Regalcare at Wakefield

Inspectors wroteBased on observation, records reviewed and interviews, the facility failed to ensure one Resident (#77), out of a total sample of 23 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically for Resident #77 who was assessed by nursing to be at high risk for skin breakdown and who experienced pain and limited mobility in his/her left lower extremity following a surgical repair, the facility failed to a. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for one Resident (#4), out of a total sample 23 residents, that informed consent, including risk and benefits, was obtained from Resident #1's legal guardian prior to administering antipsychotic medication.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a homelike environment was maintained on one of three units. Specifically, on the [NAME] Unit, the facility failed to ensure that the unit refrigerator that was on the unit in a resident space was kept in a manner that was consistent of a reasonable homelike environment as evidenced by a brown, rusted color that was stained across the entire bottom part of the front of the refrigerator.

Inspectors wroteBased on observations, record review and interview, the facility failed to assess the use of a potential restraint for one Resident (#34) out of a total sample of 23 Residents. Specifically, for Resident #34, the facility failed to assess the use of a scoop mattress as a potential restraint.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure for one Resident (#1), out of a total sample of 23 residents, that recommended services were implemented in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Evaluation Determination Summary. Specifically, Resident #1 was screened to meet PASRR criteria for SMI (serious mental illness) with recommended behavioral health services, individual psychotherapy.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure standards of professional nursing practice for one Resident (#1) out of a total sample of 23 residents. Specifically, the nursing staff documented in Resident #1's medical record that 1:1 supervision was being provided during meals when it was not provided in accordance with the physician's orders.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one Resident (#77) received treatment and care in accordance with professional standards of practice, out of total sample of 23 residents. Specifically for Resident #77 who had surgery on 1/22/26, the facility failed to send the Resident #77 to his/her orthopedic follow up appointment on 2/4/26 for suture removal and the sutures were not removed until 2/24/26, 35 days after surgery, potentially placing the resident at risk for complications.

Inspectors wroteBased on interview and observation the facility failed to ensure medications were secure on two of three resident units. Specifically, the facility failed to:Secure a narcotic medication in the Solerna Unit medication room.a. Secure medications which were left unsupervised at the [NAME] Unit nursing station and b. secure a treatment cart on the [NAME] Unit.

Inspectors wroteBased on records review, and interviews, the facility failed to obtain diagnostic services as ordered by the provider for one Resident (#77), out of a total sample of 23 residents. Specifically for Resident #77 who experienced pain in the left lower extremity the facility failed to obtain a left lower extremity ultrasound (non-invasive imaging test used to detect blood clots, evaluate venous flow, and assess venous valve function in the leg).

Inspectors wroteBased on observations, interviews and record review, the facility failed to notify the physician of a significant change in status for one Resident (#72) out of a total sample of 26 residents. Specifically, the facility failed to notify the physician when Resident #72 verbalized Suicidal Ideation (SI) and acute psychological distress.

Inspectors wroteBased on observations, record review and interview, the facility failed to protect two Residents (#72 and #17), from abuse and neglect, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility neglected to provide psychosocial support including ongoing monitoring, intervention and notification of the physician timely in a Resident who has a known history of suicidal ideation (SI) and observed to be making statements of SI by multiple staff without intervention. 2. For Resident #17 the facility failed to prevent verbal abuse.

Inspectors wroteBased on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: The facility failed to ensure licensed nursing staff who were on the schedule on 1/28/25, 1/29/25 and 1/30/25, were trained and competent to identify, assess, and intervene when one Resident (#72), who was admitted with Suicidal Ideation's, made repeated statements of wanting to commit suicide.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two Residents (#72 and #80) with a history of suicidal ideation (SI) and depression, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility failed to provide Resident #72 with appropriate behavioral health services following verbalizations of SI and psychosocial distress. 2. for Resident #80 the facility failed to indicate any behavioral health care plan or interventions were implemented after identifying Resident #80's history of attempted suicide or suicidal ideations.

Inspectors wroteBased on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for non-functioning call bell systems and Infection Control program related to COVID-19 vaccinations. Findings Include: During the survey period, multiple residents were identified as having signed consent to receive the COVID-19 vaccine however the facility failed to order the vaccine from the pharmacy or provide any monitoring of the vaccination status of Residents. During the survey period, two out of three nursing units were identified as having non-functioning call bell systems in place. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist were addressed by the facility in a timely manner for five Residents (#51, #52, #72, #7, and #86) out of a total sample of 26 Residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#45) out of a total sample of 26 residents was free from significant medication errors. Specifically, the facility failed to ensure nursing held midodrine (medication used to raise blood pressure) in accordance with the physician's orders.

Inspectors wroteBased on observation and interview, 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, 1. The facility failed to ensure that nursing performed hand hygiene and changed a wound dressing in accordance of professional standards to prevent infection. 2. The facility failed to sanitize shared resident equipment between resident uses.

Inspectors wroteBased on observation and interviews, the facility failed to ensure it provided a means for residents to communicate to staff on two out of three nursing units.

