splint, another refused therapy due to incontinence concerns, and a third was not documented as receiving required splint care. The facility's policy on documenting restorative care was not followed.
Failure to Timely Revise Fall-Prevention Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to timely implement and revise fall-prevention care plan interventions following multiple falls for one resident. The resident was admitted with muscle wasting and atrophy, had a BIMS score of 5/15 indicating impaired cognition, and required staff assistance with bed mobility and transfers. On one observation, the resident was seen lying in bed with their feet hanging off the side, the bed not in a low position, and a blanket and sling pad underneath them, shortly after returning from the hospital following a fall in which they hit their head while on a blood thinner. Incident reports documented that on one date the resident was found on their right side on the floor in front of their wheelchair before bedtime, with range of motion performed and no apparent injuries noted. A subsequent incident report documented that on another date the resident, described as alert and oriented x1, was observed on the floor with their head down, with an abrasion to the right side of the face, old bruises to the left ring finger and right thigh, increased confusion, inability to follow simple directions, and episodes of throwing themself to the floor and to the side of the bed several times with difficulty redirecting. The resident was also documented as receiving Eliquis 5 mg twice daily. Review of the fall care plan showed no new fall-prevention interventions were added after these falls and after the resident’s readmission to the facility. Staff interviews confirmed that timely interventions should be implemented by the floor nurse after a fall, and facility policy stated that the licensed nurse will review and/or revise the care plan and link it to the resident Kardex, but this was not done for this resident following the documented falls.
Failure to Follow Physician Orders for Staple Removal and TLSO Brace Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and hospital after-visit instructions for two residents. One resident was admitted with osteomyelitis of the ankle and foot, a left below-knee amputation, and protein calorie malnutrition, and had severe cognitive impairment. The hospital After Visit Summary specified that staples from the left below-knee amputation stump were to be removed in four weeks at a scheduled vascular surgery follow-up appointment. The day after admission, a physiatry PA entered an order for staple removal per protocol. The wound care LPN and the PA observed that the staples were overgrown with skin and, uncertain how long the staples had been in place and without recalling a review of the AVS recommendations, proceeded to remove the staples at the facility, causing some bleeding. This removal occurred 17 days before the AVS-documented timeframe for staple removal and before the vascular surgeon could see the resident and review the chart. The second resident was admitted with an unspecified fracture of the T9–T10 vertebra and muscle disorders, had severely impaired cognition, and required staff assistance with bed mobility and transfers. Physician orders directed that a TLSO back brace be worn whenever the resident was out of bed and that the brace be applied before the resident was weight bearing. On multiple observations over several days, the resident was seen sitting up in a wheelchair or stationary chair, including in the dining room, without the back brace applied, while the brace was observed on the dresser in the room. A family member stated the resident was supposed to have the brace on whenever out of bed and did not know why it was not applied. The care plan and progress notes contained no documentation of refusals to wear the brace, although an LPN reported the resident tended to remove the brace and acknowledged it should be documented if the resident removed or refused it. A facility policy stated it is the responsibility of the licensed nurse to follow physician orders.
Unsupervised Exits and Failure to Enforce Leave of Absence Procedures
Penalty
Summary
Failure to ensure a hazard-free environment and adequate supervision occurred when two residents exited the facility without following the required leave of absence (LOA) procedures and without staff awareness. One resident with alcohol dependence, opioid dependence, frequent falls, and moderate cognitive impairment (BIMS 11/15) left the building without signing out in the LOA log or notifying staff. This resident had an admission elopement assessment score indicating low risk and a physician order permitting LOA with medications and supervision. Video review showed the resident walking through the lobby toward the front door wearing outdoor clothing, passing the front desk without being acknowledged by the staff member covering the desk, who later stated they were unsure if the person was a resident or a family member. After the cognitively impaired resident exited, staff became aware of the situation only when a CNA received a call from a family member reporting a possible resident off property walking with a walker near a local restaurant, observed to fall to their knees and then continue walking. A nurse then searched outside in dark, cold, and slippery conditions and located the resident inside a nearby restaurant. Upon return, assessment identified an abrasion on the knee and a skin tear below the right anterior knee. In an interview, the resident stated they had simply walked out the front door, spoken with someone's family outside, and proceeded toward a store for snacks, adding that no one spoke to them as they left and that they must have forgotten to sign out. In a separate incident, another resident who routinely exited and re-entered the facility multiple times daily for smoking also left the facility without signing out in the LOA book, meaning nursing staff were not notified of the departure. This resident was documented as cognitively intact with a BIMS score of 15/15 and had been assessed as at no elopement risk. Staff interviews revealed that the resident's frequent LOAs were known to reception staff, the DON, and the social worker, and that the expectation was for LOAs to be logged at the nurse station and for nurses to be informed of departures, even when a CNA accompanied the resident. Staffing on the resident’s wing at the time was reported as two nurses and three CNAs for 68 residents, with staff indicating they should have three nurses and four CNAs and describing frequent short staffing due to call-offs and scheduling.