Regency At Troy

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shift change time, and the admitting nurse had enough time to complete the admission orders. They added that the concern was brought up to the leadership's attention. NS D was notified of the concern for not having timely admission orders to care for Resident R901 and they reported that they understood the rationale for

the concern.An interview with Unit Manager (UM) B was completed on 8/21/25 at approximately 10 AM.

They were queried about the staff expectation and time frame for the admission orders for care and medication reconciliation for new admissions. UM B reported that the expectation for the staff is to reconcile and the initial orders in place within the 1st hour of admission and start the nursing admission assessment.

If a resident arrived during the shift change the oncoming nurse would reconcile and initiate the admission orders between 1-2 hours and start the nursing assessment even if the whole assessment gets completed later. An interview with Director of Nursing (DON) was completed on 8/20/25 at approximately 5:20 PM.

They were queried about the facility process for admission orders, medication reconciliation and nursing assessment. They added that staff had till mid-night on the day of admission to complete the nursing assessment and it may take several hours to complete their medication reconciliation and residents may have to wait several hours and the time frame varied. When queried about the admission orders for Resident R901,

they reported the nurse supervisor and administrator attempted to resolve the concerns and they were unable to resolve; did not provide any further explanation/rationale on why Resident R901 did not have any admission orders in the EMR for immediate care for several hours after admission to the facility. When queried about the resident/family member concerns about the medications that were administered, the DON reported that the resident was confused and no medications were administered. They were notified of

the concern and the rationale for the concern during interview.A facility provided document titled Physician's Order with a revision date of 8/20/25 read in part, Purpose: Physician Orders are obtained to provide a clear direction in the care of the resident.Electronic orders will be maintained per EMR software specifications.admission physician orders not signed timely will be identified by the facility for physician signature.admission order will be signed within 24-72 hours.Treatment rendered to the resident must be in accordance with specific standing, written, verbal, or oral telephone order of a physician or licensed health professional ordering within their scope of practice and clinical privileges.Orders must be recorded in the resident's record. The Policy, however, did not specify the expectations or any timeline for the facility staff to initiate admission physician orders for immediate care for a resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Troy

2685 West Maple Road Troy, MI 48084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

“No”.

Level of Harm - Minimal harm or potential for actual harm

The Process for Resident R907’s Oxycodone orders and administration were further discussed with the Medical Director and DON which identified on date of admission 5/16/25 at 11:39 PM. LPN “D” created and confirmed the Oxycodone 5 mg give every four hours was not correct and should have been scheduled as needed.

Residents Affected - Few

The DON was asked if the Controlled Drug Receipt/Record/Disposition Form labels with documented Oxycodone 5 mg 1 tablet by mouth every four hours as needed for pain should be compared to what is on

the MAR, the DON said yes and identified Nursing was not comparing the two orders in which one was prescribed as giving Oxycodone every four hours and the correct order from the Medical Director was written to administer as needed, and the error should have been caught. The DON acknowledged Nursing was not reviewing the Oxycodone medication prior to administering and Nursing did not transcribe the Physician orders correctly.

Review of the facility policy titled; Physician’s Orders dated 8/2025 documented: “The licensed nurse receiving the order must verify to ensure the order is complete and that it includes: …Accurate frequency…”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency at Troy

2685 West Maple Road Troy, MI 48084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

This intake pertains to intake # 2587857.Based on observation, interview, and record reviews, the facility failed to properly label, and date opened insulin pens for two of two residents (Resident R911 and Resident R912) reviewed for medication storage, resulting in insulin pens being mixed up and the potential to administer the incorrect insulin to a resident and adverse reactions. Findings include:Complaint 2587857On 8/20/25 at approximately 9:19 AM, an observation of the Maple East cart was made and a review of insulin was made with the Unit Manager B and Nurse L. It was noted that Resident R911 had a Lantus insulin pen with their name on it but the insulin pen was in a bag with Resident R912's name on it. The medication cart also had a total of 6 insulin pens with no date of when they were opened. An interview was conducted at the same time the medication cart was observed with Unit Manger B and Nurse L, they were asked about the residents' insulin that was

in the incorrect resident's bag and should insulin pens be dated upon opening. Nurse L reported that the medication should have been labeled for the appropriate resident and that insulins should be dated once

they are opened. Nurse L reported that they had just started the use of insulin pens verses the vials and that they would start putting an open date on them.No additional information was provided by the exit of survey.

Event ID:

Facility ID:

If continuation sheet