Inspectors wroteBased on employee training records reviewed and interview the facility failed to implement, and maintain an effective training program for staff, which includes, at a minimum, training on behavioral health care and services (consistent with §483.40) that is appropriate and effective, as determined by staff need and the facility assessment for 24 out of 24 direct care staff training records reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a dignified existence for one Resident (#73) out of a total sample of 26 residents. Specifically, nursing pulled a patient backward down the hallway in his/her wheelchair, rather than forward facing.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#86), out of a total sample of 26 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement care plans for two Residents (#66 and #63) out of a total sample of 26 residents. Specifically, 1. For Resident #66, the facility failed to implement fall mats. 2. For Resident #63, the facility failed to implement a care plan for heel protection booties.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team, as required, for one Residents (#51) out of a total sample of 26 residents. Specifically, for Resident #51 the facility failed to review and revise the care plan related to eating function during the comprehensive care plan review.

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to meet professional standards of practice for one Resident (#14) out of a total of sample of 26 residents. Specifically, for Resident #14 the facility failed to obtain the dose of a Lidocaine patch (patch used to treat pain) prior to administration.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#63) out of 26 sampled residents, the facility failed to ensure an orthotic device was worn as ordered.

Inspectors wroteBased on interview and record review, the facility failed to provide care according to professional standards of practice for two Residents (#66 and #51) out of a total sample of 26 residents, relative to nutrition interventions and weight monitoring when the Resident was identified as being at nutritional risk and had weight loss. Specifically, 1. For Resident #66, who had weight loss, the facility failed to obtain weights according to current professional standards of practice. 2. For Resident #51 the facility failed to obtain a reweigh to determine weight loss.

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 the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#86), out of a total sample of 26 residents. Specifically, for Resident #86, the facility failed to change the PICC line dressing once compromised, and nursing failed to obtain orders and implement recommendations for the removal of the PICC line.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#57), out of a total sample of 26 residents. Specifically, for Resident #57, the facility failed to ensure that nursing changed Resident #57's oxygen tubing as ordered by the physician.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#57) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 26 residents. Specifically, the facility failed to ensure clamps were kept with the Resident in accordance with the plan of care and the physician's orders in case of emergency.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive trauma informed care plan for one Resident (#72) out of a total sample of 26 residents. Specifically, Resident #72 has a known history of trauma and the facility failed to develop a care plan with resident specific triggers and interventions.

Inspectors wroteBased on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#72), with a known history of mental disorders, suicidal ideation, and adjustment difficulty. Specifically, the facility failed to develop, implement, and update the plan of care, resulting in the Resident experiencing on going psychosocial distress and requesting hospitalization for suicidal ideation's after 2 days of repeated vocalizations of suicidal ideation without intervention from the facility.

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, nursing failed to secure the medication and treatments carts on 1 of 3 units.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate documentation in the medical record for one Resident (#66) out of a total sample of 26 residents. Specifically for Resident #66 the facility failed to ensure that the physician's order for the wander guard was accurate.

Inspectors wroteBased on record review, and interview, the facility failed to offer COVID-19 vaccines, in accordance with national standards of practice to 8 of 8 resident records reviewed, out of a total sample of 26 residents. Specifically, the facility failed to offer COVID-19 vaccines to the eligible residents when: -The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended an additional dose of updated (2024-2025 formula) of COVID-19 vaccine be administered for older adults,aged [AGE] years and older. -The COVID-19 vaccine was not medically contraindicated and had not already been immunized with the recommended additional COVID-19 vaccine dose.

Inspectors wroteBased on record review and interview, the facility failed to provide an accurate estimated cost of services to resident's or their representatives, for three out of three resident records reviewed, to ensure they were informed of their potential financial liabilities of the cost of items and services provided in addition to the daily per diem room rate.

Inspectors wroteBased on observations and interviews, the facility failed to post nursing staff data daily, at the start of each shift, as required. Specifically, the facility failed to ensure they consistently posted the staffing as required.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. Specifically: 1. The facility failed to maintain an environment free from physical disrepair, which included damaged walls, damaged ceilings, damaged floor, torn window screens, and broken window blinds on one of three resident units. 2. The facility failed to ensure that comfortable air temperatures were maintained on one of three resident units. 3. The facility failed to ensure a Resident room was free of bugs.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide a dignified existence to one Resident (#43) out of a total sample of 29 residents. Specifically, for Resident #43 the facility failed to provide privacy and dignity while in his/her room. Findings Include: Review of facility policy, titled Quality of Life- Dignity, dated as revised 2009, indicated the following but not limited to: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self- esteem and self- worth. * The policy further indicated staff shall promote, maintain and protect resident privacy including bodily privacy during assistance with personal care. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to honor the right of self-determination to choose providers of health care services for one Resident (#81) out of 29 total sampled residents. Specifically, following alleged physical abuse, the facility failed to honor a request for Resident #81 to not have contact with the accused caregiver.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to implement a comprehensive person-centered care plan for one Resident (#60) out of a total sample of 29 residents. Specifically, the facility failed to implement the plan of care to apply heel lift booties (a boot to prevent skin breakdown) to bilateral feet while in bed for Resident #60. Findings Include: Resident #60 was admitted to the facility in November 2023 with diagnoses including fracture of unspecified part of neck of right femur, pain, protein calorie malnutrition, Alzheimer's disease, and muscle weakness. Review of Resident #60's most recent Minimum Data Set (MDS) Assessment, dated 1/21/24, indicated that Resident #60 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating that Resident #60 has severe cognitive impairment. [...]

Inspectors wroteBased on observation, policy review and interviews the facility failed to ensure infection control practices were implemented during medication pass.