Regency Care of Arlington, LLC

Inspectors wroteBased on observation, interviews, and record review, review of facility policies, the facility failed to ensure food was stored, prepared, and maintained in accordance with professional standards for food service safety. a sanitary manner. This failure had the potential to affect 136 of 155 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure proper hand hygiene during meal service for 12 residents (R) from a sample of 35 residents. Staff failed to perform hand hygiene when passing meal trays to R63, R75, R86, R103, R122, R133, R409, R411, R412, R413, 414, and R415. Staff handled residents' food without wearing gloves. The facility also failed to post the correct signage for personal protective equipment (PPE) for two residents of six residents on transmission-based precautions. (R3 and R139). The facility also failed to ensure that the posted precautions were followed for one of six residents on transmission-based precautions (Resident #34). These combined failures have the potential to widely transmit infectious agents and increase the risk of facility-acquired infections.

Inspectors wroteBased on observation, staff interviews, and chart review, the facility failed to maintain a clean, home-like environment for one resident, Resident #49, out of thirty-five residents in the survey sample, as well as for one of four units (300 unit) in the facility.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator and to the State Agency within two hours of the allegation being reported to facility staff. This involved one resident (R)84) in the sample of 35 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to adversely affect the residents and their Resident Representatives (RR) by not having the knowledge of where and why a resident was being transferred, and/or how to appeal the transfer, if desired, as well as preventing the State LTC Ombudsman from identifying inappropriate discharges.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 35 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for two of thirty-five residents in the survey sample (Residents #129 and #359).

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to develop care plan interventions for one resident (Resident #3) from a sample of 35 residents. Resident #3 (R3) had physician's orders for care of his suprapubic catheter site but no interventions were care planned for this device. This failure has the potential for the resident not to receive the proper care of his catheter.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate suprapubic catheter care and handling for one resident (Resident # 3) from a sample of 35 residents. This failure increases the potential for R3 to develop recurring urinary tract infections (UTIs) or other complications.

Inspectors wroteBased on observation, interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident #3) from a sampled 35 residents was properly positioned while receiving gastrostomy tube feeding. This failure has the potential for the resident to develop aspiration problems from the tube feeding.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed two errors out of thirty-four opportunities resulting in a 5.8% error rate.

Inspectors wroteBased on facility document review, clinical records review and staff interview, the facility staff failed to ensure the infection prevention and control program (IPCP) antibiotic stewardship included antibiotic use protocols and an accurate system for monitoring antibiotic use.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure at least one staff member was designated as the infection preventionist who is responsible for the facility's IPCP (infection prevention and control program).

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for three of 18 resident's in the survey sample. 1. Resident #82's MDS section B (vision) and section H (Bladder and Bowel) was coded incorrectly. 2. Resident #133's MDS section A (discharge) was coded incorrectly. 3. Resident #131's MDS section A (discharge) was coded incorrectly. The Findings Include: 1. Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of [DATE]. Resident #82's cognitive score was a 13 indicating cognitively intact. On [DATE] at 10:06 AM an interview was conducted with Resident #82. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to review and revise the CCP (comprehensive care plan) for six of 29 residents in the survey sample, Resident #47, #97, #118, #131, #107 and #8. 1.) The facility staff failed to update Resident #47's care plan related to snacks and an AV (arteriovenous) fistula (no longer in use). 2.) The facility failed to update Resident #97's care plan related to trach care interventions for dislodgement of a tracheotomy tube. 3.) Resident #118's care plan was not reviewed and revised to remove the focus area, Resident is a smoker. 4.) Resident #131's care plan was not reviewed and revised to include his repositioning of his tracheotomy tube, nor was the care plan revised to delete the use of hemostats to open up the stoma in the event the tube was coughed out. 5). [...]

