Inspection Reports for
Regency Retirement Village of Huntsville
2004 Max Luther Dr NW, Huntsville, AL 35810, United States, AL, 35810
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
86% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations related to multiple concerns including medication administration, infection control, care planning, and quality of care.
Complaint Details
The complaint investigations included issues with medication administration, infection control, care planning, and quality of care. Specific complaint/report numbers cited include AL00043580 and AL00047090.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to notify providers of medication availability issues, inaccurate resident assessments, failure to develop accurate baseline care plans, failure to provide timely medication administration, inadequate personal hygiene care, delayed treatment of urinary tract infection leading to hospitalization and death, incomplete medical record documentation, and inadequate infection prevention practices.
Deficiencies (13)
Failed to ensure call light was accessible to Resident Identifier (RI) #15 on two of five days of the survey.
Failed to notify Certified Registered Nurse Practitioner (CRNP) when medication was not available for administration to Resident Identifier (RI) #330 on 01/05/2023 and 01/06/2023.
Failed to ensure a discharge Minimum Data Set (MDS) Assessment was completed and transmitted after Resident Identifier (RI) #62 was discharged.
Failed to ensure accurate coding of CPAP use and urinary/bowel continence in admission MDS assessments for Residents #3 and #180.
Failed to ensure an accurate baseline care plan was developed for Resident Identifier (RI) #180.
Failed to ensure a care plan conference was scheduled to include Resident Identifier (RI) #180's resident representative.
Failed to ensure Resident Identifier (RI) #23 had an intravenous saline lock removed after Normal Saline was completed on July 27, 2024.
Failed to ensure Resident Identifier (RI) #23's fingernails were kept clean and cut.
Failed to ensure Resident Identifier (RI) #180 received prompt treatment after signs and symptoms of a Urinary Tract Infection, including timely collection of urine specimen, notification of urinalysis results, and administration of antibiotics, resulting in hospitalization and death.
Failed to ensure Resident Identifier (RI) #180's medical record contained times for verbal/telephone orders and documentation of urine specimen collection and failed to document administration of levofloxacin dose as a late entry.
Failed to ensure Quality Assessment and Assurance Committee (QAAC) thoroughly reviewed factors related to Resident Identifier (RI) #180's hospitalization and failed to systemically address delay in treatment.
Failed to ensure Certified Nursing Assistant (CNA) #20 provided incontinent care for Resident Identifier (RI) #335 in a manner to prevent risk of urinary tract infection, including proper glove use and wiping technique.
Failed to ensure resident clothing was handled in a manner to prevent potential cross contamination for Resident Identifier (RI) #333; clothing was observed hanging on the resident's door knob in the hallway.
Report Facts
Residents sampled: 31
Missed doses of Lactulose: 5
Ammonia level: 197
Urinary Tract Infections (UTIs) counted: 12
Urinary Tract Infections (UTIs) counted: 7
Urinary Tract Infections (UTIs) counted: 16
Urinary Tract Infections (UTIs) counted: 5
Urinary Tract Infections (UTIs) counted: 16
Urinary Tract Infections (UTIs) counted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies related to Resident #180 and #330 |
| CNA #20 | Certified Nursing Assistant | Named in incontinent care deficiency for Resident #335 |
| CRNP | Certified Registered Nurse Practitioner | Named in medication and treatment delay deficiencies related to Resident #180 and #330 |
| DON | Director of Nursing | Named in multiple interviews related to deficiencies and corrective actions |
| RN #12 | Registered Nurse Charge Nurse | Named in observation and interview related to Resident #23's hygiene deficiency |
| IP | Infection Preventionist | Named in infection control deficiencies and interviews |
| ADM | Administrator | Named in interviews related to Quality Assurance and corrective actions |
| Pharmacist (RPh) #4 | Pharmacist | Named in medication availability and pharmacy service deficiencies |
| LPN #7 | Licensed Practical Nurse | Named in training and care plan deficiencies |
| CNA #21 | Certified Nursing Assistant | Named in incontinent care deficiency for Resident #335 |
| Laundry Supervisor (LS) | Laundry Supervisor | Named in infection control deficiency related to laundry handling |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 29, 2019
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with federal regulations regarding resident dignity, accurate resident assessments, and medication management.
Findings
The facility was found deficient in maintaining resident dignity during care, ensuring accurate Minimum Data Set (MDS) assessments, and removing expired medications from stock. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
Failed to ensure Resident Identifier #50's dignity was maintained during care, as staff rushed tasks causing the resident to feel unimportant.
Failed to ensure Resident Identifier #83's Minimum Data Set admission assessment was accurately completed for falls with major injury.
Failed to ensure expired medications (Cerovite liquid and Orasol gel 20%) were removed from stock in the central supply area.
Report Facts
Residents sampled: 20
Residents reviewed for falls: 2
Expired medications found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant (COTA) | Employee Identifier #1 worked with Resident Identifier #50 and was involved in reporting concerns about rushed care | |
| Rehab Director | Employee Identifier #3, asked about reporting of resident concerns | |
| Director of Nursing | Employee Identifier #4, interviewed about reporting and follow-up of resident concerns and medication storage | |
| Licensed Practical Nurse/MDS Coordinator | Employee Identifier #6, responsible for MDS assessment coding | |
| Central Supply Coordinator | Employee Identifier #5, responsible for medication storage and acknowledged expired medications |
Inspection Report
Deficiencies: 3
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident dignity, accurate resident assessments, and proper medication storage in the nursing facility.
Findings
The facility failed to maintain resident dignity for one resident who felt rushed during care, inaccurately completed a resident's Minimum Data Set (MDS) admission assessment regarding falls with major injury, and stored expired medications in the central supply area. These deficiencies were identified through interviews, record reviews, and observations.
Deficiencies (3)
Failed to ensure Resident Identifier #50's dignity was maintained during care, as the resident felt rushed by staff.
Failed to ensure Resident Identifier #83's Minimum Data Set admission assessment was accurately completed for falls with major injury.
Failed to ensure expired medications (Cerovite liquid and Orasol gel 20%) were removed from stock in the central supply area.
Report Facts
Residents sampled: 20
Residents reviewed for falls: 2
Expired medication dates: 201901
Expired medication dates: 201906
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant (COTA) | Employee Identifier #1 worked with Resident Identifier #50 and was involved in reporting concerns about rushed care | |
| Rehab Director | Employee Identifier #3, asked about reporting of resident concerns | |
| Director of Nursing | Employee Identifier #4, interviewed about reporting and follow-up of resident concerns and medication storage | |
| Licensed Practical Nurse/MDS coordinator | Employee Identifier #6, interviewed about inaccurate MDS coding for Resident Identifier #83 | |
| Central Supply Coordinator | Employee Identifier #5, responsible for medication storage and acknowledged expired medications |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with food safety standards related to the storage, labeling, and discarding of food brought in by family or visitors and kept in resident refrigerators on the units.
Findings
The facility failed to ensure that food kept in resident refrigerators was labeled and discarded after 3 days as required by facility policies. Observations found unlabeled and expired food items in refrigerators, posing a risk of food poisoning.
Deficiencies (1)
Failure to ensure food kept in resident refrigerators was labeled and discarded after 3 days.
Report Facts
Residents affected: 2
Date of survey completed: Aug 23, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed food storage and discussed policy on labeling food | |
| Certified Nursing Assistant | Observed food storage in second refrigerator | |
| Registered Nurse/Unit Manager | Interviewed about facility policy and responsibility for discarding expired food | |
| Licensed Practical Nurse (LPN) | Interviewed about facility policy and responsibility for discarding expired food |
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