Regeis Care Center

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that allegations of abuse were investigated thoroughly and that residents were protected from further abuse during the investigation. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for abuse. Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 roughly handle and hit Resident #1 on the buttock. The Director of Nursing failed to thoroughly investigate the allegation of abuse and remove Certified Nurse Assistant #1 from direct care and access to residents after allegations were reported. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm to 222 residents.

Inspectors wroteBased on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of six (6) residents (Resident #1) sampled for abuse. Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 rough handed and hit Resident #1 on their buttock. A review of the facility surveillance video footage dated 02/17/2026 at 4:34 PM corroborated what the visitor reported to the Director of Nursing and later reported to the New York State Department of Health.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for abuse. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 who has unsteady gait and was at risk for fall, was seen on the facility's surveillance video footage on 02/17/2026 ambulating in the hallway without assistance. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure the facility 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. This was evident in one (1) out of six (6) residents sampled (Resident #1). Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 abused Resident #1. The facility surveillance video footage dated 02/17/2026 at 4:34 PM corroborated what the visitor reported to the Director of Nursing and later reported to the New York State Department of Health. Facility administration did not immediately investigate the alleged abuse and protect residents from further potential abuse. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to address each residents' medical, physical, mental, and psychosocial needs. This was evident in 1 (Resident #146) of 1 resident reviewed for Antibiotic Use, out of 37 total sampled residents. Specifically, a care plan was not developed for Resident #146's diagnosis of Sinusitis and antibiotic use.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for 1 of 1 resident reviewed for Insulin (Resident #149), out of a sample of 37 residents investigated. Specifically, Resident #149 had a physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 200 milligrams per deciliter or more than 350 milligrams per deciliter. [...]

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure that food served were at an appetizing temperature. This was evident in 1 (Resident #134) of 4 residents reviewed for Dining Observation out of 37 total sampled residents. Specifically, food served during lunch meal service was not maintained at palatable and appetizing temperatures.

Inspectors wroteBased on observations , record review, and interviews during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure that the survey results were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for 11 (#10, #22, #31, #43, #44, #91, #97, #147, #148, #149, and #173) out of 16 residents attending the Resident Council meeting. Specifically, the survey results were kept in unlabeled plastic sleeve and was located across the Finance Department's office down the hall from the main entrance and not in plain view. Additionally, the survey results did not include complaint investigations made during the 3 preceding years.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 01/13/2025 to 01/21/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 3 (Residents #164, #152, and #64) of 18 residents reviewed for Resident Assessment. Specifically, Residents #164, #152, and #64's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure a resident with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. This was evident for 3 of 4 residents reviewed for Urinary Catheter out of 39 total sampled residents (Residents #34, #62, #149). Specifically, 1) there were multiple observations of Resident #34's Foley Catheter (FC) drainage bag touching the floor and there was no physician order (PO) for FC, 2) there were multiple observations of Resident #62's FC drainage bag touching the floor, and 3) there were multiple observations of Resident #149's FC drainage bag touching the floor.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #73) of 1 resident(s) reviewed for Dialysis and 1 (Resident #544) of 1 resident(s) reviewed for Hospitalization out of 39 total sampled residents. Specifically, 1) a CCP was not developed to address Resident #73 hemodialysis (HD) and Diabetes Mellitus (DM) treatment and, 2) a CCP was not developed to address Resident #544's oxygen therapy.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 11/28/2022 to 12/5/2022, the facility did not ensure residents were involved in developing the comprehensive care plan (CCP) and making decisions about their care. This was evident for 1 (Resident #81) of 3 residents reviewed for Participation in Care Planning out of 39 total sampled residents. Specifically, Resident #81 was not invited to participate in their quarterly CCP meeting with the interdisciplinary team (IDT).

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 11/28/22 to 12/05/22, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during review of the Kitchen. Specifically, 2 cold sandwiches placed on resident meal trays during tray line service were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below.

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not ensure that residents were provided with information on how to file grievances. Specifically, all resident council members at the Resident Council Meeting were unaware that they had the right to file a grievance in writing and to obtain a decision regarding his or her grievance in writing. This was evident for 12 out of 12 residents who attended the Resident Council Meeting.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that services provided, as outlined per the comprehensive care plan, met professional standards of quality. Specifically, residents prescribed oxygen as needed did not have oxygen saturation levels monitored as ordered to assess the need for oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care (Resident #141 and #220).

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident's right hand splint was not applied as ordered and per the Comprehensive Care Plan (CCP). This was evident for 1 of 2 resident reviewed for limited range of motion (Resident #119).

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that appropriate care and services to prevent complications of tube feeding were provided. Specifically, the medication nurse did not use the correct amount of water to flush the feeding tube prior to initiating tube feeding. This was evident for 1 of 3 residents reviewed for Tube Feeding (Resident #203).

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident on oxygen therapy received respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, residents prescribed oxygen as needed did not have oxygen saturation levels monitored as ordered to assess the need for oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care (Resident #141 and #220).

Inspectors wroteBased on observations and staff interviews during the re-certification survey, the facility did not ensure infection prevention and control practices were followed to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) a resident's motorized scooter was observed parked inside the 6th floor clean linen room where clean linens were being stored; (2) during wound care treatment observation, the Licensed Practical Nurse (LPN) was observed closing and opening the treatment cart, then started pulling the irrigation syringe cap with her bare hands and placed the syringe back inside the irrigation bottle filled with Dakin's solution. The LPN also failed to performed hand hygiene before touching the irrigation syringe. [...]