Regency Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for two of five sampled residents assessed for elopement risk, Resident (R)82 and R259. 1. The facility assessed R259 to be at risk for elopement and R259 was care planned as at risk for elopement due to exhibited exit-seeking behavior. However, the resident exited the facility undetected by staff on 09/08/2022 at approximately 4:10 PM and was outside unsupervised for approximately five minutes. 2. The facility assessed R82 to be at risk for elopement for exhibited exit-seeking behaviors. Tthe facility, however, failed to develop and implement an elopement care plan for the elopement risk until 11/03/2022, seven (7) days after R82 first eloped on 10/27/2022. The resident exited the facility again, without staff's knowledge, on 01/02/2023. Staff failed to follow the resident's interventions and the resident…

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, interview, record review, facility document and policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement and to prevent residents from becoming missing for two of five sampled residents assessed for elopement risk, (Resident (R)82 and R259) out of the total resident sample of twenty-three (23). R259 on 09/08/2022, and R82 on 10/27/2022, eloped from the facility unescorted, unsupervised, and without staff knowledge. The facility's failure to have an effective system in place to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/20/2024 and was determined to exist on 09/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F 689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care…

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 interview, record review and facility policy review, it was determined the facility failed to identify a change in condition for one (1) of thirteen (13) sampled residents. Review of Resident #8's clinical record revealed the facility admitted the resident with the diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Heart Failure. Review of Resident #8's Nursing Documentation, dated 11/03/19 at 10:55 PM, revealed a shift note for Exacerbation of Respiratory Condition, which stated the resident's lungs were not clear and rhonchi were heard upon auscultation and the resident had a non-productive cough. However, this change in respiratory status was not communicated to the physician. On 11/04/19 at 12:06 AM, Resident #8 was out of bed, found to be unsteady on his/her feet, and experienced shortness of breathe. Nursing applied oxygen, assisted the resident to bed, raised head of bed up, administered steroids and pain medication. However, nursing did not notify the physician of a change in condition. Review of Resident #8's weights revealed, on…

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, interview, record review, and facility policy review it was determined the facility failed to have an effective system to protect residents from sexual abuse for one (1) three (3) of a total sample of fifty-six (56) residents (Resident #26). Interview and record review revealed the facility failed to assess Residents #5 and #26 for the capacity to consent to sexual relations. Nor did the facility conduct behavior monitoring of Resident #5, to ensure Resident #26 and other residents were protected from potential sexual abuse. Review of Resident #5's nursing progress notes, first noted on 09/13/18, revealed the resident exhibited inappropriate sexual behavior to self in public areas and also directed this behavior towards Resident #26. Review of the Psychiatric Periodic Evaluation, dated 10/05/18, revealed Resident #5 was aware that a person could not be able to give consent and therefore could not be a willing participant in sexual behavior, and the resident's judgment in the matter seems to…

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 interview, record review, and facility policy review it was determined the facility failed to have an effective system to ensure staff reported allegations of sexual abuse when they occurred and to ensure these allegations were reported to State agencies for one (1) of two (2) of a total sample of fifty-six (56) residents, Resident #26. Record review revealed Resident #5 requested and engaged in sexual acts with Resident #26, including exposure of his/her genitals and masturbation in common areas. Interview with staff revealed these sexual acts were not always reported because the facility was aware and it occurred often. In addition, the facility failed to report the incidents to the required State agencies. The facility's failure to report potential resident abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/13/19 and was determined to exist on 09/13/18. The facility was notified of the IJ on 08/16/19. The facility provided an Acceptable Allegation of Compliance (AOC) on 08/20/19,…

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 interview, record review, and facility policy review it was determined the facility failed to have an effective system to investigate allegations of sexual abuse and to protect residents from further potential abuse for one (1) of two (2) of a total sample of fifty-six (56), Resident #26. Resident #5 performed a sexual act with Resident #26, made requests for oral sex, exposed his/her genitals, and masturbated in the presence of Resident #26 and other residents; however, the facility failed to investigate the allegations to prevent potential abuse and ensure resident safety. The facility's failure to investigate an allegation of potential abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/13/19 and was determined to exist on 09/13/18. The facility was notified of the IJ on 08/16/19. The facility provided an Acceptable Allegation of Compliance (AOC) on 08/20/19, which alleged removal of the Immediate Jeopardy on…

