Above average — CMS composite of the measures below.
A standard survey is most likely before 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 On The Lake - Fort Gratiot during CMS and state inspections, most recent first.
The facility did not provide adequate staff training on fire safety procedures, as two dietary staff members could not correctly explain how to activate the range hood suppression system, and one could not identify the correct extinguisher for a grease fire. These deficiencies were confirmed by the Maintenance Director and Dietary Manager, potentially affecting all residents during a kitchen fire emergency.
An LPN was observed retrieving an unlabeled and undated inhaler from the medication cart for a resident with Alzheimer's and impaired cognition who required assistance with medication administration. The DON was unsure if inhalers needed to be dated, despite facility policy requiring medications to be dated and discarded per manufacturer guidelines. This failure to properly label and date the inhaler resulted in a deficiency.
A resident with multiple medical conditions experienced stomach pain and vomiting, which was reported to a nurse and treated with Zofran, but there was no documentation that the physician or family were notified of this change in condition. The resident was later transferred to the hospital for further decline, and the medical director was unaware of the earlier symptoms.
The facility failed to apply heel protector boots per physician orders for two residents and failed to apply positioning devices per physician orders for one resident. One resident was observed without heel boots, which were found in a wheelchair, and another resident had heel boots on the floor next to their bed. Additionally, a resident was observed multiple times without the required lambswool padding in their wheelchair, and the unit manager confirmed the discontinuation of the right arm bolster and lambswool padding without specifying the date of the change.
The facility failed to secure smoking/vape pens for a resident diagnosed with Atrial fibrillation. The resident was observed with a vape/smoking pen on their overbed table on two occasions. The Unit Manager and the resident's assigned nurse confirmed that residents are not allowed to have vape/smoking pens in their rooms. The Unit Manager removed three unopened boxes and one open smoking/vape pen from the resident's room. The DON confirmed that the facility does not permit vape pens, in accordance with the facility's Non-Smoking Policy.
The facility failed to ensure that a resident's call light was within reach, despite the resident's need for assistance with bed mobility and transfers. The call light was observed out of reach on two occasions, and the DON confirmed that it should always be accessible. The facility's policy also required call lights to be within reach, which was not adhered to in this case.
Deficient Fire Safety Training and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.
Plan Of Correction
Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.
Failure to Label and Date Inhaler in Medication Cart
Penalty
Summary
A deficiency was identified when an LPN was observed retrieving an inhaler from the medication cart for a resident, which was found to be unlabeled and undated. Upon inquiry, the LPN confirmed that there was no date opened on the inhaler. Review of the resident's physician order indicated the use of Ventolin HFA Inhalation Aerosol Solution, to be administered four times daily for shortness of breath. The resident's medical record showed a diagnosis of Alzheimer's disease, impaired cognition, and a need for assistance with activities of daily living, including medication administration. Further review of the facility's policy on medication management stated that medications are to be dated and discarded according to manufacturer guidelines. When questioned, the DON expressed uncertainty about the requirement to date inhalers and indicated a need to review the policy. The failure to label and date the inhaler as required by both facility policy and federal regulations led to the cited deficiency.
Plan Of Correction
Corrective action taken for resident 56. The unlabeled inhaler was removed from the cart and replaced with a new inhaler from pharmacy which was labeled and dated appropriately. All residents have the potential to be affected by the deficient practice. All med carts were audited by unit managers and no unlabeled/dated medications were found. The Medication Management Policy was reviewed by the IDT and deemed to be appropriate. All licensed nurses will be educated on the Medication Management Policy with an emphasis on labeling and dating medications according to manufacturer guidelines. Resident name labels have been made available at each nursing station. The DON/designee will conduct random audits of the medication carts to ensure that all medication are appropriately labeled and dated. These audits will be weekly x4 weeks and then monthly x2 until compliance has been maintained. The results will be brought to QAPI for further recommendations. The DON/NHA are responsible for continued compliance.
