Regency at Lansing West

Inspectors wroteThis citation pertains to Intake 2740541. Based on interview and record review, the facility failed to prevent a fall for 1 (R1) of three reviewed.

Inspectors wroteThis citation pertains to Intake 2740541. Based on interview and record review, the facility failed to maintain accurate medical records for 1 (R1) of three reviewed.

Inspectors wroteThis citation pertains to intake MI00150279. Based on interview and record review, the facility failed to prevent a fall for one (Resident #150) of three reviewed for accidents, resulting in a fall with bilateral femur fractures when Resident #150 fell from her bed.

Inspectors wroteThis citation pertains to Intake MI00149066. Based on observation, interview, and record review, the facility failed to immediately report an allegation of abuse to the State Agency for one (Resident 200) of three reviewed, resulting in a sexual abuse allegation to go unreported to the State Agency.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for three Resident Residents (#43, #53, and #91) out of three reviewed for Beneficiary Notification. Findings Included: Resident #43 (R43) Review of the medical record revealed R43 was admitted to the facility 12/01/2022 with diagnoses that included cerebral atherosclerosis (arteries in brain become hard, thick, and narrow due to build up of plaque), pain in left wrist, anxiety, dementia, delusional disorders, emphysema, polyneuropathy, atrial fibrillation, communication deficits, chronic obstructive pulmonary disease (COPD), depression, stroke, and hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary services were provided for Activities of Daily Living (ADL) for three out of four residents (Resident #9, 71, and 83) resulting in the potential for care needs not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory blood tests were provided and completed timely and as ordered for one out of one residents (Resident #11). Findings Included: Per the facility face sheet R11 had an initial admission date of 10/17/2019, and a readmission date of 7/3/2021. Record review of R11's Physician's orders dated 1/6/2024, revealed R11 was to have a CBC (complete blood count) CMP (comprehensive metabolic profile), and Liver tests done annually. A BMP basic metabolic panel), lipids, TSH (thyroid stimulating hormone) test perform every six months, and an HgbA1c (measures average blood sugar levels over the past three months) performed every three months. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of five residents (Resident #9) had water available at the bedside, resulting in the potential for dehydration. Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction (one sided weakness caused by a stroke), glaucoma (condition that causes damage to the optic nerve, and dry eye syndrome of bilateral lacrimal glands (gland that produces tears). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/24 revealed R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental status. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care plan interventions were maintained for one resident (#4) of 3 residents reviewed for falls, resulting in resident 4 sustaining a fall with a left elbow abrasion. Findings Include: According to the clinical record including the Minimum Data Set (MDS) dated [DATE] and 09/08/23 Resident #4 (R4), was admitted to the facility with diagnoses that included cerebral infarction with left sided hemiplegia and hemiparesis. R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) on the 06/08 and the 09/08/23 MDS, both MDS assessments also reflected R4 was coded to require extensive assist with two persons for transfers. [...]

Inspectors wroteThis citation pertains to MI00139852 Based on interview and record review the facility failed to honor one resident's (#7) Advance Directives (a written statement of a resident's wishes regrading medical treatment) for DNR (Do not Resuscitate) of three residents reviewed resulting in the resident's medical preferences not to be followed at the end of life and the potential of other residents not to have their medical preferences followed at the end of life. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for two Residents (R29 and R94) of four reviewed for pressure ulcers, resulting in worsening of pressure wounds requiring re-hospitalization related to wound infection that required use of intravenous antibiotic treatment and multiple debridement's for R94 and development of two facility acquired unstageable deep tissue pressure ulcers, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and sanitize food service equipment effecting 108 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased interior food service equipment illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure updated and accurate advance directive information was in place for four residents (Resident #2, #13, #78 and #94) of five reviewed for advance 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 the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. label open multi-dose tuberculin vial with open date in 2 of 2 medication room and 1 of 4 medication carts reviewed for labeling, dating and expiration of medications; and 2. Dispose of expired over the counter medication after manufacture expiration dates, resulting in the potential for medications given to residents to have decreased potency, reduced strength, effect, and medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for three (Resident #22, #64, and #317) of four residents reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 1 (Resident #88) of 22 reviewed for comprehensive care planning, resulting in R88 fall from elevated bed and fractures that required hospitalization and surgical intervention.

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure residents receive showers according to their plan of care for one resident (#51) of three residents reviewed for hygiene and grooming, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Findings Included: Resident #51 (R51) Review of the medical record revealed R51 was admitted to the facility 01/27/2021 with diagnoses that included fracture of left femur, type 2 diabetes, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), pain in left and right hand, insomnia, anxiety, abnormal posture, lack of coordination, Charcot's joint (bone and joint change that occur secondary to loss of sensation) of left foot and ankle, Charcot's joint of right foot and ankle, hypertension, depression, morbid obesity, and pain in left hip. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide indwelling urinary catheter care for one resident (#96) of four residents reviewed for indwelling urinary catheter care resulting in urinary tract infection for resident #96 and the potential to cause infection in 15 other residents with an indwelling or external urinary catheter. Finding Included: Resident #96 (R96) Review of the medical record revealed R96 was admitted to the facility 01/16/2023 with diagnoses that included encephalopathy (brain disease that alters brain function), atrial fibrillation, dysphagia (difficulty swallowing), unstageable pressure ulcer of sacrum, adult failure to thrive, hypertension, hypothyroidism (low thyroid hormone), insomnia, vascular dementia, mood disturbance, and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify 1 Resident's (R 94) facility wound physician of change in condition(wound status) of 2 Residents reviewed for pressure ulcers, resulting in R 94 having delayed treatment and physician consultation related to his skin break down and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician ordered parameters upon the administration of blood pressure medications for one (R38) of six residents reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors were observed from a total of twenty-seven opportunities for two (Resident #101 and #365) of three residents reviewed for medication administration, resulting in a medication error rate of 7.41% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) appropriately clean a glucometer (a blood glucose monitoring system) after checking a blood sugar for 1 resident (# 101) of 1 reviewed for blood glucose monitoring and 2) maintain appropriate infection control practices during wound care for 1 resident (#94) from a total sample of 22 residents, resulting in the potential for cross-contamination, spread of blood borne pathogens, and increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure information within the Survey Book was up to date and maintained to include reports of respective surveys and the facility plan of correction for identified deficiencies, resulting in the potential for residents, visitors, and families to be uninformed of the facility's deficient practices in a current facility census of 108 residents.