Regency at Chene

Inspectors wroteThis citation pertains to intake 3030345. Based on observation, interview, and record review, the facility failed to notify the legal guardian, when an injury occurred for one resident (R102) out of five residents reviewed for notification of change.

Inspectors wroteThis citation pertains to intake 3051950. Based on observation, interview, and record review, the facility failed to provide a homelike environment by not ensuring the availability of an adequate supply of linen for two residents (R101 and R104) of three residents reviewed for care, resulting in residents having unmet care needs. This deficient practice has the potential to affect all 152 residents who resided in the facility.

Inspectors wroteThis citation pertains to intake 3051950. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for two residents (R101 and R104) of three residents reviewed, resulting in the potential for dissatisfaction with the meal experience.

Inspectors wroteThis citation pertains to Intake Number(s): 3022409 and 3022328. Based on interview and record review, the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one (R801) of two residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area and maintenance of equiptment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: On 4/14/2026 at 8:53 AM observed the hand sink near the walk in cooler with a self-closing faucet motion activated sensor. When turned on the sink ran for approximately 5 seconds before turning off. On 4/14/2026 at 9:17 AM observed the hand sink near the cookware with a self-closing faucet motion activated sensor. When turned on the sink ran for approximately 5 seconds before turning off. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 4/14/2026 beginning at 10:22 AM a facility tour was conducted with Housekeeping and Laundry Supervisor (HLS) EOn 4/14/2026 at 10:27 AM observed a hopper with black particles along the inside edge of the hopper bowl in the soiled utility laundry room. An interview at this time with HLS E found the hopper is not used. Further observation found the faucet handle missing from the hand sink. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 4/14/2026 at 10:10 AM observed three outdoor waste receptacles in an enclosure. An interview with Housekeeping and Laundry Supervisor (HLS) E at this time found trash is picked up three times a week. One of the waste receptacles was observed with the lids in the open position and cardboard piled above the rim. Scattered debris including plastic bags were observed along the back wall of the enclosure. HLS E indicated they would call someone to move cardboard and close the lid. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five residents (R5, R8, R27, R84, R85) out of five residents reviewed for immunizations, were provided pneumococcal vaccination and education resulting in the potential for development and spread of pneumonia among vulnerable residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure five residents (R5, R8, R27, R84, R85) out of five residents reviewed for immunizations, were provided Covid-19 vaccination and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform one resident (R154) of five residents about the risks and benefits of a proposed treatment and to receive consent for the use of the treatment, resulting in the administration of an antipsychotic medication without resident understanding and consent.

Inspectors wroteBased on observation, interview, and review, the facility failed to ensure a call light was within reach of one resident (R162) out of one resident reviewed for accommodation of needs, resulting in unmet care needs and the potential for further unmet care needs

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the bathroom was free from odors for two (R47 and R107) of four residents reviewed for homelike environment, resulting in unpleasant odors due to poor ventilation.

Inspectors wroteBased on interview and record review the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for one resident (R27) and Level 2 (3878) was completed for two residents (R4, R125) out of five residents reviewed for PASARRs.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply splinting devices and perform range of motion (ROM) exercises as recommended by therapy for one (R5) of four residents reviewed for limited ROM, resulting in the potential for increased joint contracture, loss of range of motion and increased pain.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document a review of Medication Regimen Review (MRR) recommendations or any action taken by the physician in response to pharmacy recommendations for one (R154) of five residents reviewed for Unnecessary Medications, resulting in the potential for the continuance of unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication regimen was free from unnecessary medications for one resident (R154) of five residents reviewed for unnecessary medications, resulting in the potential for the continuance of unnecessary medications and adverse drug reactions experienced by the resident.

Inspectors wroteThis citation pertains to intake 2735896. Based on interview and record review the facility failed to implement adequate supervision for one cognitively intact resident (R903) from three residents reviewed for safety resulting in R903 exiting the building with family unbeknownst to the facility and unknown whereabouts.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely required information upon facility entry and during the annual recertification survey affecting all residents who reside in the facility causing a delay in the survey process. On 5/5/2025 at 8:30 AM upon facility entry the survey team leader requested a facility census, a resident list, and facility matrix from Registered Nurse (RN) H. RN H did not provide the requested information. On 5/5/2025 at approximately 9:15 AM the facility census, resident list, WIFI access, and facility matrix were requested from the Director of Nursing (DON). On 5/5/2025 at approximately 9:45 AM the Nursing Home Administrator (NHA) provided the facility census, resident list, facility matrix, electronic medical record (EMR) access and WIFI access. The facility provided WIFI access did not work throughout the survey. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assist in the removal of facial hair and ensure showers were provided for one female resident (R54) and provide nail care for three residents (R10, R17, R100) of 29 residents reviewed, resulting in unmet hygiene needs and the potential for feelings of diminished dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure, label and dispose of expired medication by professional standards for two of four medication carts reviewed for secured, expired and unlabeled medications, resulting in the potential for unsafe medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hygienic practices were performed while serving resident's meals, resulting in the potential for food contamination.

