Regency Healthcare & Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 15, 2023

  Based on interview, record review and review of other facility documentation it was determined that for one (R37) out of twelve residents reviewed for abuse, the facility failed to prevent abuse. For R37 sexual abuse by a staff CNA (Certified Nursing Assistant). An immediate jeopardy (IJ) was identified starting on 6/5/23. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 6/10/23. R37 had sustained psychosocial harm as R37 was still affected by the abuse. Findings include: A facility policy and procedure titled Identifying Types of Abuse documented . 1. […]

• Actual harm, patternF760May 16, 2023

  Based on record review and interview, it was determined that for one (R51) out of nineteen residents reviewed in the investigative sample it was determined that the facility failed to ensure that R51's care was free of significant medication errors. The facility failed to obtain and administer numerous doses of the drug, Erivedge, which was ordered to prevent further growth of cancer. R51's disease progressed while off the medication per the oncologist resulting in harm. In addition, the facility failed to order the correct route of Erivedge administration. […]

• Actual harm, isolatedF689Dec 31, 2024

  Based on interview, and record review, it was determined that for one (R2) out of three residents reviewed for accidents, the facility failed to provide a safe environment by having two staff members present to assist with turning when R2 received a shower on 10/25/24. R2 sustained harm due to the traumatic removal of the nephrostomy tube during care and needed to be transported to the hospital for emergency treatment. On 10/26/24, R2 was again sent to the emergency room for evaluation of the injuries to his face, torso and lower extremeties. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, this deficiency was determined to be past non-compliance as of 10/29/24. […]

• Actual harm, isolatedF684Dec 15, 2023

  Based on record review and interview, it was determined that for one (R46) out of two residents reviewed for hospitalization s, the facility failed to follow the resident's physician's order for monitoring R46's lithium level. This caused a mental status change with a resultant hospital admission with a high serum lithium level of 2.43 resulting in harm to R46. Findings include: 5/25/22 - R46 admitted to the facility with diagnoses including but not limited to stroke with left-sided weakness, post-traumatic stress disorder (PTSD) and bipolar disorder. 7/11/23 - E2 (DON) entered a verbal order from E17 (MD) for lithium 300 mg by mouth every 12 hours for bipolar disorder with a serum lithium level to be drawn on 7/17/23. […]

• Actual harm, isolatedF684Nov 18, 2022

  Based on record review, interview, and review of facility policy and procedure, it was determined that for two (R63 and R446) out of two residents reviewed for a change in condition, the facility failed to immediately identify a significant change in condition when R63 experienced a change in motor function of his left arm and hand from his baseline, beginning with the neurological evaluation (neurochecks) on 10/15/22 at 10:14 AM through 10/15/22 at 10:14 PM. On 10/16/22 at 7:50 AM, 911 was called by the facility to transfer R63 to the emergency room (ER). Emergency Medical Services (EMS) records indicated that the call was received by EMS on 10/16/22 at 7:50 AM, approximately 22 hours from the onset of a significant change of condition on 10/15/22 at 10:14 AM. […]