Regency Redmond Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF658Apr 7, 2023

  Based on interview and record review it was determined the facility failed to ensure Staff 15 (CMA) administered medications per the current standard of practice. This resulted in Resident 131 experiencing adverse medication consequences and being sent to the hospital for treatment and observation. Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. […]

• Actual harm, isolatedF760Apr 7, 2023

  Based on interview and record review it was determined the facility failed to ensure residents were free from significant medications errors for 1 of 6 sampled residents (#131) reviewed for medication. Resident 131 received an excessive dose of morphine (opioid pain medication) which resulted in hospitalization . Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. […]

• Actual harm, isolatedF757Jun 24, 2021

  Based on interview and record review it was determined the facility failed to ensure an anticoagulant medication was adequately monitored for 1 of 3 sampled residents (#6) reviewed for medication. Resident 6 was diagnosed with an intracranial bleed (brain bleed) and required ongoing care at a hospital. Findings include: Resident 6 was admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] requires monitoring of INR (International Normalized Ratio) due to a potential for abnormal bleeding. On 12/7/20 a physicians order included the following: [MEDICATION(S)] 7.5 mg one tablet PO once a day four days a week. […]

• Actual harm, isolatedF760Feb 1, 2021

  Based on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#5) reviewed for safe medication administration. Resident 3 experience unmanaged pain for a prolonged period. Findings include: Resident 5 admitted to the facility in 11/2020 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A 11/2020 MAR indicated [REDACTED]. Additionally, two nurses were required to observe the removal of the old patch, placement of the new patch and document disposal via the narcotic log book. Two staff were to date and sign the new patch when applied and remove the old patch per schedule. […]

• No harm, potential for more than minimal, patternF727Aug 16, 2024

  Based on observation, interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day seven days per week for nine out of 60 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports and payroll records dated 2/1/24 through 3/31/24 revealed nine days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. […]