Cape Regency Rehabilitation & Health Care Center

Inspectors wroteBased on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in safe operating condition, specifically (a) the plate warmer cart and (b) the walk-in freezer in the main kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two Residents (#6 and #11) with wounds, out of a total sample of 23 residents, received necessary treatment and services to promote healing. Specifically, the facility failed: 1. For Resident #6, to complete weekly skin assessments and to follow the vascular physician's recommendations for care and treatment of a non-pressure wound to the Resident's left right foot; and 2. For Resident #11, to discontinue treatment to an arterial ulcer on the lateral left foot, leading to two different treatments being conducted daily and failed to follow the physician's order for the treatment by applying an adhesive bandage.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that staff assisted one Resident (#84), out of a total of 23 sampled residents, in replacing bilateral hearing aids that went missing to maintain hearing ability and enhance communication.

Inspectors wroteBased on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for one Resident (#76), out of a total sample of 23 residents. Specifically, the facility failed to: a. Ensure a recommendation from October 2024 by the pharmacy consultant to evaluate continued need of Oxycontin and MS Contin (both opioid medications that are used for severe pain) was reviewed and responded to by the provider; and b. Ensure February 2025 consultant pharmacist recommendations were acted upon timely to clarify the need for Protonix (reduces stomach acid) 40 milligrams (mg) twice a day, and to evaluate the need for continued use of as needed Oxycodone (medication used for breakthrough pain).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that medications were accurately reconciled by nursing for one Resident (#76), out of a total sample of 23 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to ensure Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots) was administered according to physician's orders following a hospitalization for a left knee joint fusion, resulting in the Resident receiving nine additional doses of the medication.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen grout and coving were maintained in a sanitary and safe condition; 2. Ensure walk-in shelving was free of rust; and 3. Ensure food was properly stored, labeled, and dated in three of three unit kitchenettes.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests.

Inspectors wroteBased on record review and interviews, the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure resources were utilized to ensure mechanical equipment was maintained in safe operating condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Review and document laboratory results for a total of 71 patients on two out of two units swabbed for Group A Streptococcus, as a measure of surveillance after three identified residents who resided in the facility tested positive; 3. Ensure proper hand hygiene was completed prior to meals for residents eating in the first floor dining area; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (#47 and #68) were treated with dignity and respect, in a total sample of 23 residents. Specifically, the facility failed: 1. To engage with Resident #47 using their preferred name (their first name shortened to a nickname), after being informed of the preferred name by the family; and 2. To provide a privacy bag to cover the urinary catheter bag of Resident #68.

Inspectors wroteBased on record review and interview, the facility failed to ensure advanced directives for one Resident (#116), out of total sample of 23 residents, were executed in accordance with the Resident's wishes, specifically, their Medical Orders for Life Sustaining Treatment (MOLST medical order form that relays instructions between health professionals about a patient's care based on an individual's right to accept or refuse medical treatment).

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident's physician and activated Health Care Proxy (HCP) about a significant medication error so as to re-evaluate the potential need to alter the treatment plan for one Resident (#76), from a total sample of 23 residents. Specifically, the facility failed to notify the primary physician and health care proxy of a medication reconciliation error resulting in Resident #76 receiving nine additional doses of Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots).

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had a homelike environment. Specifically, the facility failed to: 1. Ensure a comfortable and homelike dining experience in one of three dining rooms; and 2. Repair a water damaged wall area around a built-in wall unit air conditioner.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards for three Residents (#64, #24, #23), of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #64, to ensure the Resident's inhaler and allergy nasal spray medications were stored securely; 2. For Resident #24, to ensure the Resident's nasal spray medication was stored securely; and 3. For Resident #23, to ensure the Resident's inhaler medication was stored securely.