Failure to Notify Physician and Family of Change in Resident Condition
Penalty
Summary
The facility failed to document notification of both the family and physician regarding a significant change in condition for one resident. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, and protein calorie malnutrition, was observed by a CNA to have stomach pain and liquid brown emesis on one day. The CNA reported these symptoms to a nurse, who administered Zofran for nausea and vomiting. However, there was no documentation that the physician or family were notified about the resident's symptoms of vomiting, which were significant enough that the medical director later stated would have warranted hospital evaluation. Further review of the resident's record showed that the resident was later sent to the hospital after being found with labored breathing and increased lethargy. The family was only informed after the resident had already been transferred to the hospital, and the medical director was not aware of the earlier episode of vomiting. The lack of timely notification and documentation of the change in condition constituted the deficiency identified in the report.
Failure to Apply Heel Protector Boots and Positioning Devices
Penalty
Summary
The facility failed to apply heel protector boots per physician orders for two residents and failed to apply positioning devices per physician orders for one resident. Resident R5 was observed multiple times without heel protection boots, which were noted to be in a wheelchair instead of on the resident's heels as required by the physician's orders. R5, who has diagnoses of Difficulty in Walking and Restless Leg Syndrome, confirmed that they sometimes do not wear the boots. The Wound Care Nurse acknowledged that the boots should be worn and documented if not in use. Similarly, Resident R24, who has diagnoses of Muscle Wasting and Atrophy and Muscle Weakness, was observed without heel boots, which were found on the floor next to their bed. The Wound Care Nurse was unaware if R24 was resistant to wearing the boots but confirmed they should be worn as per the physician's orders. R24 has severely impaired cognition and requires assistance with bed mobility and transfers. The facility also failed to apply positioning devices per physician orders for Resident R1, who has diagnoses of Weakness and Abnormal Posture. R1 was observed multiple times without the required lambswool padding in their wheelchair, and the unit manager confirmed that the right arm bolster was discontinued and the lambswool padding was stopped when R1 received a new wheelchair, although the exact date of the change was not confirmed. The physician's orders and care plan for R1 specified the use of these positioning devices to ensure proper support and positioning.
Failure to Secure Smoking/Vape Pens for Resident
Penalty
Summary
The facility failed to secure smoking/vape pens for a resident diagnosed with Atrial fibrillation. On two separate occasions, the resident was observed with a vape/smoking pen on their overbed table. When questioned, the Unit Manager and the resident's assigned nurse confirmed that residents are not allowed to have vape/smoking pens in their rooms. The Unit Manager subsequently removed three unopened boxes and one open smoking/vape pen from the resident's room. The Director of Nursing confirmed that the facility does not permit vape pens, in accordance with the facility's Non-Smoking Policy, which strictly prohibits all forms of E-Cigarettes and vaping materials within the facility.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that the call light was within reach of a resident (R1) who required assistance with bed mobility and transfers. On two separate occasions, the call light was observed to be out of reach of the resident, once hanging on the end of the bed and once on the floor past the end of the bed. The resident had diagnoses of weakness and abnormal posture and an impaired cognition score of 8/15, indicating the need for assistance and a safe environment. The resident's care plan specifically included interventions to keep the call light within reach to ensure safety and encourage its use for assistance. During an interview, the Director of Nursing (DON) confirmed that the resident was able to use the soft touch call light but not a regular call light, and that the call light should be within reach at all times. The facility's policy also stated that call lights should be placed within the residents' reach and answered in a timely manner. Despite these guidelines, the facility did not comply, leading to the deficiency noted in the report.
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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 Fort Gratiot
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Port Huron | 0.1 mi | ★★★★★ | 0 | 0 |
| Marwood Manor Nursing Home | 8.1 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Yale | 16.7 mi | ★★★★★ | 0 | 0 |
| Medilodge Of St. Clair | 20 mi | ★★★★★ | 16 | 0 |
| Medilodge Of Richmond | 23.7 mi | ★★★★★ | 1 | 0 |
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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.