Inspectors wroteDPS 2) Based on observation, interview, and record review the facility failed to ensure the provision of care per professional standards of practice were implemented for infection control practice of hand hygiene during wound care, for two Residents (R121 and R143) of three Residents reviewed for infection control, resulting in the potential for spread of infection, worsening wounds, and the potential decline in overall health status. Resident # R121 On 05/06/25 at 9:22 AM, R121 was observed in bed, fully dressed, and watching TV. R121 was observed to have a left above the knee amputation (Above-the-knee amputation (AKA) involves removing the leg from the body by cutting through both the thigh tissue and femoral bone). R121 said they had a recent surgery about a month ago due to an infection. R121 indicated that staff changed their wound dressings daily. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure functional equipment in a safe and sanitary manner, resulting in broken equipment and an unsanitary environment. This deficient practice had the potential to affect 143 of 146 residents in the facility.

Inspectors wroteThis citation pertains to intake MI00152511. Based on observation, interview, and record review, the facility failed to treat the resident with dignity and respect for one resident (R81) of four residents reviewed for dignity and respect, resulting in staff taking a picture of R81's buttocks, leaving the resident feeling embarrassed, ashamed, nervous, and scared.

Inspectors wroteBased on observation, interview and record the facility failed to develop and implement care plan interventions to monitor, prevent and accident for one resident (R54) of 29 residents reviewed, resulting in a potential for a unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (R408) of one resident reviewed for dialysis services had timely and complete physician orders for dialysis, restrictions associated with an arteriovenous (AV) fistula, and clearly defined fluid restriction parameters. This failure created the potential for missed treatment, compromised vascular access and inadequate fluid management. Findings Include: On 5/7/2025 at approximately 11:00 AM, observed R408 had three cups of liquid at her bedside. There was also one liter bottle of juice on the bedside table directly behind R408. On 5/7/2025 at 11:30 AM, a review of R408's clinical medical record was conducted. The electronic medial record (EMR) lacked a physician order for dialysis. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wheelchair footrests were in place during a wheelchair transfer and to assist with seated posture for one resident (R19) of two residents reviewed for positioning resulting in the potential for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pressure ulcer care per health care provider order and standards of clinical practice for two Residents (R121 and R143) of four Residents reviewed for wound care, resulting in incorrect wound care, and the potential for wound worsening, infection, and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate foot care for one resident (R100) out of eleven residents reviewed for Activities of Daily Living (ADLS).

Inspectors wroteBased on observation, interview, and record review the facility failed to apply splints and provide Range of Motion (ROM) exercises for one resident (R100) out of four residents reviewed for limited ROM.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident (R54) of 29 residents was free from accident hazards as a results of the resident's call light not being within reach and potentially hazardous products left at the resident's bedside, resulting in a potential for an accident to occur.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one resident (R28) of three residents reviewed with oxygen, resulting in the potential for compromised air exchange.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the security of the electronic medical record (EMR) of one resident (R306) out of 29 residents reviewed. Findings Include: On 5/7/2025 at 9:30 AM, a medication cart on unit 300 was observed left unattended with the EMR screen open and displaying R306's PHI. The cart faced the hallway, which was actively used by staff and residents, exposing confidential details to unauthorized individuals. On 5/7/2025 at 9:40 AM, Licensed Practical Nurse (LPN) C exited R306 room and, upon interview, confirmed they left the art unsecured with PHI visible. LPN C acknowledged this was not in compliance with facility protocol. 05/07/25 9:53 AM, the unit manager (LPN) B was interviewed and said the computer should have been locked, and no medications should be left unattended on the cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure routine dental services were provided to one resident (R10) of three residents reviewed for routine dental services, resulting in unmet oral health needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the proper assistive device was provided to enhance and promote independence in eating for one resident (R126) of 30 residents observed during dining on the second floor, resulting in a potential for a decline in eating skills and abilities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure relevant Hospice documentation was accessible for two residents (R28, R67) of nine hospice residents from a total of twenty-nine sampled residents, resulting in a lack of coordination of comprehensive services and care provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to administer the Pneumococcal and Influenza vaccines to one resident (R10) of five residents reviewed for infection control resulting in the likelihood for increased risk for acquiring, transmitting and experiencing complications from the pneumonia and the flu. Findings Include: On 5/12/25 at 10:20 AM, the Infection Control Program was reviewed with the Infection Control Registered Nurse (RN) A. RN A was provided a list of residents to be reviewed for vaccinations. RN A provided documentation that R10 did sign to receive the Pneumococcal and Influenza vaccinations on 8/8/2024. There was no documentation that R10 had received either the Pneumococcal or Influenza vaccinations. RN A said she was unable to find the documentation that the vaccination was administered in the vaccination book or in the electronic medical record (EMR). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident (R134) of one resident reviewed for MDS assessments, resulting in the potential for inaccurate and inadequate care plans.

Inspectors wroteThis citation pertains to intake MI00150096. Based on observation, interview and record review the facility failed to follow the standard of practice for medication administration for one (R101 of four residents reviewed for medication administration.

Inspectors wroteThis citation pertains to intake MI00150096. Based on observation, interview, and record review, the facility failed to have complete and accurate medical records for one (R101) of four residents reviewed for medication administration resulting in the medication administration record (MAR) left blank and the inability to determine what nurse was assigned to the resident according to the MAR.

