Regency at St. Clair Shores

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for one resident (R11) out of four residents reviewed for Activities of Daily Living (ADL) care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional call light system (system in which a resident can call for assistance) for one (R170) of 15 residents reviewed for call light function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to call lights in a timely manner for 11 residents (R47, R110, and a confidential group of nine residents) out of 11 residents reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one resident (R24) of one resident reviewed with dignity and respect.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop or revise care plans for two residents (R11, and R13) of three residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide psychotropic medications in a timely manner for one resident (R80) of one reviewed for pharmacy services.

Inspectors wroteThis citation pertains to Intakes MI00153087 and MI00153316. Based on observation, interview, and record review the facility failed to prevent incidents of misappropriation of narcotic pain medication for four residents (R901, R902, R903, R904) of four residents reviewed for misappropriation of property.

Inspectors wroteThis citation is pertaining to Intake MI00151818. Based on interview and record review, the facility failed to schedule and coordinate follow up appointments as recommended for one resident (R700) of one resident reviewed for coordination of care.

Inspectors wroteThis citation pertains to Intake MI00146820. Based on observation, interview and record review, the facility failed to ensure resident safety for one (R800) of one resident resulting in a fall with bruising.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan for an abdominal drainage tube was initiated within 48 hours of admission for one (R340) of one residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was involved in they're plan of care and care conference meetings for one (R20) out of one residents reviewed for care planning meetings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for dependent residents resulting in moisture associated skin damage (MASD) for one (R110) out of one resident reviewed for incontinence care.

Inspectors wroteThis citation has two Deficient Practices. Deficient Practice Statement #1. Based on observation, interview and record review, the facility failed to initiate care orders and monitor an accordion drainage device (a collection device connected to a drain that allows for continuous suction) for one of one (R340) residents reviewed for care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change a pressure ulcer dressing for one resident (R44) out of eight reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply prafo boots (custom-fitted device that can help manage ankle/foot anomalies) to two residents (R77 and R20) out of two residents reviewed for range of motion.

Inspectors wroteBased on observation, interview and record review, facility failed to properly label medications with resident identifier or open date in two of four medicaiton carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control standards regarding hand hygiene, cleaning vital signs equipment (blood pressure, pulse oximeter) between residents, and cleaning the top of an insulin vial prior to drawing up insulin.

Inspectors wroteBased on observation, interview, and record review the facility failed to post ombudsman contact information in an accessible area affecting all 124 residents that reside in the facility.

Inspectors wroteThis intake pertains to Intake MI00138670. Based on interview and record review, the facility failed to timely implement interventions or properly treat an existing pressure injury for one resident (R700) out of three reviewed for wounds, resulting in the hospitalization for debridement of the wound. Findings Include: A review of an Intake called into the State Agency noted the following, .Complainant states that facility neglected to properly treat the bedsore .complainant states the bedsore got progressively worse and the size of a grapefruit. Complainant states on [date] the resident was sent to the hospital for debridement . A review of the medical record revealed that R700 admitted into the facility on 5/12/2023 with the following diagnoses, Multiple Sclerosis and Dysphagia. [...]

Inspectors wroteThis citation pertains to intake MI00140941 Based on interview and record review, the facility failed to provide two-person assistance during care for one resident (R712) out of one reviewed for falls, resulting in a fall from bed and death. Findings Include: A review of an incident and accident report dated [DATE] revealed the following, Nursing Description: CENA (Certified Nursing Assistant) was in Resident's room to provide care. While CENA was at the sink [they] heard a loud thump. CENA went back to Resident's bed and saw that [R712] was lying on the floor. CENA informed Writer that Resident was on the floor. Writer observed Resident lying on the floor on [their] right side on the left side of [their] bed with [their] head slightly under the bed frame. Writer asked Resident did [they] roll out of bed on [their] own, Resident stated yes with a head shake. [...]

Inspectors wroteThis citation pertains to Intake MI00140941. Based on interview and record review, the facility failed to update the care plan with an immediate intervention following a fall for one resident (R712) out of one reviewed for falls. Findings Include: A review of an incident and accident report dated [DATE] revealed the following, Nursing Description: CENA (Certified Nursing Assistant) was in Resident's room to provide care. While CENA was at the sink [they] heard a loud thump. CENA went back to Resident's bed and saw that [R712] was lying on the floor. CENA informed Writer that Resident was on the floor. Writer observed Resident lying on the floor on [their] right side on the left side of [their] bed with [their] head slightly under the bed frame. Writer asked Resident did [they] roll out of bed on [their] own, Resident stated yes with a head shake. [...]

Inspectors wroteThis citaiton pertains to Intake MI00141641. Based on interview and record review, the facility failed to monitor and administer Vancomycin (antibiotic) for one resident (R703) out of two reviewed for medication administration. Findings Include: A review of a Intake called into the State Agency revealed the following, The complainant states [R703's] discharge paperwork from the hospital states[R703]is supposed to receive Vancomycin 2x per day .complainant states the facility doctor changed the order in the computer but changed it on the wrong medication and the staff began administering [R703's] Vancomycin 3x per day. On 1/2/2024 at 10:09 AM, a phone interview was conducted with R703. R703 stated that the facility was trying to give them Vancomycin three times a day instead of two as the hospital discharge paperwork stated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were dated and discarded when expired, and failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a dignified existence and value residents' private living space, for four residents (R26, R29, R97, and R233), residents residing on the second floor (Glen Lake unit), as well as a confidential group (Resident Council) of 10 residents, resulting in diminished quality of life, and resident feelings of frustration, dissatisfaction, and decreased self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food in a palatable manner and at the preferred temperature for seven residents (R14, R18, R22, R29, R76, R77, and R236) of seven residents reviewed for food palatability, resulting in dissatisfaction during meals.

Inspectors wroteBased upon observation, interview and record review, the facility failed to identify and accommodate the resident's shower preference and frequency for one (R117) of six residents reviewed for bathing resulting in resident dissatisfaction with bathing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment as exhibited by soiled carpet in multiple areas, for 2 residents (R69, and R2) of 132 residents who reside in the facility and 10 confidential group council members, resulting in resident dissatisfaction with living space.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of notice of bed hold policy upon transfer to the hospital for one sampled resident (R130) of one resident reviewed for transfers, resulting in the potential for residents and/or resident representatives not being aware of the facility bed hold policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the documentation of a nursing assessment post-catheter dislodgement for one resident (R129) of one reviewed for catheters, resulting in the potential for a delay in care or unmet acute care needs.

Inspectors wroteThis citation pertains to Intake MI00134789. Based on observation, interview, and record review, the facility failed ensure the consistent provision of fresh drinking water, affecting three residents (R2, R53, and R69), residents residing on the second floor, as well as a confidential group (Resident Council) of 10 residents, resulting in resident dissatisfaction and the potential for dehydration or fluid imbalance.

Inspectors wroteResident #14 (R14) On 4/18/23 at 9:08 AM, R14 was interviewed about their care at the facility and stated, We need more staff around here. On 4/19/23 at 11:38 AM, R14 was further interviewed about staffing at the facility and indicated that they frequently waited thirty minutes or more for their call light to be answered by staff. R14 indicated that toileting assistance was their main concern. R14 indicated that they frequently did things themselves without assistance due to long call light wait times. R14 stated, It makes me angry. On 4/19/23 at 11:47 AM, a review of R14's electronic medical record (EMR) revealed that R14 was admitted to the facility on [DATE] with diagnoses that included, Traumatic subdural hemorrhage (Bleeding and pressure inside the skull) and Psychotic disorder with delusions. [...]