Regency Oaks Health Center

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately, and updated to reflect new Mental Illness (MI), or Suspected Mental Illness (SMI) diagnoses for five (#8 , #18, #4, #19, and #36) of thirty-two sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to maintain or improve functional abilities, when formalized physical and occupational therapy were discontinued for one (#19) of one sampled resident. Findings Included: During an interview and observation on 12/9/24 at 9:18 a.m., Resident #19 said she was frustrated because her therapy was stopped due to insurance, she was notified by the facility and filed an appeal immediately because she was not receiving therapy. Also an emergency appeal had been submitted and she should receive feedback today, 12/9/24. Review of the admission record showed Resident #19's admission date was 9/29/24 with diagnoses to include but not limited to polyneuropathy, congestive heart failure, rheumatoid arthritis, muscle weakness, and abnormalities of gait and mobility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing activities program of their choice for one (#18) of thirty-two sampled residents.

Inspectors wroteBased on observation, review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing and therapy staff, the resident's physician, and the resident's representatives, the facility failed to implement a systematic process to carry out their abuse policy for one Resident #17, who was cognitively intact and dependent on staff for incontinent care of two residents reviewed for abuse. The facility failed to take actions to report, thoroughly investigate, and take corrective action to prevent abuse to its residents. The facility failed to remove staff alleged to perpetrate the abuse and failed to thoroughly investigate the allegation to determine the root cause of the reported abuse to ensure the safety of the resident involved and ensure all facility residents would remain safe from a similar incident. On 11/24/2022 between 7:00 a.m. [...]

Inspectors wroteBased on record review, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's physician, and review of clinical and medical records, policies, and procedures, it was determined the facility failed to provide a systematic process to ensure residents were free from abuse and trauma for one resident (#17) of two residents reviewed for abuse by failing to report an allegation of abuse within the required timeframes to the required state agencies and authorities. On 11/24/2022 around 2:56 a.m. Resident #17 told Staff C, Certified Nursing Assistant (CNA) to stop performing incontinent care. The staff member refused to stop after being told multiple times no. On 11/24/2022 between 7:00 a.m. and 8:30 a.m. the Medical Director (MD) informed Staff A, Licensed Practical Nurse (LPN) that Resident #17 stated, I was raped after telling a male aide no. [...]

Inspectors wroteBased on review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing staff, the resident's physician, and the resident and the resident's representative, it was determined the facility failed to provide a systematic process to implement their abuse policy for one resident (#17) of two residents reviewed for abuse. The facility failed to thoroughly investigate to determine the root cause of a reported allegation of abuse and failed to remove staff alleged to perpetrate the abuse to ensure the safety of the resident involved and ensure all facility residents would remain safe from a similar incident. On 11/24/2022 around 2:56 a.m. Resident #17 told Staff C, Certified Nursing Assistant to stop performing incontinent care. The staff member refused to stop after being told multiple times no. On 11/24/2022 between 7:00 a.m. and 8:30 a.m. [...]

Inspectors wroteBased on observation, review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing staff, Resident #17, the resident's physician, and the resident's representative, the facility failed to follow professional standards of practice to maintain the resident's highest practical and psychosocial well-being by not ensuring their Behavioral Health Services for Trauma Informed Care was followed for one resident (#17) of two residents reviewed for abuse. The facility failed to take actions and respond to a family member and cognitively intact resident's request for female caregivers only. The first request was made on 10/26/2022 by the family member and the resident to the Staff C, Certified Nursing Assistant (CNA), who performed the admission intake; [...]

Inspectors wroteBased on record review, interviews with nursing and administrative staff, the resident and the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's Medical Director, the facility Administration failed to use its resources effectively to lead and direct the overall operations of the facility in accordance with resident needs, regulations, and company policies related to abuse for one resident (#17) of two residents reviewed for abuse. On 11/24/2022, Resident #17, an elderly female who was cognitively intact and dependent on staff for incontinent care and services, reported a male Certified Nursing Assistant (Staff C, CNA) performed incontinence care that she had repeatedly refused. Resident #17 reported the event to the Medical Director, who then reported it to the supervising nursing staff. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not honor resident choices related to a request to discontinue an as needed (PRN) medication for one resident (#30) out of a sample of three residents.

Inspectors wroteBased on observation, interview, medical record review, the facility policy, and professional standards of practice the facility failed to provided care and services for forty-eight hours for one resident (#22) out of a sample of two residents identified with a new pressure injury.

Inspectors wroteBased on observations, medical record review, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty six medication administration opportunities were observed, and four errors were identified for three residents (#101, #7 and #150) of five residents observed.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the minimum temperature for the rinse cycle of the high temperature dish machine per the manufacturer's recommendation in one of one kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate and effective supervision for one resident (#32) with a pattern of falls to prevent continued falls of three residents sampled. Resident #32 sustained four falls (5/5/21, 5/16/21, 5/21/21 and 5/22/21) in a 17- day period from 5/5/21 to 5/22/21.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure necessary care and services for one resident (#32) related to a suture of three residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound care according to professional standards of practice by double gloving, not performing hand hygiene and using the gloved finger to apply the paste in the wound for one resident (#15) of three residents sampled.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to keep kitchen equipment related to one burner (back right side, burner #4) of an eight-burner stove functioning in a safe, and operating condition.