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, interview, record review, and review of the facility's policy, it was determined the facility failed to implement the care plan for two (2) of three (3) sampled residents out of a total sample of fifty-six (56) residents (Resident #25, #46). Resident #46 was care planned for alteration in comfort related to his/her fracture of the radius and muscle spasms. However, nursing staff did not know about the resident's fracture and certified nursing assistant (CNA) #3 repositioned the resident in his/her bed by pulling on the resident's fractured wrist. In addition, staff did not assist Resident #25 with a change of clothing. The findings include: Review of the facility's policy Pain Management revised 03/01/18, revealed residents were evaluated as part of the nursing assessment process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. Pain management consistent with professional standards 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review it was determined the facility failed to ensure resident care plans were revised to meet care needs for one (1) of one (1) sampled residents out of a total of fifty-six (56) total residents (Residents #106). Resident #106's Care Plan was not updated with interventions related to the resident's new diagnosis of Pneumonia with Antibiotic therapy or any interventions related to this diagnosis. In addition, licensed nursing staff failed to monitor the resident for edema related to his/her diagnosis of Congestive Heart Failure; the resident died at the facility. Review of Resident #106's clinical record revealed no updates for the intervention given by the Advanced Practice Registered Nurse (ARPN), to elevate the resident's left lower extremity (LLE) and left upper extremity (LUE) was elevated at least four (4) times a day above the resident's heart and that his/her care plan was updated with the ordered interventions. The findings include: 1. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the facility's policy titled, Emergency Cart, review dated [DATE] and revision dated [DATE] revealed the facility would maintain at least one (1) emergency cart per nursing care floor. Emergency carts would contain all supplies required to establish and sustain basic life support. Equipment from the emergency cart would be used only when emergency care was provided. Equipment taken from the emergency cart would be identified and replaced promptly. The emergency cart would be checked every twenty-four (24) hours, and after every use. The Emergency Cart Checklist purpose ensured all supplies critical to basic life support were readily available on the emergency cart. Review of Resident # 8's clinical record revealed the facility admitted the resident on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Heart Failure, Chronic Atrial Fibrillation, and Wedge Compression Fractures of the First, Second, and Third Vertebra. Continued review of the medical record…

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 interview, record review, and facility policy review it was determined the facility failed to ensure nursing staff performed Respiratory Assessments for one (1) of three (3) sampled residents of a total sample of fifty-six (56) residents (Resident #106). Interview and record review revealed nursing failed to monitor and assess for respiratory decline that included auscultation of lung sounds, evidence of sleep apnea, edema in extremities, and/or weight fluctuations related to Resident #106's diagnoses of Congestive Heart Failure and new onset of pneumonia. Interview with Licensed Practical Nurse (LPN) #6 on, [DATE] at 12:25 PM, revealed on [DATE] she was assigned to care for Resident #106 and was unaware of the resident's recent diagnosis and treatment for pneumonia. She stated she administered the resident's medication around 10:30 AM on [DATE]; and if the resident had a pneumonia diagnosis then she should have assessed the resident's lungs at that time but she did not. In addition, she could not…

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, interview, record review, facility policy review, and review of the job description for the Center Executive Director, it was determined the facility failed to be effectively administered in a manner that enabled effective use of resources to attain and maintain the highest practicable physical, mental, and psycho-social wellbeing for two (2) of thirteen (13) sampled residents, Resident's #6 and #8. Review of a closed clinical record revealed the facility readmitted Resident #6 on [DATE], after a hospitalization for Pneumonia with sepsis and fluid overload. Review of the resident's nursing assessments revealed they were incomplete or non-existent. Record review and interview revealed nursing staff found the resident unresponsive in the bed on [DATE], and failed to initiate cardiopulmonary resuscitation (CPR) to honor Resident #6's advance directive for a Full Code. Furthermore, record review revealed the facility admitted Resident #8 on [DATE] with the diagnoses of Heart Failure, Chronic…

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, interview, record review, review of the facility's policy, and the Center's Executive Director (CED) job description it was determined the facility failed have an effective system to address system failures related to providing Respiratory and Emergency Services through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. The QAPI Committee, failed to identify discrepancies related to staff delivery of Respiratory Care Services; nor with the provision of Emergency Services in order to meet residents advance directive wishes, and did not implement a formal plan of action to address. Based on interview, record review, and facility policy review it was determined the facility failed to provide resident's with consistent respiratory/cardiovascular services for two (2) of thirteen (13) sampled residents. Record reviews for Resident's #6 and #8 revealed incomplete or non-existent respiratory and cardiovascular nursing assessments during several days of their facility…

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.