Regency at Waterford

Inspectors wroteThis citation pertains to Complaint # 2788554Based on observation, interview and record review the facility failed to ensure a resident was safely transferred in a facility contracted transportation vehicle for one (R701) out of two residents reviewed for accidents/transportation, resulting in R701 sustaining a C6 fracture (broken bone in the sixth cervical vertebra), a C7 compression fracture (structural collapse or break in the seventh cervical vertebra), hospitalization and pain.

Inspectors wroteThis citation pertains to intake #'s 2699473, 2699484, and 2699520. Based on interview and record review, the facility failed to notify the Doctor, Nurse Practitioner, or Physician's assistant of an acute change of condition and ensure a timely transfer to the emergency room (ER) for one resident (R202), of two residents reviewed for an acute change of condition, resulting in R202 not being transferred to the emergency room timely, deemed not a candidate for surgical intervention, and ultimately death from sepsis.

Inspectors wroteThis citation pertains to Intake 2577773. Based on interview and record review, the facility failed to ensure privacy of medical information was maintained for a one (R201) of two residents reviewed for Protected Health Information (PHI).

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

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective plans of action to correct identified quality deficiencies related to implementation of their abuse policy for obtaining a complete background check for newly hired staff (Certified Nursing Assistant/CNA 'X'), resulting in continued deficient practice. This had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive infection control program and ensure adherence to Center For Disease guidance for infection control practices regarding transmission based precautions and hand hygiene for seven residents, (R#'s 90, 125, 51, 234, 29, 84, and 11) of fourteen residents reviewed for infection control, resulting in the potential for the spread of infection. This deficient practice had the potential to affect all residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats throughout the facility, including the kitchen. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteR16 On 5/22/25 at 8:30 AM, upon entering the 600 hall, R16 was observed seated in a wheelchair in the hallway positioned next to two Nurses that were standing next to the medication cart. The Nurses were heard discussing R16's soiled pants and need to be changed. One of the Nurses proceeded to yell down the hallway very loudly, Do you know who his aide is?. A Certified Nursing Assistant (CNA) was observed seated behind the nursing station approximately 50 feet away and was observed to yell loudly back to this Nurse, Who (name of R16)?. On 5/22/25 at 11:27 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of concerns reported during the resident council meeting regarding whether they felt staff treated them with dignity and respect. [...]

Inspectors wroteBased on observation, interview and record review facility failed to demonstrate evidence of follow-up and resolution to resident group concerns related to water pass, follow-up on lost/damaged clothes and personal laundry process for four of eight residents that participated in the confidential resident group interview, resulting in ongoing concerns and dissatisfaction with levels of service and feelings of frustration.

Inspectors wroteR284 On 5/20/25 at 9:43 AM, R284 was observed sitting on their bed. R284 was asked about care at the facility. R284 explained they did not sleep well because the staff were talking and laughing loudly in the hallway at night. Review of the clinical record revealed R284 was admitted into the facility on 5/15/25 with diagnoses that included: congestive heart failure, end stage renal disease and pulmonary hypertension. According to a Brief Interview for Mental Status (BIMS) exam dated 5/16/25, R284 was cognitively intact. On 5/21/25 at 9:35 AM, R284 was observed lying in bed. R284's door was closed, and staff could be heard talking in the hallway. R284 explained the staff at night were much louder than what could be heard presently, and it kept them awake. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy that requires complete background checks for newly hired staff for one (Certified Nursing Assistant/CNA 'X') of five staff members reviewed for criminal background checks.

Inspectors wroteThis citation has two deficient practice. Deficient Practice #1 Based on observation, interview and record review, the facility failed to implement Physician orders for blood pressure monitoring and administration of medication based on ordered parameters for one resident (R11) of two reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a splint/ positioning device (palm protectors) and range of motion were implemented for one (R49) of two residents with hand contractures (hardening of the muscles, tendons, and other soft tissues) reviewed for positioning and range of motion(ROM) resulting in the potential for contracture progression, pain, and further decline in range of motion with compromised skin integrity.

Inspectors wroteThis citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to document resident falls in the clinical record, thoroughly investigate the root cause analysis of falls, and immediately implement appropriate interventions after falls for one resident (R63) of two residents reviewed for falls, resulting in the potential for additional avoidable falls.

Inspectors wroteBased on interview and record review the facility failed to ensure freedom from unnecessary antibiotic therapy for five residents, (R#'s 92, 16, 6, 20, and 91) of five residents reviewed for unnecessary antibiotic use, resulting in the potential for the development of antimicrobial resistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Four medication errors were observed from a total of 26 opportunities for three (R11, R120, R124) out of four residents reviewed during medication administration, resulting in an error rate of 15.38%.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage of medications for four of eight medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure meals were maintained and served at a palatable temperature affecting multiple residents, including R284, and three of eight residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline.

