Regalcare at Quincy

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four Residents (#11, #30, #33, #35), out of a total sample of 15 residents, had their call bell devices accessible and within reach to utilize them to call for staff assistance while in their rooms.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 10 of 10 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).

Inspectors wroteBased on document review, observation, and interview, the facility failed to develop, implement and individualize comprehensive plans of care for five Residents (#202, #4, #12, #33, and #36) out of a total sample of 15 residents. Specifically, the facility failed: 1. For #202, to individualize and implement the pain and risk for pain care plan; 2. For Resident #4, to develop and implement a care plan for the use of Seroquel (an antipsychotic medication) that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan for the use of Seroquel that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 4. For Resident #33, to develop and implement a care plan intervention after he/she sustained a fall; and 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure two Residents (#41 and #36), out of a total sample of 18 residents, were free of accident hazards. Specifically, the facility failed: 1. For Resident #41, to ensure a wound treatment cart was locked when unattended by licensed staff to prevent unauthorized access to potentially harmful items; and 2. For Resident #36, to ensure the Resident's freestanding oxygen cylinder was properly stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#200), out of a total sample of 18 residents. Specifically, the facility failed to: -ensure documentation of PICC line dressing changes -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have significant impact on treatment, or cause serious harm) -measure and document arm circumference -measure and document the total catheter length when the PICC line was pulled out by the Resident to ensure the catheter was intact.

Inspectors wrote2. Resident #12 was admitted to the facility in February 2025 and had diagnoses including anxiety and depression. Review of the MDS assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a BIMS score of 13 out of 15, had anxiety, depression (other than bipolar) and received antipsychotic medication daily. Review of the medical record indicated but was not limited to: -Quetiapine Fumarate 100 mg at bedtime (2/13/25) Review of February 2025 and March 2025 MARs indicated Quetiapine was administered as ordered by the physician. Further review of the medical record failed to indicate any resident-specific targeted behaviors were identified and monitored for Resident #12's use of Quetiapine. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse on one of two units; 2. Ensure two of two medication rooms were locked when not in direct supervision of the licensed nurse; and 3. Ensure the over the counter (OTC) medication room was locked when not in direct supervision of the licensed nurse on one of one units.

Inspectors wroteBased on observations, interviews, and meal test tray results, the facility failed to serve meals that were palatable and at appetizing temperatures on two of two 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: 1. Ensure food was properly stored in the walk-in freezer in the main kitchen; 2. Ensure to properly date, label, and store food and drink items in one of two kitchenettes; 3. Ensure, a. the wall in the main kitchen behind the dishwashing station was kept in a clean and sanitary manner; b. the counter next to the sink in one of two kitchenettes was kept in a clean and sanitary manner; 4. Ensure staff wore hair restraints in the main kitchen during meal preparation and service

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection 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. Implement a complete and accurate infection surveillance plan to identify, track and monitor for infection; 2. Ensure treatment carts were secured and locked to prevent Resident #41 from gaining unauthorized access resulting in infection control concerns; and 3. For Resident #36, ensure oxygen concentrator filters were clean and free of debris.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff developed baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#12), in a total sample of 18 residents. Specifically, the facility failed to ensure a baseline care plan was developed for the Resident's: a. diagnosis of Post Traumatic Stress Disorder (PTSD-results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being); and b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for two Residents (#29 and #4), out of a total sample of 15 residents. Specifically, the facility failed to: 1. Ensure a physician's order for the application of compression stockings were applied to Resident #29 daily; and 2. Ensure a healthcare proxy (HCP) invocation was completed for Resident #4 in accordance with the standard of practice.

Inspectors wroteBased on record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#12), with a history of trauma, out of a total sample of 18 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to assess one Resident (#12), out of a sample of 18 residents, for the use of a bed rail. Specifically, the facility failed to assess the risk of entrapment from the use of a bed rail (side rails, bed side rails, safety rails, grab bars and assist bars: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths), review the risks and benefits of side rails and obtain informed consent from the resident prior to installation of a bed rail. Findings Include: Review of the facility's policy titled Proper Use of Side Rails Policy, last revised 4/2022, indicated but was not limited to: -An assessment will be conducted to identify the reason for using side rails and the risk of entrapment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#12 and #4), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #12, to ensure the February 2024 consultant pharmacist recommendation was acted upon timely by the physician to add instructions for Trelegy Ellipta inhaler (used to treat chronic obstructive pulmonary disease (COPD) and works by opening airways, reducing inflammation, and keeping the airways open and improving lung function) orders; and 2. [...]

