Regency at Chene

In the surveyor’s words

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

• Immediate jeopardy, isolatedF695Apr 19, 2024

  This citation has two deficient practices. Deficient Practice Statement 1 Based on observation, interview, and record review, the facility failed to ensure an emergency tracheostomy (an incision into the windpipe made to relieve an obstruction to breathing) was accessible, resulting in the likelihood of serious injury, serious harm, serious impairment, or death for one resident (R138) who required mechanical ventilation. In an observation on 4/16/24 at 9:55 a.m., R138 laid in bed and had a tracheostomy (trach). There was not an emergency trach visible in R138's room. In an observation and interview on 4/16/24 at 10:32 a.m., Licensed Practical Nurse (LPN) L was asked about R138's emergency backup trach and could not locate one in R138's room. […]

• Actual harm, patternF697Dec 9, 2021

  Based on observation, interview, and record review the facility failed to consistently assess, document, and manage resident's pain, for three sampled residents (R31, R110 and R336) out of five residents reviewed for pain management, resulting in resident complaints of pain. Findings include: R31 Record review on 12/8/21 of R31's face sheet revealed admission into the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) dated [DATE], R31 had intact cognition and was extensive assist with Activities of Daily Living (ADLs). During an observation of wound care on 12/8/21 at 10:58 AM in R31's room, after observation of wound care R31 was observed tears streaming down face. […]

• Actual harm, isolatedF686Feb 13, 2023

  This citation pertains to MI00129879, MI00130059, and MI00131366. Based on interview and record review the facility failed to assess and implement interventions to prevent the development of pressure ulcers for one (R196) of six residents reviewed for pressure ulcers resulting in the development of one unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and one Stage 3 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) that went untreated during a12-day, Covid Unit stay. […]

• Actual harm, isolatedF689Feb 13, 2023

  This citation pertains to MI00130059. Based on observation, interview, and record review the facility failed to properly transfer one resident (R61) of six residents reviewed for falls resulting in the fracture of R61's right femur (thigh bone), right tibia (shin bone of calf), and right fibula (lateral bone of the calf, top of outer ankle) during a transfer from toilet to wheelchair. Findings include: On 2/7/23 at 2:40 PM R61 was observed seated in her wheelchair watching TV in the room. R61 said she had a recent fall in the bathroom because the CNA (certified nursing assistant) did not transfer her the right way. R61 stated, She (CNA K) took me to the bathroom and then pulled my wheelchair out away from me. […]

• Actual harm, isolatedF580Oct 18, 2021

  This citation pertains to intake MI 340. Based on interview and record review, the facility failed to provide notification of a significant change in condition due to not revising the family contact information in a timely manner for one (R#917) of 12 residents reviewed for change in condition, resulting in the family not knowing the resident required hospitalization for a medical emergency, the opportunity to participate in medical decisions regarding care, and mental anguish. Findings include: On 10/12/21 at 11:07 a.m. R917's emergency contact (EC) R was contacted via telephone regarding the resident's care while at the facility. EC stated, My father went to the hospital on 9/30/21 and the facility did not notify us. […]