Regency House

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #1 and #3) reviewed for dialysis services. The facility failed to ensure the dialysis communication forms were completed to include the pre and post dialysis assessment for Resident #1 and Resident #3. The facility failed to ensure residents had a physician order for dialysis treatment and to inspect vascular access sites for Resident #1 and Resident #3. The facility failed to develop a person-centered care plan for Resident #1 and Resident #3 to address their dialysis needs. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 20 residents (Resident #5, Resident #41, Resident #76) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #5's diagnosis of bilateral presbycusis (hearing loss, in both ears, related to damage of the inner ear that develops gradually as you get older). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 46 (Rooms 2, 3, 4, 5, 6, 7, 9, 10, 12, 14, 15, 16, 17, 20, 21, 23, 25, 26, 28, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 49, 50, 51, 52, 53, 54, 55, 56, 58, 59 and 60) of 60 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 5 residents reviewed for physician notification. (Residents #76) 1. The facility failed to notify the physician of Resident #76's family's demand to use a head strap for her wheelchair. This failure could place residents at risk of not receiving appropriate medical treatments, which could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 3 (Resident #76) residents reviewed for restraints. The facility failed to provide assessment, care planning, and a physician's order for the use of a head strap (Velcro strap permanently affixed to the head rest of the wheelchair) restraint for Resident #76. This failure could result in residents having physical restraints used that limited their movement without being evaluated for medical need.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #30) reviewed for catheter care. Resident #30's urine collection bag was observed hanging on the armrest of his wheelchair and above the bladder. This failure could place residents at risk for catheter associated urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure the Food Supervisor (FS) was wear a mustache guard while there was uncovered food in the kitchen. This deficient practice could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure one of six stove top burners ignited automatically. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #65, Resident #17) reviewed for care plans. 1. The facility failed to have a care plan addressing Resident #17's Enhanced Barrier Protection with her Pressure Ulcer. 2. The facility failed to have a care plan in place to accurately address Resident #65's behavioral problems. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 2 of 8 medication carts (Med Cart #1, Med Cart #2), reviewed for pharmacy services. The facility failed to ensure Med Cart #1, Med Cart #2 remain locked while unattended. This failure could place residents at risk of and unauthorized access to medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #17 and #43) reviewed for infection control. The facility failed to ensure CNAs A and B followed EBP procedures by not wearing a gown while transferring Resident #43 with the mechanical lift. (Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents). The facility failed to ensure the Treatment nurse followed EBP procedures by not wearing a gown while providing wound care for Resident #17. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #43) reviewed for quality of care. The facility failed to ensure CNA A did not lift Resident #43's urine collection bag above his bladder while she transferred the resident with the use of a mechanical lift. This failure could place residents at risk for catheter associated urinary tract infections (CAUTI).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an encoded, accurate and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 4 of 5 residents (Resident #22, #46, #63, and #77) reviewed for MDS assessments. 1. The facility failed to ensure Resident #22's quarterly MDS assessment was completed and transmitted timely. 2. The facility failed to ensure Resident #46's quarterly MDS assessment was completed and transmitted timely. 3. The facility failed to ensure Resident #63's significant change MDS assessment was completed and transmitted timely. 4. The facility failed to ensure Resident #77's annual MDS assessment was completed and transmitted timely. This deficient practice placed residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #2) reviewed for infection control practices. CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #2. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired foods were discarded. This failure could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 2 meals observed for resident rights. Residents sitting at the same table were not served at the same time. Staff assisting Resident #14 stood while feeding her. This failure could place residents at risk for decreased meal satisfaction.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms, 1 of 2 (wound treatment cart #1), and 1 of 4 (Medication cart #1) reviewed for medication storage. The facility failed to ensure expired medications were removed from the medication room refrigerator the wound care/ treatment cart #2 and medication cart #4. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #2 and #38) of 4 residents reviewed for infection control. LVN A failed to prevent cross contamination during Resident #2's wound care. CNA B failed to wash her hands prior to personal care and change her gloves during incontinent care of Resident #38. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents, (Resident #2) reviewed for skin integrity in that: The facility failed to assess Resident #2's heel upon return from the orthopedic doctor for signs of skin breakdown. The facility failed to prevent Resident #2's heel from having further breakdown. LVN A failed to prevent cross contamination during wound care for Resident #2's heel. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, infection, and decreased quality of life.