Regent Park Rehabilitation and Healthcare

Inspectors wroteThe facility reported a census of 61 residents; the sample included 15 residents. Based on interview and record review, the facility failed to inform Resident (R) 12, R7, and R4 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility identified a resident census of 61. The sample included 15 residents, with three reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to provide the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Notice of Non-coverage (ABN) Form CMS-10055, for Resident (R) 22.

Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with one resident reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide care and services to prevent a reduction in ROM or contractures (abnormal fixation of a joint or tendon) for Resident (R) 49 when staff failed to follow the order for device to reduce risk or complications related to her left-hand contracture.

Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with one resident reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide care and services for Resident (R) 49 when oxygen was not provided to the resident when orders were in place.

Inspectors wroteThe facility identified a census of 73 residents, with three reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide sufficient supervision for Resident (R) 1 to prevent R1 from exiting the building after an employee. This deficient practice placed R1 at risk for elopement, falls, and injury.

Inspectors wroteThe facility identified a census of 66 residents. The facility had two kitchens. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation. This placed all residents who ate food from the facility at risk for food-borne illness.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents with two reviewed for accidents. Based on observation, record review and interview, the facility failed to secure pressurized oxygen cylinders in a safe, locked location and out of reach of the six cognitively impaired independently mobile residents. The facility additionally failed to maintain Resident (R)11's bed at a safe height while she was unsupervised in her room. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/08/24 at 07:03 AM a walkthrough of the facility was completed. Upon inspection of the facility's Clean Room in between the 100 and 200 hallways, the entry door was propped open. The room contained 37 pressurized oxygen cylinders placed in racks marked full. At 07:07 AM, Licensed Nurses (LN) I closed the door upon request. [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents, four medication carts, and four medication rooms. Based on observation, record review, and interviews, the facility failed to properly label and store medications in one of four medication carts and one medication room. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Inspectors wroteThe facility reported a census of 66 residents. The sample included 17 residents with three reviewed for accommodation of needs. Based on observations, interviews, and record review, the facility failed to provide wheelchair foot pedals for Resident (R) 40. This deficient practice placed the resident at risk impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)11's pressure-reducing interventions were implemented correctly when her low air-loss mattress pump was not set to the appropriate weight setting. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents with four residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 35's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This deficient practice placed R35 at increased risk of developing respiratory infection and complications.

Inspectors wrote- R40's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (high blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), overactive bladder (urine urgency), and glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). R40's Quarterly Minimum Data Set (MDS) dated 04/03/24 documented a Brief Interview of Mental Status (BIMS) score of seven which indicated moderately impaired cognition. R40 required staff assistance with activities of daily living (ADLs). [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to maintain ongoing communication with hospice services related to R11's bi-weekly hospice visits. The facility additionally failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R11. This deficient practice placed both residents at risk for delayed services and uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to a functional and fully operational call light system for each resident. This deficient practice placed the residents at risk for delayed care and decreased psychosocial well-being. Findings Included: - On [DATE] at 08:59 AM Resident (R)212 sat in her room for breakfast. She stated her call light had not worked since she was admitted on [DATE]. She stated nursing instructed her to yell out for help if she needed anything. She stated she did not receive a bell and was unsure if staff completed frequent checks on her. She stated she was afraid of falling with no way to alert anyone to come help her. On [DATE] at 09:05 AM a call light inspection and test revealed R212's call light did not work upon pushing the button. [...]

Inspectors wroteThe facility identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location for residents or visitors.