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#23 and #87), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended pneumococcal vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed: 1. For Resident #23, to ensure the Resident's medical record included documentation that indicated the Resident/Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination and declined vaccination; and 2. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 had an unwitnessed fall, and was found in the bathroom kneeling on the floor, the Facility failed to ensure the Provider and Family Member #1, were notified.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 was found on the bathroom floor after an unwitnessed fall by nursing staff, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Nurse #1 said she assessed Resident #1 after the incident, she did not document it, did not complete an incident report or write a progress note, and did not report the unwitnessed fall to the oncoming shift nurse, so he/she could be monitored.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Ensure staff performed hand hygiene in between each resident during a medication pass and did not touch the medications with their bare hands; 3. Ensure staff performed hand hygiene in between glove changes during a dressing change treatment for Resident #257; and 4. Ensure transmission based precautions (TBP) were implemented according to Centers for Disease Control and Prevention (CDC) guidance for Resident #21.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for review with the Resident Council.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on 1 of 3 resident care units.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean microwaves in three out of three kitchenettes.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians. Specifically, the facility failed to: 1. Complete antibiotic usage audit tools, which are used to track, report, and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program; and 2. Ensure antibiotics prescribed are necessary for one Resident #40.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen walk-in freezer was maintained in safe operating condition.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure a baseline care plan was developed for two Residents (#257 and #259) for their history of substance abuse, out of a total sample of 21 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to develop individualized, person-centered care plans regarding pain management for two Residents (#257 and #259), out of a total sample of 21 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure one Resident (#41) was administered their medications in accordance with professional standards and the facility policy. The total sample was 21 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed for two Residents (#33 and #65), out of a total sample of 21 residents, to ensure staff provided the necessary respiratory care and services in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #33, to ensure continuous positive airway pressure (CPAP) mask and tubing were stored properly in a sanitary manner to prevent potential contamination from germs and environmental debris; and 2. For Resident #65, to ensure CPAP mask and tubing were stored in a sanitary manner to decrease the risk of potential contamination.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to maintain an effective resident-centered pain management program to assist one Resident (#257) in meeting their individual pain goals, out of a total sample of 21 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to consistently provide substance use disorder counselling and services for two Residents (#257 and #259), out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to safely store medications on one out of three units observed. Specifically, the facility failed to ensure medication carts were secure when not in view of the licensed nurse.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (lab) services were obtained for one Resident (#89), out of a total sample of 21 residents. Specifically, the facility failed to follow the physician's plan to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), HgbA1c (hemoglobin A1C), lipid panel, and TSH (thyroid-stimulating hormone).

Inspectors wroteBased on document review and interview, the facility failed to accurately update the nurse staffing plan to reflect the current needs of the facility upon completion of their annual assessment.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for two Residents (#106 and #65) with unplanned, significant weight changes, out of a total sample of 25 residents. In addition, the facility failed to weigh residents according to physician's orders and implement nutritional interventions to prevent further weight loss. Specifically, the facility failed 1. For Resident #106, to ensure the Resident was weighed upon admission and weekly as ordered and implement nutrition recommendations timely to prevent weight loss. 2. For Resident #65, to ensure the Resident was weighed per physician's orders or reevaluated following a significant weight loss.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that food is stored, prepared, and distributed in accordance with professional standards. Specifically, the facility failed to: 1.) Ensure that food was stored, prepared, and distributed under sanitary conditions; and 2.) Ensure three unit kitchenette refrigerators were maintained in a sanitary manner to store food and fluid.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop a comprehensive person-centered care plan for four Residents (#10, #214, #68, and #112) and implement a care plan for one Resident (#6), out of a total sample size of 25 residents. Specifically, the facility failed 1.) For Resident #10, to ensure staff developed a comprehensive care plan for the care and treatment of a pressure area to the left lateral foot; 2.) For Resident #214, to ensure staff developed a comprehensive care plan following a fall at the facility resulting in a facial laceration; 3.) For Residents #68 and #112, to ensure staff developed a comprehensive care plan for the use of psychotropic medications; and 4.) For Resident #6, to ensure staff implemented a care plan for fall interventions.

Inspectors wroteBased on observation, staff and resident interviews, and review of food temperature logs, the facility failed to ensure that food and drink are palatable, attractive, and served at a safe and appetizing temperature.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to maintain personal equipment (wheelchair armrests) in good condition for five Residents (#87, #73, #55, #75, and #167), from a total sample of 25 Residents.

Inspectors wroteBased on record review and interview, the facility failed to review and revise the plan of care for one Resident (#16) following a hospitalization for aggressive behavior and a Resident to Staff altercation, out of a total sample of 25 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure that Nurse #9 documented the required information in the medical record for the removal of a PICC (peripherally inserted central catheter) line in accordance with professional standards of practice and the facility's policy for one Resident (#61) of one Residents with a PICC line, from a total sample of 25 residents.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards, through ongoing communication and collaboration with the dialysis facility for one Resident (#67), out of a total sample of 25 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to 14 days, unless documented by the attending physician or prescribing practitioner that it is appropriate to extend beyond 14 days for one Resident (#61), out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to: 1.) Label medications and biologicals and properly store them, in accordance with currently accepted professional principles; and 2.) Ensure medications were stored at the proper temperature to ensure their efficacy.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure the physician/physician's assistant (PA) were notified promptly of the critical results of laboratory tests, which fell outside of the clinical reference range, for one Resident (#61), out of a total sample of 25 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards and practice for 2 out of 3 closed Resident records (#114 and #116) and one Resident (#22) record, out of a total sample of 25 residents. Specifically, the facility failed 1.) For Resident #114 and Resident #116, to ensure they had a physician's order to discharge home with services; and 2.) For Resident #22, to ensure he/she had a physician's order to discontinue hospice services.

Inspectors wroteBased on interview and documentation review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement transmission-based precautions to prevent the potential spread of suspected Clostridioides difficile (C-diff; a bacterium which causes serious diarrheal infections) per the facility's policy for one Resident (#4), out of a total sample of 25 residents.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure rapid antigen testing was conducted in a manner that is consistent with current standards of practice established by State and Federal agencies to maintain proper infection control and ensure the validity of the test results.