Regency Health Care and Rehabilitation Center

Inspectors wroteBased on interviews, Resident Identifier (RI) #180's medical record, the facility's policies titled Urine Sample Collection, Antibiotic Stewardship Program, Loeb's Minimum Criteria for Starting Antibiotic Therapy, Revised McGeer Criteria for Infection Surveillance Checklist, and Laboratory Services and Reporting, the facility failed to ensure RI #180 received prompt treatment after the facility's staff identified that he/she was exhibiting signs and symptoms of a Urinary Tract Infection. The facility failed to ensure a system was in place for the proper collection of urinary specimens for culture and sensitivity. Further, the facility did not have a system to ensure ordered antibiotics were administered as expected by the ordering health care provider. On [DATE] the Certified Registered Nurse Practitioner (CRNP) ordered a urinalysis (UA) for RI #180. [...]

Inspectors wroteBased on interviews, record review, and review of facility policy titled Quality Assessment and Assurance the facility's Quality Assessment and Assurance Committee (QAAC), the facility's Quality Improvement Performance Improvement (QAPI) committee, failed to thoroughly review all factors related to Resident Identifier (RI) #180's hospitalization on [DATE]. The facility did not identify the delay in treatment that resulted from the facility's failure to promptly obtain RI #180's urine specimen, promptly notify the Certified Registered Nurse Practitioner (CRNP) of RI #180's urinalysis (UA) results, and failure to administer RI #180's antibiotic timely. The facility's QAAC further failed to systemically address the factors that resulted in delay in treatment. On [DATE] RI #180 was noted to have decreased urinary output, urine odor, blood-tinged urine, and increased confusion. [...]

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled Pharmacy Services, the facility failed to ensure medications were available and administered as ordered for Resident Identifier (RI) #330, a resident with Liver Disease, upon admission to the facility on [DATE]. RI #330 missed doses of Rifaximin and Lactulose, medications for treatment of RI #330's Liver Disease, resulting in elevated blood ammonia levels. This affected one of 19 sampled residents.

Inspectors wroteBased on observations, interviews, record review and a facility policy titled Call Lights: Accessibility and Timely Response, the facility failed to accommodate the needs of Resident Identifier (RI) #15 by failing to ensure the call light was accessible on two of five days of the survey. This affected RI #15, one of 31 sampled residents.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled Notification of Changes, the facility failed to ensure the Certified Registered Nurse Practitioner (CRNP) was notified when medication was not available for administration to Resident Identifier (RI) #330 on 01/05/2023 and 01/06/2023. This affected one of 31 sampled residents.

Inspectors wroteBased on record review, interview, and review of a facility policy titled MDS 3.0 Completion the facility failed to ensure a discharge Minimum Data Set (MDS) Assessment was completed and transmitted after Resident Identifier (RI) #62 was discharged from the facility on 05/14/2024. This affected one of 31 sampled residents.

Inspectors wroteBased on interviews, residents' medical record, and the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manuals, the facility failed to ensure 1) Section O of Resident Identifier (RI) #3's admission Minimum Data Set (MDS) assessment was accurately coded to reflect the use of a Continuous Positive Airway Pressure (CPAP) during the assessment period and 2) Section H of RI #180's admission MDS assessment with an Assessment Reference Date (ARD) date of 12/17/2023 was accurately coded to reflect urinary and bowel continence. This deficient practice affects RI #3 one of three sampled residents for respiratory care and RI #180 one of 31 sampled residents for MDS. Findings Include: 1) The Centers for Medicare and Medicaid Services Long-Term Care Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 documented: [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure an accurate baseline care plan was developed for Resident Identifier (RI) #180. This affected one of 31 sampled residents reviewed for a baseline care plan.