Inspectors wroteBased on interview and record review the facility failed to operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for us of antibiotic medications. This deficient practice affected multiple residents at the facility when residents who were deemed as not meeting criteria were prescribed on antibiotic therapy, resulting in the potential for increased antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessment and a physician's order for self administration of medications for one resident, (R46), of one resident resident reviewed for self-administration, resulting in the potential for inappropriate medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote self-determination for two (R112 and R13) of two residents reviewed for choices.

Inspectors wroteBased on observation, interview, and record review facility failed to establish a resident centered comprehensive care plan for one (R49) of one Resident with contractures (hardening of the muscles, tendons, and other soft tissues) reviewed for care plans resulting in unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered per professional standards for two (R120 and R124) of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) care for showers, hair care, nail care, and facial hair care were provided for three residents, (R#'s 103, 53, and 284), of four residents reviewed for ADL care, resulting in verbalized complaints and frustration with personal hygiene and grooming.

Inspectors wroteBased on observation, interview, and record review facility failed to consistently implement pressure ulcer prevention interventions as ordered for one (R49) of two residents (with pressure ulcers) reviewed for pressure ulcer prevention/management. This deficient practice has potential for worsening pressure ulcer and development of new pressure ulcer (s):

Inspectors wroteBased on interview and record review, the facility failed to ensure one (R110) resident of one reviewed for Post Traumatic Stress Disorder (PTSD) received appropriate trauma assessment with resident specific interventions for one (R110) of one Resident reviewed for trauma informed care resulting in the potential for trauma triggers and re-traumatization.

Inspectors wroteThis citation pertains to intake(s): MI00151872 Based on interview and record review, the facility failed to implement the abuse policy that requires a complete background check for newly hired staff for one (Staff C) of three staff members reviewed for background checks/abuse.

Inspectors wroteThis citation pertains to intake(s): MI00151872, MI00151053 Based on interview and record review, the facility failed to timely report allegations of abuse to the abuse coordinator and State Agency for two (R501 and R503) of two residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake(s): MI00151919 Based on observation, interview, and record review, the facility failed to ensure meals were enjoyable and served at palatable temperatures due to use of disposable Styrofoam containers for three sampled residents (R502, R504, and R505) from a total of three sampled residents reviewed for food palatability.

Inspectors wroteThis citation pertains to intake #MI00146351 Based on interview and record review, the facility failed to ensure timely submission of physician/physician extender progress notes for each visit for two residents (R#'s 901 and 902) of two residents reviewed for progress notes.

Inspectors wroteBased on interview and record review the facility failed to report to the Administrator and the State Agency an injury of unknown origin for one (R903) of one resident reviewed for abuse.

Inspectors wroteThis citation pertains to intake #146351. Based on interview and record review, the facility failed to ensure clinical documentation met professional standards for one resident (R901) of two residents reviewed for professional standards.

Inspectors wroteThis citation pertains to intake #MI00147067 and MI00147277 Based on interview and record review the facility failed to complete accurate skin assessments, ensure residents were seen in a timely matter by wound staff/practitioners, ensure appropriate treatment and services/interventions were timely implemented for pressure ulcers for two residents (R#'s 902 and 903) of two residents reviewed for pressure ulcers. Resulting in R903 developing a stage 3 pressure ulcer to their sacrum, left heel and worsening of their right heel.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dignified dining experience for multiple residents, including (R8, R90, R20 and R79) out of sixteen residents reviewed for dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water and other fluids were available and accessible for one resident (R78) of one resident reviewed for accommodation of needs resulting in the potential for thirst and complications from dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) care for two residents (R#39 and 98) of four residents reviewed for ADL care, resulting in the potential for hunger and embarrassment from poor personal hygiene.

Inspectors wroteBased on interview and record review, the facility failed to advocate for legal representation for one resident (R107), of one resident reviewed for a provision of social services, resulting in R107 having no one to legally advocate for them.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain accurate medical records regarding resident treatment for one (R74) out of one resident reviewed for medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow accepted practices for infection control as it relates to transmission-based precautions (TBP) and contact precautions for six residents, (R#'s 118, 16, 85, 25, 43, and 116) of 10 residents reviewed for infection control, resulting in the potential for the development and spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two residents were assessed for the safe self-administration of medication (R12 and R43) of two residents reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing services met professional standards for medication administration for one resident (R114) out of one reviewed for professional standards. Findings Include: On 6/11/24, a clinical record review revealed R114 was admitted to the facility on [DATE], with most recent admission with Hospice services on 5/30/24. R114's diagnoses included: COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation (abnormal heart rhythm), hypertension, heart disease, and new onset bladder pain and spasms. Psychiatric history included anxiety and dementia. A Brief Interview for Mentals Status (BIMS) score totaled 5/15 indicating R114 has severe cognitive impairment. On 06/10/24 at 10:17 AM, R114 was observed lying in bed and identified 2 pills lying next to resident (one white tablet and one green capsule). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide meaningful, diverse and engaging activities for one (R74) out of two residents reviewed for activities.

