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)
19.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
447% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including medication administration, infection control, care planning, and quality of care.
Complaint Details
This complaint investigation included allegations of medication errors, infection control breaches, inadequate care planning, delayed treatment of urinary tract infection, and quality assurance failures. The investigation found multiple deficiencies contributing to resident harm, including one resident's death due to urosepsis and septic shock.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to notify providers of medication availability issues, inaccurate assessments, failure to develop accurate baseline care plans, medication administration errors, inadequate assistance with activities of daily living, delayed treatment of urinary tract infection leading to hospitalization and death, poor documentation practices, inadequate quality assurance processes, and infection control breaches related to laundry handling.
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 complete and transmit a discharge Minimum Data Set (MDS) Assessment after Resident Identifier (RI) #62 was discharged.
Failed to ensure accurate coding of admission MDS assessments for Resident Identifiers (RI) #3 and #180 related to CPAP use and continence.
Failed to ensure an accurate baseline care plan was developed for Resident Identifier (RI) #180.
Failed to schedule a care plan conference including 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 for 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; also failed to document a late entry for medication administration.
Failed to ensure Quality Assessment and Assurance Committee (QAAC) thoroughly reviewed factors related to Resident Identifier (RI) #180's hospitalization and systemic delays 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 cross contamination; clothing was observed hanging on Resident Identifier (RI) #333's door knob in the hallway.
Report Facts
Sampled residents: 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 relation to missed medication administration and documentation for Resident Identifier #180 |
| CNA #20 | Certified Nursing Assistant | Named in relation to improper incontinent care for Resident Identifier #335 |
| CRNP | Certified Registered Nurse Practitioner | Named in relation to medication orders and treatment of Resident Identifier #180 and #330 |
| DON | Director of Nursing | Named in relation to multiple findings including medication availability, care planning, and quality assurance |
| RN #12 | Registered Nurse Charge Nurse | Named in relation to observations of Resident Identifier #23's fingernail hygiene |
| IP | Infection Preventionist | Named in relation to infection control policies and UTI prevention efforts |
| ADM | Administrator | Named in relation to quality assurance and performance improvement activities |
| Pharmacist (RPh) #4 | Pharmacist | Named in relation to medication availability and pharmacy services |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including medication administration, infection control, care planning, and quality of care.
Complaint Details
This complaint investigation involved multiple reports including AL00043580 and AL00047090. Issues included medication administration errors, infection control failures, care planning deficiencies, and quality assurance failures. Immediate jeopardy was identified related to delayed treatment of urinary tract infection for RI #180, which was later removed after corrective actions.
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 care plans, medication administration errors, inadequate personal hygiene care, delayed treatment of urinary tract infection leading to hospitalization and death, incomplete medical record documentation, inadequate infection control practices, and deficiencies in quality assurance processes.
Deficiencies (13)
Failed to ensure call light was accessible to resident RI #15 on two of five days of the survey.
Failed to notify Certified Registered Nurse Practitioner when medication was not available for administration to RI #330 on 01/05/2023 and 01/06/2023.
Failed to complete and transmit discharge Minimum Data Set (MDS) Assessment for RI #62 within required timeframe.
Failed to accurately code admission MDS assessments for RI #3 and RI #180 regarding CPAP use and continence status.
Failed to develop accurate baseline care plan for RI #180 including incorrect catheter care and lack of family communication.
Failed to schedule care plan conference including resident representative for RI #180.
Failed to remove intravenous saline lock after completion of Normal Saline infusion for RI #23.
Failed to ensure RI #23's fingernails were kept clean and cut, posing risk for infection.
Failed to provide prompt treatment for RI #180's urinary tract infection, delayed urine specimen collection, delayed notification of lab results, and delayed antibiotic administration resulting in hospitalization and death.
Failed to document times for verbal/telephone orders and urine specimen collection for RI #180; late entry documentation without clear indication.
Failed to ensure Quality Assessment and Assurance Committee thoroughly reviewed factors related to RI #180's hospitalization and failed to address systemic issues causing delay in treatment.
Failed to ensure Certified Nursing Assistant provided perineal care to RI #335 in a manner to prevent risk of urinary tract infection, including improper wiping technique and failure to change gloves or perform hand hygiene.
Failed to ensure resident clothing was handled to prevent cross contamination; clothing was observed hanging on resident RI #333's door knob outside the room while on isolation.