Inspectors wroteBased on interviews and record review, review of the facility policy titled, Care Planning-Resident Participation the facility staff failed to ensure a care plan conference was scheduled to include Resident Identified (RI) #180's resident representative an opportunity to discuss the plan of care. This affected one of 31 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observations, interviews, medical record review, a review of [NAME] and [NAME], Fundamentals of Nursing, NINTH EDITION, and facility policy titled Medication Administration. The facility failed to ensure that Resident Identifier (RI) #23 had an intravenous saline lock removed after Normal Saline was completed on July 27, 2024. This deficient practice affected RI #23; one of 31 sampled residents during the recertification survey. Findings Include: Review of [NAME] and [NAME]'s Fundamentals of Nursing, NINTH EDITION, revealed the following: . Chapter 23 Legal Implication in Nursing Practice . Health Care Provider's Orders. The health care provider (physician .) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe the orders are in error or harm patients . [...]

Inspectors wroteBased on observations, interviews, medical record review and a review of a facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure Resident Identifer (RI) #23's fingernails were kept clean and cut. This deficient practice affected RI #23 one of five residents sampled for ADL care. Findings Include: A review of a facility policy titled: Activities of Daily Living (ADLs) with a revised date of 02/2021 revealed: Policy: The facility will assist residents to reduce the likelihood that their abilities in ADL's deteriorate unless deterioration is unavoidable. Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain . grooming, and personal and oral hygiene . RI #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include: [...]

Inspectors wroteBased on observation, interviews, resident record review, and review of a facility policy titled Perineal Care the facility failed to ensure Certified Nursing Assistant (CNA) #20 provided incontinent care for Resident Identifier (RI) #335 in a manner to prevent risk of a urinary tract infection (UTI). During the survey on 08/15/2024 CNA #20 was observed wiping bowel movement from RI #335's buttocks and anus area to the front of his/her perineal area. CNA #20 wore the same pair of soiled gloves for the entire process of incontinent care. This affected one of two residents sampled for infection prevention during incontinent care.

Inspectors wroteBased on interviews, medical record review and review of facility policies titled Documentation in Medical Record and Verbal Orders the facility failed to ensure Resident Identifier (RI) #180's medical record contained the times for verbal/telephone orders received on 01/03/2024, 01/06/2024, and 01/10/2024. Further, the facility failed to ensure RI #180's urine specimen obtained on 01/05/2024 via catheter was documented. The facility further failed to ensure Licensed Practical Nurse (LPN) #13 did not document administration of RI #180's 01/14/2024 dose of levofloxacin 500 milligram as administered on 01/18/2024 without clearly indicating that it was documented as a late entry. This affected one of 31 sampled residents.

Inspectors wroteBased on observation, interviews, resident record review, and review of a facility policy titled Laundry-Infection Control, the facility failed to ensure resident clothing was handled in a manner to prevent the potential for cross contamination for RI #333. On 07/28/2024 clothing was observed hanging on RI #333's door knob in the hallway. This affected one of 31 sampled residents.

Inspectors wroteBased on interviews, resident record review and review of a facility policy titled Dignity, the facility failed to ensure Resident Identifier (RI) #50's dignity was maintained during care. RI #50 reported to the surveyor that he/she was rushed to complete tasks during care which resulted in RI #50 feeling unimportant. This deficient practice affected RI #50, one of 20 sampled residents.

Inspectors wroteBased on interview and review of Resident Identifier (RI) #83's record, the facility failed to ensure RI #83's Minimum Data Set (MDS) admission assessment, section J was accurately completed on 8/6/19 for falls with major injury. This affected RI #83, one of two residents reviewed for falls.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that expired medications, Cerotive liquid and Orasol gel 20% were removed from stock. This deficient practice was observed during the medication storage observation in of the facility's central supply area.

Inspectors wroteBased on observations, interviews, and facility policies titled, Common Refrigerators, and Use and Storage of Food Brought in by Family or Visitors, the facility failed to ensure food kept in the resident refrigerators on the unit, were tabled and discarded after 3 days. This effected 2 of 2 resident refrigerators on the units.