Regency Park Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled, HLTC Advance Directives for Health Care Policy, the facility failed to establish mechanisms for documenting and communicating the resident's choices for code status (advanced directives) to staff responsible for the resident's care for one of 34 sampled residents (R) (R1). The deficient practice had the potential to prevent R1 from expressing her right to formulate an advanced directive.Findings include:A review of the facility policy titled HLTC Advance Directives for Health Care Policy revised [DATE], documented under Purpose: Support the resident's right, in accordance with Georgia law, to formulate Advance Directives, honor existing Advance Directives, and revoke Advance Directives. Under Policy and Procedure: 1. The facility will promote the resident's right to formulate an Advance Directive, including the right to accept or refuse medical or surgical treatment, and revise or revoke an existing Advance Directive at any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident and staff interviews, record review and review of the facility's policy titled, Care Planning, the facility failed to implement the care plan for risk of falls for one of 34 residents sampled (R) (R17). This deficient practice had the potential to place the resident at risk of decreasing the resident's practicable physical, mental and psychological well-being.Findings include:Review of the facility's policy titled Care Planning dated 11/1/2019, documented under Policy: .D. Care Plan Reviews.1. The resident's comprehensive care plan will be reviewed, revised, and updated on a PRN basis, as determined by new and/or temporary resident condition changes that do not meet the significant change MDS criteria, yet require care plan updates per policy.Review of care plan for R17 dated 11/2/2020 revealed that staff are to assist R17 with toileting and stay in attendance during toileting as indicated. An additional review of the care plan revealed that staff are to respond promptly to all requests for assistance.During an observation of R17 on 8/13/2025 at 10:14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure that staff used proper infection control practices as evidenced by staff not performing appropriate hand hygiene between glove changes during catheter and perineal care for one of four residents (R) (R3) with catheters. The deficient practice had the potential to transfer pathogens and increase the risk of infection transmission for R3.Findings include:Review of the facility's policy titled titled Hand Hygiene with a revision date of 3/20/2024 revealed under Policy:.A. Hand Hygiene.1. Hand hygiene will be performed by washing hands with soap (anti-microbial) or using alcohol-based hand rub (ABHR) on hands. 2. Healthcare personnel (HCP) will perform hand hygiene with ABHR or soap and water for the following clinical indications that include but are not limited to after removing gloves or other personal protective equipment. Review of the electronic medical record (EMR) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and record review of the facility's policy titled Food Receiving and Storage with revised date of 2/22/2024, the facility failed to label and date open food items stored in the freezer. The census was 85. Findings included: The facility's policy titled Food Receiving and Storage revealed, Food shall be received and stored in a manner that complies with food and safe food handling practices. The policy further documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated with a used by date. An initial observation of the kitchen on 4/9/2024 at 8:55 am revealed the following were opened and not dated or labeled: frozen cookie dough (120 pieces), fish patties (10 pieces), beef patties (40 pieces), hash brown (1/2 bag), and fries (1/2 bag). During an interview on 4/9/2024 at 8:50 am, the Certificate Food Manager (CFM) revealed that he has only been working in current position for a few months. He stated that he was aware that the open food items in the refrigerator needed to be labeled and dated but he did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) forms were completed for one of three sampled residents (R) (R27). Findings included: A review of a facility-completed worksheet Beneficiary Notice-Residents discharged Within the Last Six Months, revealed that R27 was discharged from a Medicare-covered Part A stay, still had benefit days remaining, and remained in the facility after their last covered day. A review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form for R27 indicated that services were initiated on 12/15/2023 and discharged from Medicare Part A services on 2/23/2024, and she remained in the facility with Part A benefit days remaining. An Advance Beneficiary Notice of Noncoverage was (ABN) was not completed for R27. A review of the Notice of Medicare Non-Coverage (NOMNC) indicated the effective date coverage of your skilled nursing facility services will end 2/23/2024. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review, the facility failed to ensure staff members wore personal protective equipment (PPE), specifically face masks, in a manner that ensured the face masks fully covered staff members' noses and mouths in order to optimize source-control strategies and reduce the potential for COVID-19 transmission for one of two floors (second floor), for one of one facility entrance, and while in resident-care areas. Findings include: A review of the facility policy Required and Extended-Use Masking Policy for Healthcare Personnel (HCP) During COVID-19 Pandemic revealed, Effective Date: January 2022. Original Implementation Date: May 2020. Reference: CDC COVID-19, 'Your Guide to Masks'; Purpose: The virus is often spread before individuals begin experiencing symptoms; This policy is designed to protect against asymptomatic transmission and is recommended by the Centers for Disease Control and Prevention (CDC - 4/13/20); Procedure: 2. If employees/HCP have