Report Facts
Sampled residents: 31
Missed doses of Lactulose: 5
Ammonia level: 197
Number of UA results reviewed: 8
Number of perineal care validation forms: 12
UTIs per month: 12
UTIs per month: 7
UTIs per month: 16
UTIs per month: 5
UTIs per month: 16
UTIs per month: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies for RI #330 and RI #180 |
| CNA #20 | Certified Nursing Assistant | Named in perineal care deficiency for RI #335 |
| CNA #21 | Certified Nursing Assistant | Named in perineal care deficiency for RI #335 |
| RN #12 | Registered Nurse Charge Nurse | Named in observations of fingernail hygiene for RI #23 |
| DON | Director of Nursing | Named in multiple interviews related to medication availability, care planning, infection control, and quality assurance |
| CRNP | Certified Registered Nurse Practitioner | Named in medication orders, treatment delays, and interviews regarding care of RI #180 and RI #330 |
| IP | Infection Preventionist | Named in infection control interviews and quality assurance discussions |
| ADM | Administrator | Named in quality assurance and corrective action interviews |
| Pharmacist (RPh) #4 | Pharmacist | Named in medication availability and pharmacy service interviews |
| LPN #7 | Licensed Practical Nurse | Named in perineal care training and assessment |
| Laundry Supervisor (LS) | Laundry Supervisor | Named in clothing handling and infection control interviews |
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
Complaint Investigation
Deficiencies: 12
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations related to multiple concerns including medication administration, care planning, infection control, and quality of care.
Complaint Details
The complaint investigations included allegations of failure to provide timely and appropriate care, medication errors, inadequate infection control, and deficient quality assurance processes. Specific complaint/report numbers AL00043580 and AL00047090 were cited.
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 and comprehensive care plans, medication administration errors, inadequate assistance with activities of daily living, delayed treatment of urinary tract infections leading to hospitalization and death, incomplete and untimely documentation, inadequate infection prevention practices, and ineffective quality assurance processes.
Deficiencies (12)
Failure to ensure call light was accessible to resident RI #15 on two of five days of the survey.
Failure to notify Certified Registered Nurse Practitioner (CRNP) when medication was not available for administration to RI #330 on 01/05/2023 and 01/06/2023.
Failure to complete and transmit discharge Minimum Data Set (MDS) Assessment for RI #62 within required timeframe.
Failure to accurately code admission MDS assessments for RI #3 and RI #180 regarding CPAP use and continence status.
Failure to develop accurate baseline care plan for RI #180, including inaccurate documentation of urinary catheter use.
Failure to include resident representative in care plan conference for RI #180.
Failure to remove intravenous saline lock after completion of Normal Saline infusion for RI #23.
Failure to ensure RI #23's fingernails were kept clean and cut, posing risk for infection.
Failure to provide prompt treatment for urinary tract infection for RI #180, including delayed urine specimen collection, delayed notification of urinalysis results, and delayed antibiotic administration, resulting in hospitalization and death.
Failure to document times for verbal/telephone orders and urine specimen collection for RI #180; failure to document administration of levofloxacin dose as a late entry.
Failure to ensure resident clothing was handled to prevent cross contamination; clothing was observed hanging on door knob outside RI #333's room.
Failure of Quality Assessment and Assurance Committee (QAAC) to identify and address delays in treatment and systemic issues related to RI #180's urinary tract infection and hospitalization.
Report Facts
Sampled residents: 31
Missed Lactulose doses: 7
Ammonia level: 197
Urinary Tract Infections (UTIs) count: 12
Urinary Tract Infections (UTIs) count: 7
Urinary Tract Infections (UTIs) count: 16
Urinary Tract Infections (UTIs) count: 5
Urinary Tract Infections (UTIs) count: 16
Urinary Tract Infections (UTIs) count: 5
Validation Checklist Perineal Care forms: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Documented late medication administration for RI #180 and explained missed Lactulose doses |
| CNA #20 | Certified Nursing Assistant | Observed providing perineal care improperly to RI #335, causing infection risk |
| CRNP | Certified Registered Nurse Practitioner | Ordered urinalysis and antibiotics for RI #180; noted delayed notification and medication administration |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies, policies, and corrective actions |
| RN #12 | Registered Nurse Charge Nurse | Observed and commented on RI #23's fingernail hygiene |
| Laundry Supervisor | Laundry Supervisor | Interviewed about improper handling of resident clothing |
| Infection Preventionist | Infection Preventionist | Provided infection control policy and practice explanations |
| Administrator | Administrator | Provided information on QAPI and corrective action plans |
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 |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with food safety policies related to the storage and handling of food brought in by family or visitors 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 policy. 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 unlabeled food in refrigerator and explained policy | |
| Certified Nursing Assistant | Observed expired food items in 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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