Regency at Fremont

Inspectors wroteBased on observation, interview and record reviews, the facility failed to effectively clean and maintain food service equipment, potentially affecting 94 residents, that receive food and beverages from the kitchen.

Inspectors wroteBased on observation and record review, the facility failed to safely transport two of four wheelchair dependent residents (Resident #3, Resident #72), reviewed for accidents and supervision, and provide direct supervision of residents in the dining rooms on the locked dementia unit.

Inspectors wroteThis site pertains to the annual survey and Intake 3017765. Based on observation, interview and record review, the facility failed to maintain appropriate hot food temperatures and failed to serve palatable/quality food items for residents eating food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the use of and utilize personal protective equipment for three of three residents (Resident #102, Resident #69, and Resident #70) reviewed for infection control and failed to clean glucometers according to manufacturer guidelines.

Inspectors wroteBased on interview and record review, the facility failed to allow the resident and/or the resident's responsible party the right to be informed and to make treatment decisions for 1 of 5 residents (R93) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate care and treatments in a timely manner for two of three residents (Resident #102 and Resident #70) reviewed for pressure wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (5%) for 1 of 8 residents (R34) observed during the medication administration task, resulting in a medication error rate of 7.41%.

Inspectors wroteThis citation is related to intake #2741450Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 7 of 25 residents reviewed for accommodation of needs.

Inspectors wroteThis citation pertains to intake # 2984523Based on interview and record review, the facility failed to (a) adequately monitor for medication side effects, (b) prescribe medications with an adequate/correct indication, and (c) frequently monitor and re-assess the effectiveness of the medications for one of three residents (Resident #100) reviewed for unnecessary medications.

Inspectors wroteThis citation pertains to intake #2715766Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #6) out of 3 residents reviewed for quality of care, resulting in a delay in medical treatment and surgical intervention for an unstable sacral fracture with spinopelvic dissociation and left superior/inferior ramus fractureFindings:Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: sacral and pelvic fractures from fall and Parkinson's Disease. Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 11/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated R6 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation had two deficient practice statements. DPS A Based on observation and record review, the facility failed to ensure call lights were within reach for 4 of 6 residents (Resident #18, Resident #31, Resident #36, Resident #63) reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to grievance issues raised by the Resident Council resulting in an ineffective forum for the presentation of grievances and recommendations to the facility affecting all facility residents.

Inspectors wroteBased on interview and record review, the facility failed to 1.) accurately document the administration of controlled medications and 2.) ensure controlled medications were administered following the providers order for 4 of 7 residents (Resident #75, #78, #62, and #80), reviewed for controlled medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transport residents in wheelchairs for 6 residents (Resident #50, #43, #31, #1, #7, and #37) out of 6 residents reviewed for accidents and hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignified care and treatment of two facility residents (R136 and R66) and failed to ensure communication for self-determination of care for one resident (61) of three residents reviewed for dignity.

Inspectors wroteBased on observation and record review, the facility failed to maintain the dignity of one of three residents (Resident #29) reviewed for dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments in 1 (R23) of 18 residents reviewed for accuracy of MDS assessment, from a total sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to formulate and implement a comprehensive communication Care Plan for one non-English speaking resident (R61) of one resident reviewed for communication.

Inspectors wroteBased on interview and record review, the facility failed to 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 1 resident (Resident #85) out of 3 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policies and procedures and prevent a facility acquired pressure ulcer, had conflicting assessment documentation, and revise the care plan for one (R27) of three residents reviewed for pressure ulcers.

Inspectors wroteBased in interview and record review the facility failed to act upon a Pharmacy recommendation for a psychoactive medication for one facility resident (R137).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices for wound and peri-care for two (R66 and R29) of two residents and follow blood borne practices for one (Resident #30) of one residents, reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to review and revise the facility assessment.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's (Resident #2) right to be free from sexual abuse by a resident (Resident #1).

Inspectors wroteThis citation pertains to intake MI000149220 Based on interview and record review, the facility failed to monitor blood pressures and/or follow physician ordered parameters prior to administering blood pressure medications for 1 of 3 residents (R3) reviewed for medication parameter monitoring, resulting in the potential for serious adverse effects of medications.

Inspectors wroteThis citation pertains to intake MI00146674 Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse of three reviewed, resulting in Resident #2 being abused by a staff member.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper label and dating of foods and documentation of food temperatures effecting 70 residents receiving meals from the kitchen resulting in increased the risk of contaminated foods and the risk of food borne illness.

Inspectors wroteBased on observation and interview the facility failed to effectively maintain the outdoor dumpsters effecting 70 residents, resulting in the increased potential for odors and the attraction of pests and rodents.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by other residents for 7 residents (R56, R62, R103, R104, R105, R106, R107) out of 13 residents reviewed for abuse and neglect, resulting in the potential for physical harm, pain and mental anguish.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs for three residents (Resident #13, #59, and #62), resulting in allegations of sexual abuse, fall with fracture, and the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse for three (Resident #13, #59 and #62) of 5 reviewed, resulting in allegations of sexual abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse that involved 3 residents (Resident #13, #59 and #62) of 5 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement comprehensive care plans for 1 (Resident #56) of 18 residents reviewed, resulting in the potential for unmet care needs and impaired wound healing/wound deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened medications were appropriately labeled and that expired medications were disposed of in 2 of 3 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects.

Inspectors wroteThis citation pertains to intake M100138378. Based on interview and record review, the facility failed to assess, document, monitor and treat for changes in condition, follow physician orders, notify physician, have effective communication with outside medical care providers, and thoroughly investigate a fall, and have complete and accurate medical records for 1 (Resident #1) of 4 residents reviewed for quality of care.