screened negative for fever/temperature 100.0 [degrees Fahrenheit], symptoms of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure a homelike environment for five of 19 sampled residents (R) (R#34, R#36, R#50, R#59, and R#68) related to receiving meals from the kitchen on Styrofoam takeout containers and plastic utensils. Findings include: Observations on 5/9/22 at 1:05 p.m. of the meal service on the first-floor revealed residents were served their lunch in Styrofoam takeout containers with plastic utensils. During an interview on 5/9/22 at 10:06 a.m., R#59 stated that all meals were served in Styrofoam takeout containers with plastic utensils. The resident stated it would be much nicer to eat off a plate with real silverware. During an interview on 5/9/22 at 10:43 a.m., R#34 said the food was always cold because it was served on Styrofoam plates. During an interview on 5/9/22 at 1:30 p.m., R#68 revealed the facility had been serving meals in Styrofoam takeout containers for a long time. The resident said the plastic utensils and Styrofoam made it hard to deal with and cut food. During a Resident Council group interview on 5/11/22 at 10:54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of the facility policy titled ADL Policy, the facility failed to provide Activities of Daily Living (ADL) care for three of five sampled residents (R)(R#47, R#48, and R#65) related to shaving, bathing, and fingernail care. Findings include: A review of a facility policy titled ADL Policy dated 1/1/19, revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). 1. A review of R#47's admission Record indicated the facility admitted R#47 with diagnoses including chronic diastolic (congestive) heart failure, Alzheimer's disease, and muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of facility policies titled, Skin Breakdown Prevention, Skin Integrity-Overview, and Skin, Wound and Pressure Ulcer Treatment-Overview, the facility failed to ensure treatment and services for prevention and management of pressure ulcers were provided in accordance with accepted standards of practice for three of four sampled residents (R) (R#33, R#65, and R#66) reviewed for pressure ulcers. Findings include: Review of the facility's policy titled, Skin Breakdown Prevention, dated 3/1/20, revealed the purpose of the policy was, To put measures in place to prevent residents from developing wounds/pressure ulcers, unless clinically unavoidable. According to the policy, The facility will utilize clinical information to determine appropriate and resident specific skin breakdown prevention measures needed. These may include, but not be limited to: Clinical assessments (admission/readmission assessments, MDS [Minimum Data Set], skin assessments and Braden…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy titled Medication Administration - General, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 33 medication opportunities were observed, and there were five errors for three of three residents (R) (R #29, R#56, R#34) for an error rate of 15.15%. Findings include: 1. A review of R#29's Orders, dated 2/17/22, directed staff to instill one drop of Restasis Multidose Ophthalmic Emulsion (chronic dry eye syndrome treatment) in each eye. An observation of medication pass with Registered Nurse (RN) LL on 5/9/22 at 9:49 a.m. for R#29 revealed RN LL administered one drop of Restasis in each of R#29's eyes. R#29 requested RN LL apply more drops. The surveyor observed RN LL instill an additional drop of Restasis into each eye. During an interview with RN LL on 5/9/22 at 9:56 a.m., RN LL erroneously stated the doctor's order for Restasis directed staff to administer two drops in each of R#29's eyes. 2. A review of R#56's Orders, dated 8/3/20, and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review, the facility failed to consult with the resident's physician to obtain treatment orders for one of 19 sampled residents (R)(R#33) related to newly identified skin breakdown Findings include: A review of the facility policy titled, Change of Condition, dated 1/1/19, revealed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of R#33's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and review of the facility policy titled Physician Services, the facility failed to ensure staff followed physician orders for one of 19 sampled residents (R)(R#1) related to the application of thrombo-embolus deterrent (TED) stockings. Findings include: A review of the facility policy, Physician Services dated 1/1/19, revealed: It is the policy of the facility to provide Physician Services in accordance to [sic] State and Federal regulations. 6. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record. During an interview and observation on 5/9/22 at 11:16 a.m., R#1 stated he/she was supposed to wear TED hose for edema. R#1 was observed to have socks and tennis shoes on both feet but did not have on TED hose. The resident stated that he/she was told by staff the TED hose had gone to the laundry, and the hose had not been seen since then. During an observation and interview on 5/10/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of a facility policy titled, Pain Management,, the facility failed to ensure one two residents (R) (R#66) of reviewed for pain received an effective pain management program. Specifically, the facility failed to administer R#66's pain medication in a timely manner and ensure orders for pain medications were initiated in a timely manner. Findings include: A review of the facility's policy titled, Pain Management, dated 1/1/19, indicated, Assessment and Recognition 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Treatment/Management: 1. With input from the resident to the extent possible, the provider and staff will establish goals of pain treatment. 2. The provider will order appropriate non-pharmacologic and medication interventions to address the individual's pain. 3. As appropriate, staff will provide the elements of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.