Regency Heights-Detroit

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, meatballs, corned beef, baked beans, and diced potatoes; 2. Ensure the caulking of the hand washing sink was in good repair; 3. Store an ice scoop in a clean and sanitary manner; and 4. Properly date-label food stored in a resident refrigerator. These deficient practices resulted in the potential for food-borne illness for the residents that eat from the kitchen and residents that reside on the first-floor unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility's walk-in freezer which had the potential to affect all residents that eat from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly maintain residents' wheelchairs for two residents (R34 and R86), out of six residents reviewed for a safe and comfortable environment, resulting in resident discomfort and potential for the spread of harmful pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance to professional standards of practice for two (R12 and R17) of five residents reviewed for medication administration resulting in the potential for medication errors to occur.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that nail care was provided for one dependent resident (R107) of three reviewed for activities of daily living care (ADLs).

Inspectors wroteBased on interview and record review the facility failed to ensure a physician ordered lab draw (Keppra level) was completed for one resident (R84) reviewed for lab results, resulting in R84's physician being unaware that the ordered Keppra level was not completed along with the potential for an abnormal Keppra blood level go undetected and untreated.

Inspectors wroteBased on interview and record review the facility failed to accurately document one resident's (R93) code status in the electronic medical record (EMR) out of six residents reviewed for advanced medical directives (AMD), resulting in the potential for R93's choices not being followed.

Inspectors wroteThis citation pertains to intake MI00149633. Based on interview and record review, the facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and physician's order for an antibiotic for one resident (R101) out of three residents reviewed for change in condition

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement interventions to prevent pressure ulcers for one (R153) of 10 residents reviewed for pressure ulcers resulting in R153 developing an Unstageable Pressure Ulcer to her left hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 142 residents who receive meal services (oral foods) out of the facility's total census of 153 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the family of a change in condition and subsequent transfer to the hospital for one (R55) of three residents reviewed for notification of change.

Inspectors wroteBased on interview and record review, the facility failed to respond to concerns from residents about staff call light response times, resulting in dissatisfaction and unmet needs among 13 residents of 20 residents with the quality of care. Findings Include: On 4/4/24 at 1:55 PM a meeting was held with the members of the council. Residents presented concerns and dissatisfaction with call light response times. An anonymous resident commented about being told by staff to put a call light on before shift change because staff is busy. An anonymous resident gave an example of call light wait time explaining one day it took three and a half hours before a call light was answered. During the meeting of 20 residents, 13 residents raised their hands in response to the question of problems with call light response times. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one (R55) of two residents reviewed for discharges and transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply splinting devices for two (R23 and R62) of eight residents reviewed for limited range of motion, resulting in the potential for increased joint contracture, loss of range of motion and increased pain. R23 On 4/03/24 at 10:39 AM R23's was observed in bed with left hand clenched into a fist. On 4/04/24 at 11:34 AM R23 was observed in bed with left hand clenched into a fist no carrot, or towel roll in hand. On 4/04/24 at 3:15 PM R23 was observed in bed with left hand clenched into a fist with no carrot or towel roll in left hand. Review of R23's Electronic Health Record (EHR) revealed the most recent admission to facility on 4/19/2022 with diagnosis that included Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis left side. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to date a respiratory water bag for one (R62) of two residents reviewed for oxygen use.

Inspectors wroteBased on interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for three residents (R23, R62, and R55) of 30 residents reviewed for accurate medical records resulting in inaccurate and incomplete medical records with inadequate care delivery.

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (R126 and R87) out of five residents reviewed for immunizations, were provided influenza vaccination and education resulting in the potential for the development and spread of influenza among vulnerable residents in the facility.

Inspectors wroteThis citation pertains to intake MI00141524. Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin and unexpected death for one (R162) of two resident reviewed for abuse.

Inspectors wroteThis citation pertains to Intakes MI139413 & MI140760. Based on interview and record review, the facility failed to (1) obtain authorization to manage personal funds (social security check), (2) properly manage a trust account, and (3) follow the guidelines to become the appropriate representative payee for one resident (R701) of three residents reviewed for resident rights, resulting in the resident and the family expressing anger and frustration of not having control over personal funds.

Inspectors wroteThis citation pertains to Intakes MI139413 & MI140760. Based on interview and record review, the facility failed to obtain authorization to use resident funds (social security) for one resident (R701) of one reviewed for misappropriation of funds resulting in the facility use of resident funds for a five month period of time without the resident's consent.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer and properly treat a pressure ulcer for one resident (R96) of five residents reviewed for pressure ulcer/injuries resulting in the development of a facility acquired Stage III pressure ulcer (Full-thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar [dead skin tissue] may be visible.).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove expired, undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked beans and BBQ ribs; 3. Properly seal frozen food items; 4. Ensure pans were clean and allowed to air dry before stacking and storage; 5. Ensure the use of beard guards of staff working in the kitchen; 6. Accurately document the walk-in freezer temperatures; 7. Ensure ladles were stored properly to prevent contamination; 8. Adequately clean kitchen surfaces; 9. Remove expired liquid nutrition supplements from active stock; 10. Properly store ice scoops in a sanitary manner; and 11. Properly clean in and around an ice machine. [...]

Inspectors wroteThis citation includes two deficient practice statements. Deficient Practice #1. Based on observation, interview, and record review, the facility failed to maintain three resident rooms (101, 116, and 120) reviewed for the environment, resulting in an unsafe and an unclean environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the second floor ice machine was maintained in a safe and sanitary operating condition, resulting in the ice machine not being protected against contamination from sewage or other sources of contamination, potentially effecting all residents consuming ice from this machine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon admissions, quarterly review, and/ or significant change for 1 resident (R62) of 4 sampled residents reviewed for advance directives, resulting in the potenital for denial of the resident's right to have life sustaining or withheld decisions honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive care plan for a prosthetic shrinker sleeve (an elastic sock made to control swelling, promote healing, and assist in shaping an amputated leg to fit an artificial leg) for one resident (R467) out of two residents reviewed for rehab services, resulting in no established goals and interventions related to shrinker sleeve use and the potential for a delay in rehabilitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform nail care for one resident (R64) and provide timely incontinence care for one resident (R151) out of 31 residents reviewed for dependent activities of daily Living (ADLS), resulting in unkempt nails, body odor, and in the potential for skin breakdown and poor self esteem of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement skin care treatments for 3 residents (R58, R74, and R135) of 3 reviewed for non-pressure related skin conditions resulting in discomfort, untimely wound care, and the potential for further harm to skin integrity and wound degradation.