Regency, A Villa Center

In the surveyor’s words

From the most serious findings on record at Regency, A Villa Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 3, 2023

  This citation pertains to intake MI00134840. Based on interview and record review the facility failed to provide adequate supervision when on January 31, 2023, at approximately 3:20 PM, Residnet #936 (R936), a cognitively impaired resident (BIMS of 3) eloped from the facility wearing a shirt, pants, and socks. The recorded temperature that day was 20 degrees Fahrenheit. R936 crossed Telegraph Road (a six lane highway) and proceeded to [NAME] Daly Road (approximately 1/4 of a mile from the facility). R936 was returned to the facility by police at approximately 4:00 PM. This deficient practice resulted in an immediate jeopardy on 1/31/23. […]

• Immediate jeopardy, isolatedF689May 27, 2021

  This citation pertains to intake MI 5669. Based on observation, interview and record review the facility failed to:1.) provide adequate supervision during an activity in the courtyard and 2.) provide adquate staff training to prevent elopement in 1 of 3 residents (R #26) reviewed for elopement, from a total sample of 33 residents, resulting in an immediate jeopardy for R#26 who was a high elopement risk, who eloped on 5/17/21 at 2:08 pm from the courtyard during an activity. R#26 was found approximately 49 minutes later, after crossing a 5 lane 45mph road, at a local restaurant 0.5 miles away and was escorted back to the facility by facility staff and police at 3:45pm on 5/17/21. This deficient practice placed 39 additional residents at risk for serious injury, harm, and/or death. […]

• Actual harm, isolatedF550Jul 3, 2024

  Based on interview and record review the facility failed to allow one resident (R210) to discharge from the facility at her request until the Ombudsman intervened on 6/27/24 of six residents reviewed for resident rights, resulting in psychological distress, depression, and physical attempts at leaving the facility. Findings include: On 7/2/24 at 1:13 PM an interview with the Ombudsman was held by telephone. The Ombudsman said that on 6/27/24 following a telephone interview with R210 and R210's significant other the Ombudsman came to the facility. R210 had explained to the Ombudsman that attempts were made for 2 days to discharge AMA from the facility and the requests were refused. The Ombudsman obtained permission from R210 to advocate for discharge rights. […]

• Actual harm, isolatedF689Mar 9, 2022

  This citation has two deficient practice statements and pertains to the following Intakes MI 1424, MI 1939, and MI 3578. Deficient practice #1. Based on observation, interview, and record review, the facility failed to properly use a mechanical lift on two occasions for one resident (R17) of nine residents reviewed for falls/accident by 1) failing to ensure R17 was safely transferred during a '2 person with mechanical lift' transfer resulting in a fractured 2nd toe of the right foot and 2) failing to properly use the 'emergency release' process on (Lift #1) when the mechanical lift's battery died during the transfer resulting in R17 being lowered to the floor by staff and subsequently sustaining nondisplaced (bone cracks/fractures in proper alignment) fractures of left tibia and fibula… […]

• Actual harm, isolatedF908Mar 9, 2022

  This citation pertains to intake MI 578. Based on observation, interview, and record review the facility failed to properly maintain two mechanical lifts (Lift #1 ,Lift #2) when two (R17 and R47) of nine residents reviewed for accidents fell to the floor because a bolt broke off the mechanical lifts during transfers of R17 and R47 resulting in injury and the potential for injury. R17 sustained a compression fracture of the T12 vertebrae. R47 did not sustain any injury. Findings include: Lift#1, R17: According to the 'Event Report' dated 11/18/21 at approximately 12:00 PM, R17 was being transferred with a mechanical lift (Lift #1). The mechanical lift broke, dropping R17 to the floor. The resident was assessed and transferred out to the emergency room for complaints of pain. […]