Regency Health Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Regency Health Care and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 21, 2024

  Based on interviews, Resident Identifier (RI) #180's medical record, the facility's policies titled Urine Sample Collection, Antibiotic Stewardship Program, Loeb's Minimum Criteria for Starting Antibiotic Therapy, Revised McGeer Criteria for Infection Surveillance Checklist, and Laboratory Services and Reporting, the facility failed to ensure RI #180 received prompt treatment after the facility's staff identified that he/she was exhibiting signs and symptoms of a Urinary Tract Infection. The facility failed to ensure a system was in place for the proper collection of urinary specimens for culture and sensitivity. […]

• Immediate jeopardy, isolatedF867Aug 21, 2024

  Based on interviews, record review, and review of facility policy titled Quality Assessment and Assurance the facility's Quality Assessment and Assurance Committee (QAAC), the facility's Quality Improvement Performance Improvement (QAPI) committee, failed to thoroughly review all factors related to Resident Identifier (RI) #180's hospitalization on [DATE]. The facility did not identify the delay in treatment that resulted from the facility's failure to promptly obtain RI #180's urine specimen, promptly notify the Certified Registered Nurse Practitioner (CRNP) of RI #180's urinalysis (UA) results, and failure to administer RI #180's antibiotic timely. The facility's QAAC further failed to systemically address the factors that resulted in delay in treatment. […]

• Actual harm, isolatedF755Aug 21, 2024

  44165 Based on interviews, resident record review, review of a facility policy titled Pharmacy Services, the facility failed to ensure medications were available and administered as ordered for Resident Identifier (RI) #330, a resident with Liver Disease, upon admission to the facility on [DATE]. RI #330 missed doses of Rifaximin and Lactulose, medications for treatment of RI #330's Liver Disease, resulting in elevated blood ammonia levels. This affected one of 19 sampled residents. Findings include: A facility policy titled Pharmacy Services dated 2017 documented . Policy: It is the policy of this facility to ensure that pharmaceutical services, . are provided to meet the needs of each resident, . Compliance Guidlines: 1. […]

• No harm, potential for more than minimal, isolatedF558Aug 21, 2024

  Based on observations, interviews, record review and a facility policy titled Call Lights: Accessibility and Timely Response, the facility failed to accommodate the needs of Resident Identifier (RI) #15 by failing to ensure the call light was accessible on two of five days of the survey. This affected RI #15, one of 31 sampled residents. Findings include: Review of a policy titled Call Lights: Accessibility and Timely Response, revised February 2021, documented: . The purpose of this procedure is to assure the facility is adequately equipped with a call light at each residents' bedside . Call Lights will directly relay to staff member or centralized location to ensure appropriate response . 5. With each interaction in the resident's room . […]

• No harm, potential for more than minimal, isolatedF580Aug 21, 2024

  Based on interviews, resident record review, and review of a facility policy titled Notification of Changes, the facility failed to ensure the Certified Registered Nurse Practitioner (CRNP) was notified when medication was not available for administration to Resident Identifier (RI) #330 on 01/05/2023 and 01/06/2023. This affected one of 31 sampled residents. Findings include: A facility policy titled Notification of Changes revised 02/2021 documented . The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include but are not limited to: . 3. […]