Regency, a Villa Center

Inspectors wroteBased on interview and record review the facility failed to ensure there was a Registered Nurse (RN) for 8 consecutive hours 7 days a week. This deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure trash cans were clean and properly lined; 2. Ensure pans were properly cleaned and allowed to air dry before stacking; 3. Properly date-label food stored in the walk-in cooler; 4. Ensure staff food and personal items were not commingled with residents' food; 5 Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food; and 6. Ensure food service equipment was maintained in a safe and sanitary operating condition. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the potential for foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at palatable temperatures for multiple residents in the facility, resulting in dissatisfaction with the meal experience.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one (R15) of one resident reviewed for accommodation of needs, resulting in the delay in incontinence care and potentially other unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, or document an effective discharge plan of care for one (R222) of five residents reviewed for discharge planning resulting in the delay of home care services and potential delay for follow-up appointments for R222.

Inspectors wroteBased on interview and record review the facility failed to complete a discharge summary that included a recapitulation of stay for two (R12, R222) of five residents reviewed for discharge planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for a foley catheter (indwelling urinary catheter) for one (R5) of three residents reviewed for catheter care resulting in the potential for inappropriate and ineffective care of the resident's indwelling catheter.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure ulcer care as prescribed for one (R5) of five residents reviewed for pressure ulcer care resulting in the potential for R5's pressure ulcer to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate indwelling urinary catheter (foley) care for one (R5) of three residents reviewed for catheter care. Findings Include: On 1/13/26 at 12:53 PM, R5 was observed lying in bed with foley catheter tubing hanging off the bed draining a small amount of amber urine into a collection bag. The collection bag had a privacy cover and was attached to the bed frame, below the level of the resident's bladder. The resident said there were problems with the foley catheter leaking urine last night. R5 said, There was urine all in my diaper and the bed. The CNA (certified nursing assistant) had to change my brief and the whole bed. The nurse came in and changed the bag. It seems to be working fine now. [...]

Inspectors wroteThis citation pertains to Intake 2711513. Based on interview and record review the facility failed to ensure correspondence between the facility and the dialysis center was implemented for one (R73) of one resident reviewed for dialysis resulting in missed communication for continuity in care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a functioning call light for one (R15) of one resident reviewed for environment resulting in unmet safety needs.

Inspectors wroteThis citation pertains to intake 1316302. Based on interview and record review the facility failed to prevent the misappropriation of resident's property for one (R702) of seven residents reviewed for abuse resulting in R702 missing 28 doses of hydrocodone (narcotic pain medication).

Inspectors wroteThis citation pertains to intake 2565437. Based on interview and record review the facility failed to report a potential incident of neglect for one (R707) of seven resident reviewed for abuse/neglect.

Inspectors wroteThis citation pertains to 2574104. Based on interview and record review, the facility failed to ensure adequate supervision to prevent a resident to resident altercation for one resident (R712) of seven residents reviewed for abuse, resulting in R712 being struck on the head by R711 and the potential for continued physical abuse to occur.

Inspectors wroteThis citation pertains to MI00153114. Based upon interview and record review, the facility failed to ensure transfer documentation was in place for one resident (R101) reviewed for transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangement and destination upon transfer from the facility.

Inspectors wroteThis citation pertains to MI00153114. Based on interview and record review, the facility failed to provide documentation in the EHR (electronic health record) for a psychiatric petition to the hospital for one resident (R101), resulting in missing clinical information regarding the resident's psychiatric status at the time of the transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician orders for one (R603) of four residents reviewed for falls, resulting in R603 not receiving a topical pain medication or having a urinalysis (laboratory test used to detect urinary tract infections) completed.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain dignity while assisting during mealtime for one resident (R163) of three residents reviewed for dignity, resulting in the potential for feelings of embarrassment and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and respect the personal privacy by opening packages of one resident (R142) of two residents reviewed for privacy, resulting in a breach of personal privacy and the feeling of anger and disrespect.

Inspectors wroteBased on observation, interview, and record review the facility failed to change soiled linens for one resident (R131) of 27 reviewed for homelike environment resulting in R131 sleeping on soiled and damp linens and dissatisfaction with living conditions.

Inspectors wroteBased on interview and record review the facility failed to record, track, and respond to resident concerns/grievances for one (R15) of one resident reviewed for grievances resulting in R15's grievance not being addressed.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly position a resident for proper medication administration and failed to ensure that medication was administered according to physician orders for one (R5) out of twenty-seven residents reviewed for medication administration, resulting in the potential for less than therapeutic effects of the prescribed medication and placing the resident at risk for choking.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL assistance for three (R107, R5, and R110) of 27 residents reviewed for ADL care resulting in unkempt hair, jagged nails, unshaven facial hair, and lack of showers/bedbaths.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standards of practice for respiratory care for one resident (R162) out of two residents reviewed for respiratory care, resulting in the improper storage of a nebulizer mask and the potential for cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and functional environment for two residents (R54) and (R147), resulting in dissatisfaction with the resident's home an a increased risk for harm.