Inspectors wroteBased on Resident interview, staff interview and clinical record review, the facility failed to develop a care plan for one of 29 resident's. Resident #82 did not have a care plan for vision. The Findings Include: Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/26/22. Resident #82's cognitive score was a 13 indicating cognitively intact. On 8/30/22 at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). On 8/30/22 Resident #82's clinical record was reviewed. [...]

Inspectors wroteBased on clinical record review, observations, and staff interview, the facility staff failed for one of 37 residents in the survey sample, Resident # 36, to implement the plan of care. Resident # 36, who had a diagnosis of Huntington's, had a care plan intervention to add padding to the walls of the resident's room that was not implemented.

Inspectors wrote2. Resident #111 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, peripheral venous insufficiency, depression, osteomyelitis in left foot, diabetes, methicillin resistant staphylococcus aureus infection, cerebrovascular disease, heart failure, chronic kidney disease, atrial fibrillation and insomnia. The minimum data set (MDS) dated [DATE] assessed Resident #111 as cognitively intact. Resident #111's clinical record documented a physician's order dated 2/4/20 for Vancomycin solution 750 mg (milligrams) to be administered intravenously twice per day for treatment of osteomyelitis in the left foot via a PICC (peripherally inserted central catheter). The record also documented physician orders dated 1/21/20 for use of Heparin solution (10 units/milliliter) to flush the right arm PICC two times a day to maintain patency. [...]

Inspectors wroteBased on resident interview, staff interview, and clinical record review, facility staff failed to provide showers for one of 39 residents in the survey sample, Resident #107.

Inspectors wroteBased on individual resident interview, resident group interview, staff interview, facility document review, and in the course of a compliant investigation, the facility staff failed to respond to call bells in a timely manner for 9 out 39 residents in the survey sample, Resident #s 152, 69, 121, 130, 151, 139, 76, 2, 117. Residents and the resident group council reported lengthy call bell response with waiting between 15 to 30 minutes and up to 2 hours for staff response.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure proper handling techniques while serving food from the steam table on one of 4 units, unit #4; and failed to ensure expired yogurt, orange juice, and flavored water was not available for distribution in the main kitchen. The findings Include: 1. On 02/25/20 at 08:31 AM, dietary aide (Other Staff, OS #4) was observed plating toast, bacon, boiled eggs directly with gloved hands. OS #4 was also observed touching the side of his face. OS #4 was interviewed at this time and stated he didn't know where the utensils were to handle the food, turned to another staff member and asked if they could call the kitchen to get some utensils. OS #4 then asked the surveyor if he could continue using his gloved hands to plate food. OS #4 was told he could not tell OS #4 what he should be doing. [...]

Inspectors wroteBased on clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for for dialysis within 48 hours of admission for one of 39 residents (Resident #170).

Inspectors wroteBased on observation, medication pass and pour observation, staff interview, clinical record review, and in the course of a complaint investigation, facility staff failed to follow physician orders for two of 39 residents in the survey sample, Resident #83 for dressing changes and skin integrity assessments, and Resident #156 for administration of Senna; and failed to ensure Resident #170 received dialysis care and services to prevent hospitalization.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 39 residents (Resident #25) received necessary treatment and services to promote healing and prevent infection during a pressure ulcer dressing change.

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to properly store and label medications and biologicals on two of four nursing units. On unit 2, two insulin pens were not labeled from the pharmacy; one multi-use vial of tuberculin PPD (purified protein derivative) solution opened greater than 30 days was available for use; and one multi-use vial of tuberculin PPD solution was without an opened date. Expired Advair was available for administration on a fourth floor medication cart.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of 39 in the survey sample, Resident #54 and Resident #14. Resident #54's clinical record inaccurately documented the resident as receiving hospice when the resident had been discharged from hospice, and there was no physician's order for the dialysis. Resident #14's name was incorrect.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, facility staff failed to follow infection control practices for three of 39 residents; Resident #83 and Resident #25 during dressing changes, and Resident #166 contact isolation precautions.