Regency At Northpointe

Based on observation and interview, the facility failed to ensure hand hygiene and use of hair coverings was implemented properly during the preparation and serving of food during 2 of 2 kitchen observations. This failure caused exposure of all residents to potential food contamination and food borne illness. Findings included: According to the CDC, Clinical Safety: Hand Hygiene for Healthcare Workers, hands should be cleaned using soap and water or an alcohol-based hand sanitizer immediately before touching a patient, before performing a task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. When washing hands with soap and water the CDC recommends, wet hands with water, apply the soap to the hands, rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, rinse hands with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting to the State Agency (SA) within the required timeframe and completing a thorough investigation for 1 (Resident 397) of 2 residents reviewed for abuse. This failure placed the resident and other residents at risk for potential abuse or neglect and a diminished quality of life. Findings included . Review of a revised October 2022 facility policy titled Abuse/Neglect/Misappropriation/Exploitation showed, the facility protected the residents from abuse and neglect by implementing procedures designed to prevent, identify, report, and investigate allegations of abuse and neglect. The policy instructed the staff to report immediately to the Abuse Hotline (a SA), but no later than 2 hours after an allegation involving abuse or neglect was made, if the events that caused the allegation resulted in serious bodily injury and no later than 24 hours if the events that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (67, 94) reviewed for hospitalizations. This failure placed the residents at risk for a disruptive and ineffective transition from the facility to the hospital setting. Findings included . <Resident 94> Review of the progress notes showed Resident 94 admitted to the facility on [DATE]. The 07/25/2024 progress notes showed Resident 94 experienced a change in condition, the staff notified the provider, the staff transferred the resident to the hospital, and notified the resident representative. In an interview on 08/27/24 at 9:03 AM, Staff U, Licensed Practical Nurse (LPN), stated that when a resident is transferred to the hospital, she notifies the Unit Manager, the Director of Nursing (DON), the family, and the doctor. Staff U stated that at the time of a resident's transfer to the hospital, they send with the resident and ambulance personnel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failure to ensure care plan revisions were made for 2 of 17 sampled residents (64, 397) whose care plans were reviewed. Failure to revised Resident 64's care plan to include additional interventions to prevent a further decrease in the ability to flex the fingers, and failure to revised Resident 397's care plan to include their preferences for bathing placed the residents at risk for diminished quality of life and unmet care needs. Findings included . <Resident 64> The 05/31/2024 quarterly assessment documented Resident 64 was severely cognitively impaired, non-verbal, had diagnoses which included stroke, and was dependent on nursing staff for activities of daily living (ADLS) such as dressing. In addition, the assessment documented the resident had impaired range of motion (ROM: the ability to move or flex a joint) to both upper and lower extremities and had received restorative services (a program in which staff work with residents to maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a resident received assistance setting up their meals for 1 of 4 sampled residents (67) reviewed for activities of daily living (ADLs). This failure placed the resident at risk of decreased dietary intake, potential weight loss and decreased quality of life. Findings included . <Resident 67> Review of the 07/26/2024 re-admission assessment documented Resident 67 had diagnoses including paralysis of the right side of the body following a stroke, difficulty speaking and swallowing, and severe calorie malnutrition. Resident 67 was severely cognitively impaired, coughed or choked during meals, held food in their mouth after meals, and required partial to moderate assistance for eating. The 07/06/2024 care plan documented Resident 67 had a deficit related to their ability to eat because of their stroke and a contracture (shortening of muscles and tendons that prevented normal movement) of their right hand. They required assistance of one staff to set up their meals. A 07/12/2024 weight change progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (91) reviewed for hearing, received the necessary treatment and services to maintain their hearing abilities. Failure to assess the etiology of and pursue services for Resident 91's identified hearing impairment, placed the resident at risk for a decline in communication, social isolation, changes in mood and behavior, and unmet needs. Findings included . Review of an 08/02/2024 admission assessment showed Resident 91 admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 91's hearing was highly impaired, used hearing aids, was able to make themself understood, and usually understood others. Staff assessed the resident to have moderate cognitive impairment. The staff assessed Resident 91 required assistance from the staff with most Activities of Daily Living (ADL), like oral hygiene, toileting, bathing, bed mobility, transfers, and dressing. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to put measures in place to ensure the staff delivered heat therapy with adequate and complete provider orders, to include monitoring for injury associated with the use of a heating pad, for 1 (Resident 397) of 1 resident reviewed for accidents. This failure placed the resident at risk for trauma associated with the use of a heating pad. Findings included . Review of an 08/16/2024 admission assessment showed Resident 397 admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 397 as cognitively intact and required assistance from the staff for completing Activities of Daily Living, like dressing, toileting, transfers, and bed mobility. Observations on 8/21/2024 at 10:32 AM, 8/22/2024 at 9:18 AM and 04:13 PM, and 8/23/2024 at 9:52 AM and 11:21 AM, showed a green pad wrapped around Resident 397's thigh while seated in their wheelchair. Resident 397 was fully dressed, to include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 2 residents (396 and 397) reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the residents at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . <Resident 396> A resident observation and interview on 08/21/24 at 09:49 AM with their Collateral Contact present showed, Resident 396 in bed and in a hospital gown. The resident stated it was hard to go to the bathroom and that she go Number 2 [bowel elimination] in their incontinence brief. No commode was nearby. Resident 396 stated that staff did not offer them a bed pan and that its use would be, more comfortable, less painful. Resident 396 described that when they experienced loss of control of their bowels it made them feel, shame myself. In another interview on 08/22/24 at 4:09 PM, Resident # 396…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the staff accurately monitored the fluid intake of 1 of 1 resident (91) reviewed for hydration. This failure placed Resident 91, who was on fluid restrictions, at risk for dehydration or fluid volume deficit. Findings included . Review of an 08/02/2024 admission assessment showed Resident 91 admitted to the facility on [DATE] with medically complex conditions, to include heart failure and an acute kidney infection. An observation on 08/21/24 at 9:18 AM showed signage above Resident 91's bed that stated the resident was on a fluid restriction. Two glasses of juice and water and a cup of coffee were observed on Resident 91's over-the-bed table. When asked why they were on a fluid restriction, Resident 91 stated, I don't know. They [staff] just told me I was on one. So, they limit the amount of fluids they have to give me. Review of an 08/05/2024 Nutrition Assessment showed Resident 91's fluid needs between 1,275 to 1,525 mL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner and oxygen orders were followed for 1 of 2 sampled residents (19) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . Per the 07/09/2024 quarterly assessment, Resident 19 had diagnoses which included morbid obesity, high blood pressure and had moderate cognitive impairments. Review of the 04/03/2024 physician order documented Resident 19 had been prescribed oxygen to maintain oxygen saturation greater than 91%, due to hypoxia (a condition in which the body is deprived of adequate oxygen). Per the August 2024 Medication Administration Record (MAR), the resident was not administered oxygen for levels of less than 92% on the following dates: -08/03/2024 oxygen level was 91% on day and night shift -08/09/2024 oxygen level was 90% on evening shift -08/10/2024 oxygen level was 90% on night shift -08/11/2024 oxygen level was 91% on day, evening and night shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure blood pressure medications were consistently monitored for 1 of 5 sample resident (90) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical conditions. Findings included . Per the 08/03/2024 admission assessment, Resident 90 had diagnoses which included high blood pressure. Review of the Physician Order Report documented the physician prescribed a blood pressure medication (Metoprolol) on 07/30/2024 to be given twice daily. The order instructed nursing staff to hold the medication if the heart rate was less than 60 beats per minute or the systolic blood pressure (the pressure in your arteries when your heart is beating and sending blood into your arteries) was under 100. In addition, the nursing staff were to notify the physician if Resident 90's blood pressure was out of the parameters listed. Review of the July and August 2024 Medication Administration Record (MAR) documented no blood pressures were taken prior to administration of the blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement measures to promote proper positioning and maintain body alignment for 3 of 5 sampled residents (Residents 2, 3, and 4), reviewed for positioning. This failure placed residents at risk for a decline in mobility, increased risk of contracture (shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and a decreased quality of life. Findings included . <Resident 2> Review of the care plan revised 06/26/2023 showed Resident 2 had an intervention for bilateral resting hand splints to be applied in the morning, then removed after eight hours. Review of the September 2023 Treatment Administration Record (TAR) showed staff were to apply Resident 2's bilateral resting hand splints at 8:00 AM and remove them at 4:00 PM. The splints were marked as applied on 09/11/2023. Observation on 09/11/2023 at 11:46 AM showed Resident 2 was lying in bed without the ordered hand splints applied. The resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plan was reviewed and revised for 1 of 36 sampled residents (Resident 67), whose care plans were reviewed. This failure placed the resident at risk for unmet care needs. Findings included . According to a 03/22/2023 comprehensive assessment Resident 67 was admitted to the facility with a diagnosis of Spastic Quadriplegic Cerebral Palsy (a disorder of the brain, that affects the person's ability to control their muscles). The assessment also showed Resident 67 was unable to walk or speak, and had severe intellectual disabilities. According to a 02/28/2023 alert progress note by Staff M, Registered Nurse (RN), the resident's condition deteriorated, and they were admitted to the hospital. A 03/03/2023 progress note by Staff N, RN, showed that the resident returned to the facility with a urinary catheter (a tube inserted into the bladder to drain urine into a bag) and IV therapy (medications given through a needle or tube that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide cueing during mealtimes for 1 of 3 sampled residents (Resident 31), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, and possible unintended weight loss. Findings included . Resident 31 had diagnoses including Alzheimer's dementia (a decline in mental ability severe enough to interfere with daily life). An annual assessment completed 02/16/2023 showed the resident was severely cognitively impaired, had physical and verbal behaviors directed at others, and rejected care. The assessment also showed the resident required supervision (oversight, encouragement or cueing) and set-up help for eating. The 02/15/2022 comprehensive care plan showed the resident was at risk for nutritional problems related to Alzheimer's dementia. Per the care plan, staff were to explain the importance of maintaining the diet ordered, monitor weights per protocol, and provide and serve the diet as ordered. The care plan also showed the resident preferred to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.