Regency at Shelby Township

Inspectors wroteThis citation pertains to intake 2992237. Based on observation, interview and record review, the facility failed to ensure interventions were implemented and care provided timely for three residents (R903, R904, and R906) of seven reviewed for care plan implementation and care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for three residents (R56, R119 and R117) out of three reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions for pressure ulcer healing for one resident (R89) out of three reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record the facility failed to ensure medications were labeled and dated when opened in one of four medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to residents needs(call lights) in a timely manner for one resident (R81 and R47) and two resident rooms (rooms [ROOM NUMBERS]) fourteen reviewed for call light response.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice proper infection control practices in a contact isolation room and properly store nebulizer/C-Pap (non-rebreather) mask for five residents (R36, R223, R221, R74, and R11) reviewed for infection control.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one resident (R25) was catheterized (straight cathed-tube inserted into the bladder to help drain urine) timely out of one reviewed for dignity, resulting in the potential for feelings of sadness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (R56) of three residents reviewed for accommodation of needs with a comfortable bed, resulting in feelings of dissatisfaction and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to develope a comprehensive care plan for one (R103) out of six residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan to reflect interventions for wandering behaviors for one resident (R76) out of one reviewed for behaviors.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up on physician's orders to scheduled an appointment for one resident (R30) of one resident reviewed for consultation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain the functional abilities of one (R70) out of one resident reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store an oxygen tank for one resident (R221) out of five reviewed for respiratory care. Findings Include: On 9/10/2024 at 10:20 AM, R221 was observed sitting in their room and was receiving oxygen via a nasal cannula. R221 stated they had recently arrived at the facility and needed oxygen continuously. In the corner of the room an oxygen tank was observed freestanding. No stand or cart was noted in the room. A review of the medical record revealed R22 admitted into the facility on 9/9/2024 with the following medical diagnoses, Lung Cancer and Chronic Obstructive Pulmonary Disease (COPD). A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin) care for one resident (R11) out of one reviewed for colostomy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing behavioral health services for one resident (R27) out of eight reviewed for behavioral health.

Inspectors wroteThis citation pertains to Intakes: MI00135903 and MI00135359. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, physical abuse, and neglect from staff to resident for one of one sampled resident (R51) reviewed for abuse resulting in, abuse, neglect and the likelihood of mental anguish using the reasonable person concept.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled and stored at the appropriate temperature, failed to maintain sanitary conditions, failed to ensure staff donned a beard restraint, and failed to ensure handwashing to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for four (R59, R95, R103, and R107) of four residents reviewed for resident assessment transmission, resulting in potential for inaccurate tracking of resident assessment, admission and discharges.

Inspectors wroteThis citation pertains to Intake MI00133827. Based on observation, interview and record review the facility failed to ensure care needs were met timely for five sampled Residents (R24, R41, R65, R234, R236) of six reviewed for activities of daily living needs, resulting in dissatisfaction with the care provided, a delay in care needs being met and the potential for unmet care needs.

Inspectors wroteThis citation pertains to Intake MI00137843. Based upon interview and record review, the facility failed to provide timely notification of a fall with injury to the family member/responsible party of one (R481) of five residents reviewed, resulting in family member/responsible party not knowing right away that the resident fell and causing a delay in the opportunity to participate in medical decisions regarding care and treatment.

Inspectors wroteThis citation pertains to Intake MI00133827. Based on observation, interview, and record review the facility failed to re-check a blood glucose level (amount of sugar circulating in the blood) after an insulin administration for one resident R433 of two reviewed for change in condition, resulting in the potential for continued blood sugar instability and diabetic complication.

Inspectors wroteThis citation has two Deficient Practice Statements. Deficient Practice #1. This citation pertains to Intake MI00131868. Based on interview and record review, the facility failed to assess, implement and ensure safe interventions were in place for one resident (R231) of five reviewed for accident/hazards, resulting in a fall.

Inspectors wroteThis citation pertains to Intake MI00131868. Based on interview and record review, the facility failed to document the replacement of an indwelling urinary catheter and a nursing assessment after reported abnormal findings for one resident (R231) of one reviewed for catheters, resulting in a delay in the evaluation and treatment of urinary complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food in a palatable manner and in an appetizing appearance for one sampled resident (R100) and seven confidential group residents, resulting in dissatisfaction during meals.

Inspectors wroteBased on observation, interview and record review, a facility staff person failed to don appropriate personal protective equipment (PPE-items such as gloves, gowns, protective eye wear, etc.) when entering a room for one (R48) of two residents in transmission based precautions (TBP-precautions used for patients who may be infected with certain infectious diseases) reviewed for infection control compliance, resulting in the potential for the spread of infection.