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document colostomy care for a resident with a known colostomy. The resident, who had a colostomy in the left lower abdomen and diagnoses including Colostomy Status and Diverticulitis of the large intestine, reported that staff sometimes forgot to empty the colostomy bag and only did so when reminded. The resident described an instance when the colostomy bag became so full that staff had to make two trips to empty it and were surprised it had not burst. The resident’s Minimum Data Set showed impaired cognition with a Brief Interview for Mental Status score of 11/15, and the resident required staff assistance with bed mobility and transfers. Record review showed that upon admission there were no physician orders related to colostomy care and no documentation of colostomy care on the Treatment Administration Record. The Unit Manager stated that admitting nurses are expected to enter orders for needs such as colostomy care and that chart audits are used to identify and correct missing orders. The DON reported being unsure why colostomy care orders were not entered at admission and indicated that unit managers double-check new admission orders. Review of the facility’s colostomy policy showed it did not address colostomy care.
Missed Annual PASARR Assessment
Penalty
Summary
The facility failed to complete an annual PASARR assessment for one resident, R12, out of two residents reviewed for PASARR assessments. R12 was observed resting in bed awake and was wearing hearing aids, repeatedly asking for the hearing aid batteries to be changed during the visit. The medical record showed R12 was admitted and later readmitted after a brief hospitalization with diagnoses including Bipolar Disorder, Depressive Disorder, and Vascular Dementia. The MDS assessment documented a BIMS score of 13/15, indicating intact cognition, and that R12 needed extensive assistance with bed mobility and transfers. Review of the record showed the last annual PASARR was completed in October 2024, and when the most recent updated annual PASARR was requested, the Social Worker stated the form had been missed when R12 was readmitted back into the facility. The NHA confirmed that PASARRs should be completed on admission and annually.
Unsupervised Medication Left at Bedside
Penalty
Summary
Medication was not properly managed for one resident with impaired cognition and dementia diagnoses. On 1/27/2026 at 6:34 AM, the resident was observed in bed with an over-bed table next to them containing a small plastic cup with five unidentified pills and a cup of water. When asked, the resident stated the medication in the cup was their morning medication but said they were not taking it anymore because it made them sick. The resident’s record showed diagnoses of vascular dementia without behavioral disturbance and Alzheimer dementia, and the quarterly MDS indicated impaired cognition and need for assistance with activities of daily living. The record did not show a self-administration of medication assessment. The resident’s care plan identified impaired cognition and communication related to vascular dementia and Alzheimer dementia and included interventions to administer medications as ordered and observe/treat for adverse side effects as needed. On 1/29/2026 at 1:45 PM, the DON stated that unless a resident has an order to self-administer, the nurse needs to stand and watch the resident take their medication. The facility policy stated that self-administration requires physician authorization and a completed self-administration evaluation, and that self-administration must be reflected in the care plan. The report also cited the requirement that drugs and biologicals be labeled appropriately and stored in locked compartments, separately locked for controlled drugs.
Delayed Wound Care Order for Pressure Ulcer
Penalty
Summary
A resident admitted with muscle weakness, moderate protein-calorie malnutrition, and impaired cognition was found to have a small open area on the inner sacrum during the admission skin assessment. Despite this finding, a wound care order was not entered until three days after admission. The Director of Nursing confirmed that although the skin assessment documented the wound upon admission, the nurse did not promptly contact the physician for a treatment order. Facility policy requires that residents admitted with any skin impairment have appropriate interventions implemented and a physician's order for treatment documented, which was not followed in this case.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in their kitchen, potentially affecting all 115 residents. During an inspection, several issues were identified, including dust buildup on top of the ovens and a prepared salad in the chef's refrigerator that was dated over ten days prior and appeared wilted and moldy. Additionally, a package of sliced American cheese was found open and undated, and several cooking utensils were stored with dried food debris or stains. Further inspection revealed that in the walk-in freezer, chocolate chip cookie dough and chicken chunks were left open to the air and not dated, as well as turkey patties. In the walk-in refrigerator, a package of sliced cheese had black mold-like growth, and a box of whole green peppers contained at least five peppers with mold or wilted areas. The Dietary Manager acknowledged these issues and mentioned that staff are trained to rotate stock, but the facility's policy on food purchasing and storage was not adhered to, leading to these deficiencies.
