Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Regency on the Lake - Fort Gratiot
Fort Gratiot, MI · 130 certified beds · Last Life Safety survey July 2, 2025
CMS Certification Number 235621 · first certified January 2007
Ownership
Operated by CIENA HEALTHCARE/LAUREL HEALTH CARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
13 citations — more than 45% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten MI facilities have been surveyed. This facility’s last Life Safety survey was July 2025. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 13 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 4, 2023 | 8 |
| June 6, 2024 | 4 |
| July 2, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-06-06 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-06-06 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-06-06 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2025-07-02 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2023-04-04 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-04-04 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2023-04-04 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-04-04 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 2
- Miscellaneous Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 2, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 22, 2025) |
June 6, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 24, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 24, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 24, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 24, 2024) |
April 4, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 25, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 25, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.