Regina Senior Living

Inspectors wroteBased on observation and interview, the facility failed to clean and sanitize food-contact equipment, remove a paper bowl used as a scoop in a sugar container and keep food boxes off walk-in freezer unit floor.

Inspectors wroteBased on observation, interview and document review the facility failed to correctly establish and ensure staff followed appropriate transmission-based precaution (TBP) for 1 of 1 resident (R66) who required enhanced respiratory precautions for COVID-19. Further, the facility failed to ensure appropriate personal protective equipment (PPE) was used for residents in enhanced barrier precaution (EBP) during podiatry treatments in a common area for 1 of 3 residents (R57) reviewed for EBP. Additionally, the facility failed to initiate EBP for 1 of 1 resident (R33) who required EBP due to a pressure ulcer.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure privacy was maintained during treatments for 3 of 3 residents (R29, R54, R57) reviewed for privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure an evaluation was completed prior to renewal of PRN (as needed) antipsychotic medications for 1 of 5 residents (R10) reviewed for unnecessary medications.

Inspectors wroteBased on interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 2 residents (R24, R33) reviewed for care planning.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available for administration per physician order for 2 of 2 residents (R1, R54) reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to monitor for effectiveness of a medication prescribed for sleep for 1 of 5 residents (R47) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to assess and evaluate the appropriateness of the colostomy care supplies and ensure proper fitting of the wafer to prevent leakages and failed to provide physician-ordered care for colostomy care for one resident (R1). This failure caused psychosocial harm to R1 when his colostomy care was delayed, and he suffered emotional distress and suicidal ideation.

Inspectors wroteBased on interview and document review, the facility failed to offer a care conference during 1 of 3 residents (R1) reviewed for ostomy care. This resulted in R1's inability to participate in his care planning.

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a comprehensive, individualized care plan for 1 of 3 residents (R1) reviewed for ostomy care. The facility failed to have a process in place to instruct staff on physician ordered ostomy care. This resulted in R1's colostomy bag leaking on multiple occasions and emotional distress for R1.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 3 residents (R1) reviewed for ostomy care, received colostomy care as ordered by the physician. This resulted in inappropriate care, as evidenced by frequent leakage incidents for R1.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. In addition, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed, and failed to monitor sanitation level of the three-compartment sink and cleaning of food equipment. This deficient practice had the potential to affect all 53 residents who received food from the refrigerators and the kitchen, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher.

Inspectors wroteBased on observation and interview and policy review, the facility failed to ensure medications were securely and safely stored and under direct observation of authorized staff in areas where residents, staff and guests could access them. This had the potential to affect 37 residents whose medications were stored in the cart.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was maintained for 3 of 3 residents (R24, R51, R151) observed for long call light response times.

Inspectors wroteBased on interview and document review, the facility failed to notify the medical provider of a change in condition in a timely manner for 1 of 1 resident (R11) reviewed for respiratory care.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident identifiable personal health information (PHI) was kept secured and not accessible to unauthorized personnel. This had the potential to affect 2 of 2 residents (R31, R37) whose personal information was listed on exposed care sheets.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced grievances and complaints about the offsite laundry service were acted upon and, if needed, investigated or resolved for 1 of 1 resident (R2) reviewed who complained their clothing was missing or damaged due to the service.

Inspectors wroteBased on interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and depressive symptoms were evaluated for 2 of 4 residents (R36, R12) reviewed for MDS accuracy.

Inspectors wroteDuring observation, interview and record review, the facility failed to comprehensively assess and monitor a resident with new onset of respiratory symptoms for 1 of 1 residents (R11) reviewed for respiratory complications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained for 1 of 3 residents (R12) reviewed for EBP. Furthermore, the facility failed to implement and maintain respiratory precautions and have proper infection survelliance for 1 of 1 resident (R11) reviewed who had active symptoms of a potential respiratory illness.

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 2 residents (R7 and R30), reviewed for hospitalization. This had the potential to affect all residents who were hospitalized .

Inspectors wroteBased on interview and document review, the facility failed to provide a written bed hold for 2 of 2 residents (R7 and R30) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review the facility failed to monitor and maintain oxygen and nebulizer tubing and mask for 1 of 1 resident (R4) reviewed for respiratory care.

Inspectors wroteBased on interview and document review the facility failed to offer or attempt non-pharmacological interventions for pain prior to administering as needed (PRN) pain medications for 1 of 5 residents (R254) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to prevent the potential for and increased risk of a urinary tract infection by placing catheter bag on the floor for 1 of 1 residents (R3) reviewed for catheter care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of the 5 residents (R2 and R29) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for 1 of 1 resident (R1) reviewed for pressure ulcers. R1 admitted to the facility without pressure ulcers, subsequently developed an unstageable pressure ulcer related to necrotic (death of tissue). The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration, and notify R1's provider of changes, resulting in R1 being hospitalized . The immediate jeopardy began on 8/15/23, when a pressure ulcer was noted to R1's buttocks without proper assessment, physician notification, and documentation of interventions and was identified on 10/4/23. The administrator and director of nursing (DON) were notified of the on 10/4/23 at 4:55 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify 2 of 3 (R1 & R2) residents' physician and representative of a significant change in status when R1 developed a pressure ulcer and R2 had an abrasion to his back that required ongoing treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident received treatment and care when a wound physician ordered daily wound care for 1 of 3 residents (R2) reviewed for quality of care. R2's physician orders were not transcribed into the electronic medical record (EMR) and was not performed.