Failure to Assess Self-Administration of Eye Drops
Penalty
Summary
The facility failed to properly assess a resident, identified as R273, for self-administration of eye drops. On observation, R273 was found to have four bottles of eye drops on their bedside table and stated they self-administered the drops because they did not trust others to do it on time. Despite R273's intact cognition and their ability to self-administer, as indicated by a Brief Interview for Mental Status score of 15/15, there was no documented order, care plan, or assessment in the medical record authorizing self-administration of the eye drops. The Director of Nursing (DON) acknowledged that the facility did not always know what medications short-term stay residents brought with them upon admission. The DON mentioned that after a nurse observed the eye drops at the bedside, they spoke with R273 and determined the resident could self-administer the medication. However, the necessary documentation, including a physician's order, assessment, and care plan, was completed only after this observation, rather than at the time of admission. Additionally, the facility's policy on self-administration of medications was requested but not provided by the end of the survey.
Failure to Complete PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the completion and submission of the Preadmission Screening and Annual Resident Review (PASARR) forms for two residents, R11 and R74, who were reviewed for mental illness or intellectual disability. R74, a veteran with a history of being a prisoner of war, suffers from nightmares and has moderately impaired cognition, requiring assistance for transfers and mobility. Upon review, it was found that the facility did not complete a PASARR Level I screening for R74, which was confirmed by Social Worker A after investigation. Similarly, R11, who has diagnoses including dementia, psychotic disturbance, mood disturbance, and schizoaffective disorder, was found to have severely impaired cognition with a BIMS score of 3. The facility also failed to complete an annual PASARR Level I screening for R11, as confirmed by Social Worker A. The facility's policy requires a Level I/3877 screening to be completed annually for all residents and submitted to the local community mental health program for those who screen positively, which was not adhered to in these cases.
Failure to Follow Physician Orders and Ensure Transportation
Penalty
Summary
The facility failed to follow a physician's order for a urology consult for a resident who was experiencing pain during urination. The resident, who had a history of Traumatic Subdural Hemorrhage, Diabetes, Hypertension, and Muscle Weakness, reported these symptoms during an interview. Despite a physician's order dated for a urology consult due to symptoms of benign prostatic hyperplasia, the facility did not have any record of such an order being completed. The Director of Nursing was unable to provide additional information regarding the consult before the survey exit. Additionally, the facility failed to ensure transportation for another resident to outside medical appointments. This resident, who was on Total Parenteral Nutrition and required a stretcher for transport, missed three out of four follow-up appointments due to transportation errors. The facility's transportation clerk was unaware of the need for a stretcher and did not reschedule missed appointments. The Director of Nursing mentioned that they were in the process of finding alternative transportation companies, but the facility's policy did not address transportation issues.
Failure to Document and Provide Restorative Care
Penalty
Summary
The facility failed to ensure proper documentation and provision of restorative care and splint application for three residents. Resident 38 was observed without a hand or wrist splint, despite documentation indicating the need for a wrist hand finger orthosis to be worn daily. The resident had not been on the therapy caseload since March 2023, and there was a lack of documentation regarding the application of the splint, with only one entry noted in October 2024. Resident 47 was observed with a walker and wheelchair but had refused therapy due to concerns about incontinence during exercise. The resident's care plan indicated a need for assistance with personal care and mobility, but there was no documentation of further refusals or restorative care provided. The resident was on the current caseload, but the facility failed to document the resident's participation in restorative services. Resident 76 was observed without a splint, despite having a documented need for a left elbow contracture brace and a wrist hand finger orthosis. The resident had been evaluated for therapy in August 2024, but there was no documentation of the application of the splint or the provision of restorative care. The facility's Director of Nursing acknowledged the missing documentation, and the facility policy required documentation of the resident's participation in restorative programs, which was not adhered to.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,052 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Hill For Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 13 | 0 |
| Westland, A Villa Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Four Seasons Nursing Center Of Westland | 2 mi | ★★★★★ | 13 | 0 |
| Optalis Health And Rehabilitation Of Canton | 2.7 mi | ★★★★★ | 41 | 1 |
| Medilodge Of Haggerty Road | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Regency At Westland.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.