Inspectors wroteThis citation pertains to intake MI149002. Based on observation, interview, and record review the facility failed to ensure appropriate PEG (percutaneous endoscopic gastrostomy (thin flexible tube inserted through the skin of the abdomen into the stomach to deliver nutrition and hydration) tube care was provided including enteral/tube feedings (liquid nutrition delivered through a PEG tube) and water administration for one (R901) of three residents reviewed for PEG tube care, resulting in R901's not receiving the prescribed amount of enteral/tube feeding or water and peg tube care not being provided in accordance to the physician's orders.

Inspectors wroteThis citation pertains to intake MI00149002. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for one resident (R901) of three residents reviewed for wound and PEG tube care (percutaneous endoscopic gastrostomy (thin flexible tube inserted through the skin of the abdomen into the stomach), resulting in the potential for the spread of infection.

Inspectors wroteThis citation has two deficient practices. Deficient Practice Statement 1 Based on observation, interview, and record review, the facility failed to ensure an emergency tracheostomy (an incision into the windpipe made to relieve an obstruction to breathing) was accessible, resulting in the likelihood of serious injury, serious harm, serious impairment, or death for one resident (R138) who required mechanical ventilation. In an observation on 4/16/24 at 9:55 a.m., R138 laid in bed and had a tracheostomy (trach). There was not an emergency trach visible in R138's room. In an observation and interview on 4/16/24 at 10:32 a.m., Licensed Practical Nurse (LPN) L was asked about R138's emergency backup trach and could not locate one in R138's room. LPN L reported there was not an emergency backup trach in R138's room. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 143 residents who receive meal services (3 nothing by mouth residents, or NPO) out of the facility's total census of 146 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the garbage storage area was maintained in sanitary condition resulting in an increased potential for the harborage and feeding of pests.

Inspectors wroteBased on observation and interview, the facility failed to ensure the 2nd floor 'wireless' nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens on the second floor resulting in the potential for delayed call light response times, and the potential for resident care needs of 47 residents to be unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity by not dressing one resident (R16) in personal clothing out of one resident reviewed for dignity, resulting in verbal frustration and impaired mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach for one resident (R43) and a wheelchair provided for one resident (R108) of six residents reviewed for accommodation of needs, resulting in unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs for one (R21) of three residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise care plans in a timely manner for two residents (R18 and R121) out of thirty residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an appropriate discharge plan to return to the community (home) for one (R79) out of three residents sampled for discharge planning, resulting in a loss of independence, unmet psychosocial needs, and support from family.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care, scheduled showers, and assist with transfers out of bed for two residents (R13 and R100) out of thirty residents reviewed for Activities of Daily Living (ADLS). Findings Include: R100 During an observation and interview on 4/16/24 at 12:57 PM, R100 was observed lying in bed with long fingernails with debris underneath nails. Resident reported that he would like his nails to be cut and cleaned. Record review of R100's Functional Ability Deficit care plan dated 12/14/23, documented Personal Hygiene- Resident is dependent. Further review of care plans and nursing progress notes revealed no preference for long nails or refusing nail care by resident in the last month. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate assessment and monitoring of wounds for one resident (R18) out of three residents reviewed for wound care management. Findings Include: During an observation and interview on 4/17/24 at 10:25 AM, R18 two open wounds on the bottom back side of right leg that measured approximately 0.5 cm (Centimeters) long and 0.5 cm wide with a depth of 0.1 cm each. Licensed Practical Nurse (LPN) G reported being made aware of wounds on 4/15/24. Record review of electronic medical records revealed admission into the facility on 5/18/23 with pertinent diagnosis of acquired absence of right and left leg above knee. According to the Minimum Data Set (MDS) dated [DATE]. R18 had slight impaired cognition and required substantial assistance with Activities of Daily Living (ADLS). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide vision services for one resident (R13) of two residents reviewed for assistive devices, resulting in inadequate eyewear for R13.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the standards of infection control for proper PPE use (gloves), hand hygiene, and point of care testing, for one resident (R79) out of four residents reviewed for medication administration, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections.

Inspectors wroteThis citation pertains to intake MI00141762. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to the hospital for one resident (R601) of three residents reviewed for emergency transfer, resulting in resident identification and medical information not being sent with EMS (Emergency Medical Service) personnel to the hospital and the potential for unmet care needs upon transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to transmission-based precautions during meal pass on Unit 300, resulting in the potential for the spread of harmful pathogens among the residents in the building.

Inspectors wroteThis citation pertains to Intakes MI00138233 and MI00139515. Based on observation, interview, and record review, the facility failed to ensure prescribed medications were provided in a timely manner for two residents (R134 and R139) out of seven residents reviewed for medication administration, resulting in resident apprehension and the potential for unmet health care needs.

Inspectors wroteThis citation pertains to Intakes MI00138483 and MI00139515. Based on interview and record review, the facility failed to ensure medications were accurately documented as administered per physician's orders for R120 and 125 resulting in inaccurate and incomplete medical records.