Inspectors wroteThis citation has two (2) deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to perform ongoing, accurate clinical assessments and ensure interdisciplinary team (IDT) collaboration for care for one resident (R116), of two residents reviewed for assessment and care, resulting in prolonged placement of an unused Percutaneous Endoscopic Gastrostomy (PEG) Tube, pain and recurrent infections at the PEG tube site. Findings Include: On 6/11/24 at 11:07, an observation of R116's PEG (a tube surgically placed in the abdomen for the use of artificial nutrition and hydration) site was conducted with Licensed Practical Nurse (LPN) A. The observation revealed a split gauze dressing dated 6/11 placed on the abdomen covering the insertion site. The exterior right side of the gauze was observed with an area of dark red blood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered Liters of oxygen per minute were delivered via concentrator for one resident (R47), of one resident reviewed for oxygen therapy resulting in elevated blood oxygen levels.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Physician orders were in place for treatment, monitoring and assessing one resident (R43) who was on hemodialysis of two residents reviewed for dialysis care.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents did not receive duplicate/unnecessary medication for one (R20) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and confirm a resident's narcotic medication (Morphine) and ensure medication carts were locked for two of three medication carts reviewed and failed to properly secure one unattended medication cart. Findings Include: On 6/11/24 at 8:47 AM, an observation of the [NAME] medication cart was conducted with Licensed Practical Nurse (LPN) A. The narcotic drawer was observed having 30 syringes (three separate clear bags each containing ten syringes) labeled Morphine Sulfate 10 mg (milligrams)/5ml (milliliters). LPN A acknowledged no resident identifiers were placed on the medication and would have to contact pharmacy. On 6/11/24 at 1:29 PM, the Director of Nursing (DON) indicated pharmacy sent them with no names, was aware of the findings and indicated they were returned to pharmacy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adaptive equipment/assistive devices used to assist with eating were provided for one resident (R17) of 19 residents reviewed for dining.

Inspectors wroteThis citation pertains to intake MI00142567. Based on interview and record review the facility failed to provide one resident(R502) with a shower resulting in a medically missed appointment due to being unclean.

Inspectors wroteCitation for intake MI00142569. Based on observation and interview the facility failed to provide a clean homelike environment, free from avoidable urine odors for two resident (R501 and R506) of two residents reviewed for environment.

Inspectors wroteThis pertains to intake MI00143370. Based on observation, interviews, and record review the facility failed to obtain and follow prescribed orders for the maintenance of a PICC (peripherally inserted central catheter) line for one resident (R501) or one resident reviewed for PICC lines.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dietary interventions were implemented in a timely manner and appropriate dietary monitoring and follow-up were provided for one resident (R89) of four residents reviewed for nutrition, resulting in R89 experiencing severe weight loss (greater than 5% in a month) On 7/25/23 at approximately 10:25 a.m., R89 was observed in their room, laying in their bed. R89 appeared to be frail/thin. On 7/25/23 the medical record for R89 was reviewed and revealed the following: R89 was initially admitted to the facility on [DATE] and had diagnoses including Disease of salivary gland, Hemiplegia and Hemiparesis affecting left side, Cerebral infection. [...]

Inspectors wroteThis citation pertains to intake #MI00138372 Based on observation, interview, and record review, the facility failed to ensure personal dignity for four residents (R#'s 67, 32, 82, and 2) of 21 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure water was within reach for three residents (R#'s 5, 2, and 60) of three residents reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review the facility failed to ensure resident treatments were documented when completed for nine residents (R11, R31, R41, R45, R53, R72, R92, and R221) of nine reviewed for Nursing standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized and meaningful activities for thirteen residents (R#'s 15, 14, 221, 29, 67, 11, 74, 32, 91, 73, 2, 45, and 82) of 47 residents who resided on the [NAME] and Telegraph Units, resulting in the potential for feelings of boredom and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriate stored in three of four medication carts, two of two medication rooms, and one of one treatment cart, resulting in the potential for unauthorized entry, misuse, contamination, and diversion.

Inspectors wroteThis citation pertains in part to intake MI00137730 Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one room (145) and one (R71) of seven residents reviewed for environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that showers were offered, provided, and documented for two residents (R25 and R48) of four residents reviewed for activities of daily living care (ADLs), resulting in feelings of depression, being dirty, and dissatisfaction with care.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services to prevent recurrent urinary tract infections (UTI's) for one (R41) of two residents reviewed for antibiotic use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications to treat pain were available for administration for two residents (R19 and R225) of two residents reviewed for pain management resulting in the potential for pain to go untreated.