Inspectors wroteBased on document review and interview, the facility failed for two Residents (#4 and #202), out of a total sample of 15 residents, to maintain a complete and accurate medical record. Specifically, the facility failed to: 1. Ensure the healthcare proxy (HCP) activation form was completed for Resident #4, including the cause and nature of the document, which were left blank; and 2. Ensure the administration of Tramadol (a pain medication) was documented on the medication administration record (MAR) for Resident #202 each time it was administered.

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment in safe working order. Specifically, the facility failed to maintain: 1. One of two microwaves located in the resident kitchenettes on the third floor; 2. The food processor in the main kitchen used for resident food; and 3. The plate warmer in the main kitchen used to heat residents' plates.

Inspectors wroteBased on observation and interview, the facility failed to maintain two of two resident nourishment kitchenettes in a clean and sanitary condition.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened.

Inspectors wroteBased on record review and interviews, the facility failed to notify the physician (MD) and/or nurse practitioner (NP) of an abnormal chest X-ray for one Resident (#41), out of one of three closed records reviewed.

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of their person-center care plans, which included conducting and inviting residents and/or their Representatives to an interdisciplinary care plan meeting following the completion of their comprehensive admission Minimum Data Set (MDS) assessments.

Inspectors wroteBased on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who was morbidly obese, incontinent of both bowel and bladder, and who required the assistance of two staff members with the use of a mechanical lift device to transfer in and out of bed, the Facility failed to ensure services provided were consistent with Resident #1's comprehensive assessment and plan of care, in an effort to maintain his/her Quality of Life. On 11/21/23, Resident #1 was observed out of bed in his/her wheelchair at 9:41 A.M. and observed again at 4:14 P.M. still in his/her wheelchair and per Resident #1's interview, he/she had not been provided with incontinent care or assisted with repositioning for comfort during that time.

Inspectors wroteBased on records reviewed, interviews and observations of one of three sampled residents (Resident #1) the Facility failed to ensure they maintained a complete and accurate medical record including but not limited to Activities of Daily Living (ADL) Flow Sheets that were to be completed by Certified Nurse Aides (CNA's) that should contain daily documentation of care provided to the resident by staff each shift.

Inspectors wroteBased on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who had severe cognitive impairment, poor safety awareness, was legally blind and required supervision to physical assistance of one staff member with wheelchair mobility, the Facility failed to ensure he/she was provided with an adequate level of supervision and staff assistance in effort to maintain his/her safety to prevent accidents/incidents resulting in serious injury. On 8/01/23 Resident #1, who resided on the Main side of his/her unit, wheeled him/herself towards the ramp on his/her unit that lead to the [NAME] side of the unit. Resident #1 was unable to control his/her wheelchair as it rolled down the ramp, and as the wheelchair came to an abrupt stop at the bottom of the ramp, he/she fell forward out of the wheelchair and onto the floor. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #4), who had experienced a fall in the community resulting in significant head trauma requiring his/her need for hospitalization, and who upon admission to the facility was assessed by nursing to be at increased risk for falls, the Facility failed to ensure services provided by nursing met professional standards of care, when on 10/08/23, after Resident #4 had an unwitnessed fall to the floor and self-reported to nursing that he/she bumped his/her head, neurological assessments were not consistently completed by nursing, as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff promoted and facilitated Resident self-determination relative to the manner of bathing for one Resident (#27), out of a total sample of 14 residents.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure nursing staff followed professional standards of practice during medication administration and observed the Resident's consumption of medications prior to leaving the room for one Resident (#204), out of a total sample of 14 residents.

Inspectors wroteBased on the Beneficiary Protection Notification Review, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) forms in advance of last covered Medicare day for one Resident (#7), out of three sampled residents.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to encode and electronically transmit the MDS data to the Centers for Medicare and Medicaid Services (CMS) processing system, for one Resident (#30), out of three resident assessments reviewed.