Regal Heights Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Regal Heights Healthcare & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2024

  3. Review of R165's clinical record revealed: 11/17/16 - R165 was admitted to the facility with diagnoses including, but not limited to, dementia and heart failure. 1/5/23 - R165's medical record documented E52's (MD) order: Transfer Status: assist of 2, Bed Mobility: assist of 1, Ambulation 1 person assist with RW (rolling walker) with wheelchair following. 11/22/23 4:30 AM- R165 fell from an elevated bed while receiving incontinence care by E53 (former CNA). 11/22/23 7:07 AM - E54 (Emergency Department MD) documented in the ED (Emergency Department) Physician Record, . History of Present Illness . patient's bed was elevated and they [staff] were changing her when she was rolled and unfortunately fell out of the bed . Secondary Survey- Head: hematoma to the right parietal region . […]

• Immediate jeopardy, isolatedF695Feb 9, 2022

  Based on observation, clinical record review, interviews, review of the facility's policies and procedures, and review of other facility documentation as indicated, it was determined that the facility failed to ensure that emergency equipment was available for accidental dislodgement for two (R6 and R8) out of two active residents in the facility reviewed for [CONDITION(S)] ([CONDITION(S)]) related care. The lack of available emergency equipment, in addition to the lack of competent trained staff in [CONDITION(S)] care posed an immediate jeopardy (IJ) situation to the residents with tracheostomies. The IJ was identified on 2/2/22 at 6:00 PM and was abated on 2/3/22 at 3:45 PM. […]

• Actual harm, isolatedF689May 23, 2026

  Based on interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three of four residents (R58, R123, and R172) reviewed for accidents. The facility failed to ensure staff consistently followed care plans requiring two-person assistance during bed mobility, toileting, and showering, resulting in residents being left or cared for by a single staff member during high-risk activities.This deficient practice resulted in actual harm for Resident R58, who sustained a head laceration requiring emergency department evaluation and sutures after falling from the bed during care when a single staff member attempted to provide care without the required two-person… […]

• Actual harm, isolatedF604May 23, 2025

  Based on interview, record review and review of other documentation as indicated, it was determined that for one (R70) out of six residents reviewed for abuse, the facility failed to assure that a physical restraint was used to treat R70's medical symptoms and was not being used for staff convenience. Findings include: R70, a resident with dementia, had two gowns on during the evening shift of 3/31/25. The first gown was on in the correct position. The second gown was oversized and the gown material was gathered and tied in a knot below R70's knees and behind her neck to prevent R70 from exposing herself. […]

• Actual harm, isolatedF689Feb 10, 2025

  Based on record review, interview and review of other related documents, it was determined that for one (R10) out of nine residents reviewed for accidents, the facility failed to provide R10 adequate supervision and assistance to prevent burns. This resulted in harm to R10 as he sustained second-degree burns over 15-20 % of his body surface area. This is being brought forward as past non-compliance with an alleged date of compliance of 10/13/24. Findings include: 2/18/19 - R10 was admitted to the facility with diagnoses, including but not limited to, Alzheimer's disease. 3/1/22 - R10's care plan documented, [R10] has impaired verbal communication R/T (related to) cognitive loss . Interventions: . […]