Regal Heights Rehabilitation and Health Care Cente

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during completion of the facility Kitchen Task. Specifically, expired food items were observed in the refrigerator, employees failed to practice hand washing, kitchen equipment were observed to be dirty, the dishwasher was found to be operating without appropriate oversight, and food items were found inconsistent with safe temperature ranges.

Inspectors wroteBased on observations and interviews, the facility did not ensure kitchen equipment was maintained in a safe working condition. This was observed on one steamtable during kitchen review. Specifically, the steamtable was observed with rusty brown stains.

Inspectors wroteBased on record review and interviews, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The was evident during the review of Registered Nurse #8's employee file. Specifically, the facility failed to maintain proper oversight of the hiring process. Facility administration hired Registered Nurse #8 despite receiving an incomplete employment application and neglecting to complete pre-employment screenings and background checks.

Inspectors wroteBased on record review and interviews, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not ensure a complete criminal background check was conducted for Registered Nurse #8. The facility failed to provide documented evidence that it verified Registered Nurse #8's professional license to be free of disciplinary actions, checked previous employers and three (3) references, or completed comprehensive background checks to uncover their criminal history prior to employment.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice. Specifically, physician's orders related to post-dialysis treatment to remove dressing on resident's permcath (a catheter inserted into a vein to use for dialysis treatments) 24 hours post-dialysis were not implemented. This was evident in one (1) resident (Resident #18) reviewed for dialysis out of a total of 38 sampled residents.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 11/27/2023 through 12/1/2023, the facility did not ensure food was served in accordance with professional standards for food service safety. This was evident for 1 (7th Floor) of 7 resident units observed during dining. Specifically, 7th Floor food service staff did not perform hand hygiene prior to serving food to residents and a fruit cup and tuna sandwich were above 41 degrees Fahrenheit (F).

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey from 11/27/2023 to 12/01/2023, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #162) of one 38 total sampled residents. Specifically, Resident #162's Foley drainage bag was not covered and was visible to anyone passing by their room.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/27/23 to 12/1/23, the facility did not ensure a resident's right to privacy and confidentiality was maintained for 1 of 35 sampled residents (Resident # 67). Specifically, the electronic Medication Administration Record (MAR) for Resident #67 was observed open on top of the medication cart, in the hallway, displaying personal and identifying health information.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessments accurately reflect the resident status. This was evident for 3 (Resident #101, #120, and #238) of 38 total sampled residents. Specifically, 1). MDS for Resident #101 and Resident # 238 did not accurately assess for contractures, 2). MDS for Resident #238 did not accurately assess for hemodalysis treatment.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 11/27/2023 to 12/1/2023, the facility did not develop and implement a comprehensive person-centered care plan (CCP) that includes measurable objectives and timeframes to meet a resident's needs. This was evident for 1 (Resident # 162) of 38 total sampled residents. Specifically, a CCP related to Foley catheter use was not developed for Resident #162.

Inspectors wroteBased on observation, interviews, and record reviews conducted during a recertification survey from 11/27/23 to 12/01/23, the facility did not ensure that each resident was provided with the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for 1 of 38 sampled residents. (Resident #256) Specifically, Resident #256 report that their sleep was disturbed at night because their roommate's television was too loud and it was not addressed.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 11/27/23 to 12/01/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 out of 2 residents reviewed for Pain Management out of 35 total sampled residents (Resident #238). Specifically, Resident #238 received pain medications and treatment without ongoing monitoring of the efficacy of the pain management.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/1/2023, the facility did not ensure the physician reviewed the resident's total plan of care at each visit. This was evident for 1 (Resident #162) of 2 residents reviewed for Foley Catheter out of 38 total sampled residents. Specifically, there was no Medical Doctor Order (MDO) given specifying the treatment and care of Resident #162's Foley catheter.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/27/23 to 12/1/23 the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice for 2 of 7 units (3rd Floor and 4th Floor). Specifically, the facility medication cart was not kept locked or under direct observation of authorized staff.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility failed to ensure that a safe, clean, comfortable and homelike environment was provided to residents. Specifically, resident rooms were observed with dirty floor mats in disrepair and unswept and sticky floors for mutiple observeations over several days. This was evident for 3 of 7 resident units observed for Environmental Observations (Floors 2, 3, and 5).

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, an RN was observed using a Blood Pressure (BP) cuff for multiple residents without sanitizing the equipment in between the residents. This was evident during medication pass for 4 of 4 residents observed during the Medication Administration Facility Task out of investigative sample size of 35 residents. (Residents #143, #190, #488, #489).

Inspectors wroteBased on observation, record review, and interview during the Re-certification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff members were observed entering resident rooms without knocking on the door. member was observed entering a dementia resident's room and another staff member was observed entering a cerebral infarction resident's room without knocking on the door. This was evident for 2 of 5 residents reviewed for Dignity (Resident #393 and 395) .

Inspectors wroteBased on observation, record review and interview during the Re-certification survey, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide a non-English speaking resident with television and reading materials in their native language per their preferences. This was evident for 1 of 3 residents reviewed for Choices from an initial pool of 35 residents (Resident #39). The finding is: [...]

Inspectors wroteBased on observation, record review and interview during the re-certification survey, the facility did not ensure that the residents received foot care and treatment in accordance with professional standards of practice, their comprehensive assessment, person-centered care plan, and the residents' choice. Specifically, a resident was not provided with foot care and treatment to address the resident's toenails care. This was evident for 1 of 1 resident reviewed for Foot Care (Resident #39).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility failed to ensure expired medications were identified timely and removed from current medication supply for disposition. Specifically, expired syringes of heparin flush and a dressing kit were observed in the medication room. This was evident on 1 of 7 units reviewed for Medication Storage (Unit 3). The finding is: The facility policy and procedures titled Medication Administration revised on 05/2017 documented nurse checks medication expiration prior to preparing medication for administration. On 09/08/2021 at 11:21 AM, an observation of the medication room on the 3rd Floor was conducted with RN #4. A cardboard box located inside cabinet to the right of the refrigerator contained the following expired items: [...]