Deficiency Records for Regal Heights Healthcare and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Regal Heights Healthcare and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-08-10 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-08 | 2023-08-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-08 | 2023-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-08-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-08 | 2023-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-08-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-08 | 2023-08-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-08 | 2023-08-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-08-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-08 | 2023-08-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-08 | 2023-08-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-08 | 2023-08-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-08 | 2023-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-08-10 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-08 | 2023-08-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-08 | 2023-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-08-10 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-08 | 2023-08-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-10 | 2022-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-10 | 2022-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-09 | 2022-03-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-09 | 2022-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-03-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-09 | 2022-03-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-09 | 2022-03-29 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-09 | 2022-03-29 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-09 | 2022-03-29 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-02-09 | 2022-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-28 | 2021-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-28 | 2021-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-12-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-07 | 2020-02-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-07 | 2020-02-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-07 | 2019-12-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-11-07 | 2019-12-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-07 | 2019-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-07 | 2019-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-07 | 2019-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-07 | 2019-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2019-12-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-11-07 | 2019-12-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-07 | 2019-12-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-07 | 2019-12-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-07 | 2019-12-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-11-07 | 2019-12-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-07 | 2019-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2019-12-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2019-12-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-11-07 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-20 | 2018-10-03 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-20 | 2018-10-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-08-20 | 2018-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-20 | 2018-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2018-08-20 | 2018-10-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-20 | 2018-10-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-08-20 | 2018-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-20 | 2018-10-03 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-08-20 | 2018-10-03 | N |