Inspectors wroteBased on interview and record review the facility failed to ensure annual Dementia Management and Abuse training were performed for one Certified Nurse Assistant (CNA) G out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs.

Inspectors wroteThis citation pertains to intake #'s MI00146301 and MI00146393. Based on observation, interview, and record review, the facility failed to ensure accurate assessments and implementation of indwelling urinary catheter care for two residents, (R901 and R902) of three residents reviewed for urinary catheters, resulting in the potential for the development of urinary tract infections and complications from indwelling urinary catheters.

Inspectors wroteBased on interview and record review the facility failed to allow one resident (R210) to discharge from the facility at her request until the Ombudsman intervened on 6/27/24 of six residents reviewed for resident rights, resulting in psychological distress, depression, and physical attempts at leaving the facility.

Inspectors wroteThis citation pertains to Intake MI00139649. Based on interview and record review, the facility failed to ensure appropriate transfer documentation was in place for one resident (R607) out of one resident reviewed for hospital transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangements upon transfer from the facility.

Inspectors wroteThis citation pertains to Intake MI00141041. Based on interview and record review, the facility failed to demonstrate professional standards of practice by not consistently obtaining resident's blood pressure readings prior to the administration of anti-hypertensive medications as ordered for one resident (R608) out of three residents reviewed for physician's orders, resulting in the potential for hypotension.

Inspectors wroteThis citation pertains to Intake MI00141603. Based on interview and record review, the facility failed to adequately complete discharge instructions and recapitulation of stay in a timely manner for one resident (R611) of three residents reviewed for a comprehensive discharge summary, resulting in the potential for lack of communication to care providers assuming the resident's care.

Inspectors wroteThis citation pertains to intake MI00141883 and MI00141437. Based on interview and record review the facility failed to consistently conduct weekly skin observations for two residents (R606 and R610) and a Braden skin assessment for one resident (R610) of three residents reviewed for maintenance of skin integrity, resulting in the potential for skin care needs to go undetected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform proper sterile hygiene practices, hand hygiene, and glove usage for one resident (R624) of two residents reviewed for tracheostomy care, resulting in the potential for tracheostomy infection and airway impairment.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of controlled drugs (drugs that are subject to high levels of regulation, such as narcotics) in sufficient detail to enable an accurate reconciliation resulting in the potential for medication missappropration and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent 11 significant medication errors for one resident (R226) when the resident was simultaneously prescribed and administered Phenytoin suspension, (an anti-seizure medication) with enteral nutrition through a PEG tube (flexible tube surgically inserted through the abdomen into the stomach to deliver medication and nutrition) resulting in the potential for decreased efficacy and less than therapeutic effect of the medication (Phenytoin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure updated and accurate Advanced Directive information was in place for one (R4) of five residents reviewed for Advanced Directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Review of an Electronic Health Record (EHR) revealed, Resident #4 (R4) had a code status of Full Resuscitate in the banner. R4's Code Status Elective Form revealed Do No Resuscitate (DNR) signed on 7/17/23. Review of an admission Record revealed, R4 admitted to the facility on [DATE] with pertinent diagnosis which included Heart Failure. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an annual update for a preadmission screening (PAS)/ Annual Resident Review (ARR) (3877) for a Level II evaluation was completed for one resident (R87) of seven residents reviewed for PASARR, resulting in the potential for the resident to not receive appropriate mental health treatment and services.

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to follow professional standards of practice for medication administration through a PEG tube (flexible tube surgically inserted through the abdomen into the stomach for nutrition/medication administration) for two of two residents (R137 and R226) when PEG tube placement was not verified prior to medication administration resulting in the potential for medications not being administered into the stomach and aspirated into the lungs.

Inspectors wroteThis citation pertains to intakes MI00137524 and MI00135643 Based on observations, interview, and record review the facility failed to provide adequate nail care for two residents (R7 and R20) reviewed for nail care resulting in the potential of low self-esteem, skin irritation, and spread of infection.

Inspectors wroteDeficient Practice #2. Based on observation, interview and record review, the facility failed to ensure proper anchoring/securing of an indwelling urinary catheter for one (R182) of five residents reviewed for urinary catheters, resulting in the potential for skin trauma.