A list of the most recent deficiencies for Regalcare at Harwich. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-16 | 2023-06-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-16 | 2023-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-03 | 2023-05-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-03 | 2023-05-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-03 | 2023-05-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-03 | 2023-05-30 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-03 | 2023-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-05-30 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-03 | 2023-05-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-03 | 2023-05-30 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-17 | 2023-02-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-17 | 2023-02-14 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-18 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-18 | 2022-04-13 | Y |
| 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 | 2022-03-18 | 2022-04-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-18 | 2022-04-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-19 | 2020-03-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-08 | 2020-02-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-01-08 | 2020-02-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-08 | 2020-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-08 | 2020-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-08 | 2020-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-08 | 2020-02-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-01-08 | 2020-02-21 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-01-08 | 2020-02-21 | 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 | 2020-01-08 | 2020-02-21 | N |
| 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 | 2020-01-08 | 2020-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-08 | 2020-02-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-12-19 | 2019-02-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-12-19 | 2019-02-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-15 | 2019-01-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-15 | 2019-01-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-15 | 2019-01-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-15 | 2019-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-15 | 2019-01-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-15 | 2019-01-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-15 | 2019-01-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-15 | 2019-01-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-11-15 | 2019-01-11 | 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 | 2018-11-15 | 2019-01-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-15 | 2019-01-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-11-15 | 2019-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-15 | 2019-01-11 | N |
| 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 | 2018-11-15 | 2019-01-11 | N |
| Have policies on smoking. | Health | 2018-11-15 | 2019-01-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-11-15 | 2019-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-19 | 2018-12-27 | N |
